Unfinished Business: More than 20 Million Children in U.S. Still Lack Sufficient Access to Essential Health Care
Children’s Health Fund, November 2016
Children’s Health Fund (CHF) estimates that, at minimum, 20.3 million children in the United States (28% of all children) face barriers to accessing essential health care. This estimate covers children who are a) uninsured; b) children who don’t receive routine primary care; and c) publicly insured children who are connected to primary care but have unmet needs for pediatric subspecialty care when needed, such as pediatric cardiology or pediatric endocrinology.
Based on the collective reach and impact of Medicaid, CHIP, and ACA, the child uninsurance rate fell from 13.9 percent in 1997 (9.6 million) to 4.5 percent (3.3 million) in 2015—a drop of more than 67%. But there is still much to be done. We need to find ways to cover that remaining 4.5 percent—some 3.3 million children, many of whom are from the most marginalized communities and regions in the United States. And while important, uninsurance figures often promote the false dichotomy of “insured” versus “uninsured” children, ignoring the millions of children who are counted as insured but go without coverage for some portion of the year. Such coverage gaps matter. Discontinuous health coverage can negatively impact timely receipt of preventative and other crucial health care services.
Beyond the issue of coverage is an equally important question: Do children who receive some form of coverage actually access the care that that coverage is supposed to provide? The answer is often no. Based on data and our analysis, Children’s Health Fund believes that there are two main categories of barriers to obtaining health care: Financial and Non-financial.
Financial barriers refer to the costs imposed by a coverage plan that prevents children from accessing the care they need. Such barriers refer to costs such as high copays, high deductibles, and unaffordable prescription drug prices. CHF calculates that there are over 13.1 million children whose families report either having problems paying medical bills or being unable to pay medical bills. Provider-based barriers also contribute to the financial burden when clinics or providers won’t accept certain forms of insurance or create environments that promote insurance stigma.
Non-financial barriers most often take the form of either geographic barriers or informational barriers. Geographic barriers include issues of transportation, such as a lack of a car or poor public transit options, and federal-designated Health Professional Shortage Areas (HPSAs) where the number of health professionals in a given geographical area is insufficient for that population’s healthcare needs. CHF estimates that over 14 million children live in HSPAs. Informational barriers include parents’ health illiteracy, dauntingly complex language used in information about coverage eligibility and accessing care, and parents’ limited English proficiency.
By Don McCanne, M.D.
In designing the Affordable Care Act, special attention was given to be sure that children were well covered by our system of public and private programs. Yet over 20 million children still have access barriers to essential health care services.
Look at some of the reasons for this impaired access and then imagine how it would be under a single payer system:
* 3.3 million children have no insurance at all. Single payer would automatically include everyone.
* Millions who are counted as insured have frequent gaps in coverage for a variety of reasons related to the fragmented nature of health care financing post-ACA. Single payer covers everyone for life, so there would be no gaps in coverage.
* High patient cost sharing and high prices frequently impair access to care. Under single payer, all essential services would be paid for in full, so there would be no financial barriers.
* Frequently certain insurance plans are not accepted by many health care providers. Under single payer, there is only one plan that would be accepted by all providers since there is no other option.
* The stigma of welfare plans such as Medicaid can interfere with access, especially for subspecialty care. Under single payer there is no separate welfare program for low-income individuals or families. Single payer would cover everyone, eliminating the stigma of assigning the poor to welfare programs.
* Over 14 million children live in federally designated Health Professional Shortage Areas, potentially impairing access. A single payer system plans and budgets capital improvements, providing improved distribution of our health care resources.
The attitude today seems to be that we have done a pretty good job of covering children, though maybe we need a few more tweaks that might slightly improve access, though it is not practical to fill in all of the voids. Nonsense. All we need is a well designed single payer system. It would dramatically improve access for these 20 million children (and everyone else) without increasing spending over our current levels.