A Race to the Top: Illinois’s All Kids Initiative

Prepared by Teresa A. Coughlin and Mindy Cohen of The Urban Institute
Kaiser Commission on Medicaid and the Uninsured
August 2007

In the summer of 2006, Illinois joined several other states in advancing health care reform by launching the nation’s first universal coverage program for children. Called “All Kids,” the initiative builds on the state’s Medicaid and State Children’s Health Insurance Program (SCHIP) programs but is funded exclusively with state funds. The program offers coverage to all uninsured children, regardless of income, health status or citizenship.

As of April 2007, about 50,000 children have enrolled in the expansion part of the All Kids initiative. About half are in households with income less than 200 percent of the FPL. Many of these are immigrant children who do not yet qualify for Medicaid and SCHIP because of program citizenship and immigration requirements. Most of the remaining new enrollment has occurred in the low-to moderate-income groups but some children in the higher income groups have also enrolled. About 100 children with $100,000 or greater family income have enrolled. Prior to the All Kids expansion, the state estimated that there were about 250,000 uninsured children across all income groups in Illinois.

By all accounts and by enrollment numbers, program outreach for All Kids has been a success. In large part, this success was attributed to the considerable campaign the state undertook to market All Kids, one that used a range of innovative strategies. The state’s streamlined application and follow-up processing, which includes a new online option, also likely contributed to the program’s enrollment success. Another likely important factor is the state’s decision to incorporate the expansion directly into its Medicaid and SCHIP programs and then market all under the single umbrella name of All Kids. In short, the outreach, the application process and the integrated program, make All Kids customer friendly and easy to understand.

Materials released by the governor’s office when the proposal was unveiled state that All Kids was designed to provide access to “good, affordable,” and “comprehensive” coverage to the state’s more than 250,000 uninsured children.

In terms of enrollment, All Kids has been a great success: Implemented July 2006, the initiative had a goal of expanding coverage to 50,000 children in the first year. Within nine months of implementation (April 2007), it had already reached that enrollment target.

http://www.kff.org/uninsured/upload/7677.pdf

Comment:

By Don McCanne, MD

Illinois’ All Kids was developed and promoted as a program that would provide health insurance coverage for all children in the state. A goal was set to cover 50,000 (one-fifth) of the uninsured children within the first year. This report celebrates the success of this program in that it achieved this target in only nine months. But is a celebration really warranted?

Before answering that, it is important to acknowledge that insuring 50,000 children who previously had no coverage is a good thing. But incrementalism is a bad thing when another 200,000 children are left without coverage.

When this program was established, it was very clear that there were many design flaws that made it virtually impossible to extend coverage to all uninsured children. Some of these flaws were covered in a Quote of the Day message over a year ago (link below). Although the current report celebrates the “race to the top,” a careful reading of the report confirms that the design flaws had their fully predictable negative impacts. In fact, it is clear from reading this report that it is improbable that coverage would ever be expanded to much more than one-fifth or one-fourth of the population of uninsured children.

Although it is now only one year into the program, it is safe to say that it is a failure. Establishing an artificial goal of accomplishing only one-fifth of the intended results does not entitle you to declare success merely because you reached that deficient goal.

It is important to understand that the failure was in the design of the program. Health policy science has advanced to the degree that outcomes of most policies are quite predictable. It is an egregious error on the part of politicians and the policy community to proceed with programs with fully predictable adverse results. To say that we should just go ahead with this program anyway and see how it works is health policy malpractice.

Illinois will never insure all of the children until they enact a program that results in automatic and permanent enrollment of every single child.

Likewise we will never insure everyone in the United States until we enact a program that results in automatic and permanent enrollment of every single individual. Those in the single payer reform movement can describe the policies that would make that happen. And it wouldn’t be necessary to test it them see if they would work.

qotd: Illinois’ dubious claim of first to cover all kids:
https://www.pnhp.org/news/2006/june/illinois_dubious_cl.php

Editorial
The New York Times
August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?pagewanted=all

Comment:

By Don McCanne, MD

We have the money. We should have “the best health care system in the world.” But building on mediocrity will only bring us more mediocrity at ever greater levels of spending.

We are already using the tax system to pay for two-thirds of our health care (Reinhardt). But now we need to do what every other nation has done: establish public policies that improve the allocation of our health care resources. That means that we must remove the private stewards of our health care funds as they have proven themselves to be utterly incompetent.

If we are going to raise our health care system above the level of mediocrity, we simply have to place our public funds under the control of our own public stewards – through a program of national health insurance.

Uwe Reinhardt quote on two-thirds of health care spending through the government:
https://pnhp.org/news/2006/december/private_plans_pay_so.php

World’s Best Medical Care?

Editorial
The New York Times
August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?pagewanted=all

Comment:

By Don McCanne, MD

We have the money. We should have “the best health care system in the world.” But building on mediocrity will only bring us more mediocrity at ever greater levels of spending.

We are already using the tax system to pay for two-thirds of our health care (Reinhardt). But now we need to do what every other nation has done: establish public policies that improve the allocation of our health care resources. That means that we must remove the private stewards of our health care funds as they have proven themselves to be utterly incompetent.

If we are going to raise our health care system above the level of mediocrity, we simply have to place our public funds under the control of our own public stewards – through a program of national health insurance.

Uwe Reinhardt quote on two-thirds of health care spending through the government:
https://www.pnhp.org/news/2006/december/private_plans_pay_so.php

California Medical Association
California Physician
August 9, 2007

CMA on Tuesday asked the Department of Managed Health Care to take action against Blue Cross of California for jeopardizing the physician-patient relationship and engaging in unlawful business practices that have reduced patient access to care.

CMA testified at a public hearing in Los Angeles that Blue Cross has violated the promises it made to California patients when it merged with Anthem Health Care in 2004. Since that merger, Blue Cross has consistently increased premiums, while reducing the amount of money spent on patient care. The insurer is now dangerously close to not having enough physicians available to serve the 8.3 million Blue Cross patients in California.

With the consolidation of the health plan industry, both nationally and in this state, competition among the insurance companies has been severely diminished, if not eliminated, much to the detriment of the very individuals these plans promise to serve patients and their treating physicians, CMA said in its written testimony. The turmoil created by Blue Cross has taken its toll on everyone. It must be remembered that it is physicians who provide medical care to patients, not health plans.

DMHC called the hearing to review commitments made by Blue Cross when it merged with Anthem three years ago. DMHC this year alone has initiated 18 enforcement actions against Blue Cross, including multiple fines a significant increase from previous years.

CMA contends that among a vast collection of misdeeds, Blue Cross has:

* reimbursed physicians at unconscionably low levels, at times below the actual cost of care;

* increased consumer premiums at a much higher rate than any other major health insurer, raising rates as much as 10 percent in a single year;

* rescinded authorization and refused to pay for care provided in good faith;

* reduced reimbursement levels without appropriate notice;

* retroactively canceled individual health insurance coverage after policyholders got sick.

For at least a decade, Blue Cross has consistently spent less on medical care than the 85 percent required by law, at the same time raising premiums and increasing profits.

While Blue Cross seems averse to paying physicians fairly and spending adequately on health care, the insurer plans to spend $2 million this year trying to defeat health reform proposals designed to increase access to care in California.

Blue Cross’s misbehavior shows significant signs of diminishing the supply of physicians, already a growing problem in California. CMA and its county component medical societies have received a number of calls from physicians who have determined that they can no longer financially and ethically provide medical care under the dictates of Blue Cross and are being forced to terminate their contracts altogether.

http://www.calphys.org/html/cc482.asp

CMA testimony:
http://www.cmanet.org/upload/bc_testimony_080707.pdf

Comment:

By Don McCanne, MD

Wall Street analysts have continued to praise Blue Cross of California and its parent company (WellPoint) as being leaders in private insurance innovations that have led to stellar performances in the equities markets. Blue Cross/WellPoint has led, and in order to remain competitive, the others (including the non-profits) have followed.

As we reform our system of health care financing, do we really want more of this type of leadership? If not, we’re going to have to let our politicians know, because they’re headed that way.

By Sarah Thomson and Elias Mossialos (London School of Economics and Political Science)
World Health Organization
Health Evidence Network
July 2004

The issue

Over the last 20 years the level of private spending on health care has risen in many western European countries, leading to concern about its impact. The main channels of private spending are private health insurance policies and cost-sharing schemes in public health systems.

Findings

Evidence shows that private sources of health care funding are often regressive and present financial barriers to access. They contribute little to efforts to contain costs and may actually encourage cost inflation.

Private health insurance

The role of private insurance in western European health systems is largely determined by the extent of statutory health insurance. The evidence shows that:

* Allowing people to opt out of statutory health insurance threatens its long-term financial stability.

* Relying on complementary private health insurance to protect people against high levels of statutory user charges can increase inequities in access to care between those who can and cannot obtain such coverage.

* Supplementary private insurance increases inequalities of access, particularly where there are no clear boundaries between public and private health care provision.

* Tax subsidies for private health insurance are inefficient – because they distort signals about the real price of insurance and generate transaction costs – and inequitable, as they tend to benefit higher income groups.

* Private health insurers lack efficiency incentives and tend to incur higher administrative costs than statutory health insurance. Publicly-funded systems are generally more successful in controlling cost inflation than mainly privately-funded systems.

* Private health insurance can increase choice for some, but not to the extent that is often suggested, and under certain circumstances it may even restrict choice.

Cost sharing

Cost sharing is widely used in western European health systems to moderate demand and/or raise revenue. However, the theoretical case for cost sharing is weak, particularly when applied to health care arising from referral or prescription. The evidence shows that:

* Cost sharing shifts costs to individuals and leads to significant reductions in the use of health care.

* Cost sharing reduces the use of both appropriate and inappropriate health care, which has negative implications for equity and efficiency.

* Cost sharing is not an effective means of containing costs.

* Differential charges can be used to encourage more cost-effective patterns of health care use.

* Because cost sharing creates financial barriers to access, it should be accompanied by mechanisms to protect heavy users of health care and lower income groups.

* Exemption systems require administrative capacity, may generate significant transaction costs and may limit cost sharing’s ability to raise revenue.

http://www.euro.who.int/document/e83334.pdf

Comment:

By Don McCanne, MD

Even though released three years ago, this primer on private health care funding of Western European countries is especially informative for the dialogue on health care reform now taking place in the United States.

The report demonstrates that both private health insurance and patient cost sharing have a negative impact on equity, efficiency and affordable access to care. Some contend that we have to accept these perversities in order to contain health care costs. But one of the most important findings in this report is that neither is effective controlling cost inflation.

I omitted the policy recommendations that were presented in this report. They recommend greater regulation of the private insurance industry, and more careful design of cost sharing. Even though they (inadvertently?) presented a very compelling case for eliminating private insurance and cost sharing, being from the London School of Economics, it appears that they would try to make private funding work.

Regardless, this is an excellent primer on the flaws of financing health care through private insurance and cost sharing. It is well worth downloading and retaining as an important resource in our national dialogue on reform.

Just ignore their policy recommendations and substitute ours: Let’s design our national health insurance program so that it provides comprehensive benefits for everyone, funded equitably, while removing financial barriers to care. Let’s contain costs through patent-friendly supply side mechanisms. Then we could send the private insurers on their way, and they can take their perversities with them.

By Grace M. Lee, MD, MPH; Jeanne M. Santoli, MD; Claire Hannan, MPH; Mark L. Messonnier, PhD; James E. Sabin, MD; Donna Rusinak; Charlene Gay; Susan M. Lett, MD, MPH; Tracy A. Lieu, MD, MPH
JAMA
August 8, 2007

Children who are uninsured or who have public health insurance, such as Medicaid, can receive vaccines free of charge through the Vaccines for Children (VFC) program.

Only 34% of states had a health insurance mandate that required insurers to follow current ACIP or American Academy of Pediatrics recommendations for children and adolescents. Seventeen percent of states had a health insurance mandate that did not require insurers to cover all recommended vaccines and 49% of states did not have any health insurance mandate.

Limitations in both federal (section 317) and state vaccine financing were reported as the dominant barriers to states’ providing vaccines to underinsured children. Lack of section 317 funding was cited as a barrier for 81% (Tdap) to 100% (pneumococcal conjugate) of state immunization programs that were not able to provide vaccines to underinsured children. State funding was either limited or unavailable for vaccine purchase for 94% or more of programs that were not able to provide vaccines to underinsured children.

The public sector safety net for offering vaccine to underinsured children seems to be under considerable strain. Past studies have suggested that many private clinicians refer underinsured children to public health clinics for vaccination. Unfortunately, a growing number of states are no longer able to provide expensive vaccines, such as the meningococcal conjugate vaccine, to underinsured children in the public sector. Furthermore, the proportion of vulnerable US children whose insurance plans either do not cover vaccines or require families to pay out-of-pocket for preventive care is likely to grow. A recent article by the American Academy of Pediatrics found that 20% of employers are offering catastrophic health insurance plans (high-deductible health plans), up from only 5% in 2003, and only 30% of these plans covered preventive care before the deductible was met. These trends are of concern because inadequate insurance coverage has been associated with forgone health care among families who lack resources.

Despite the ability of vaccines to prevent illness and death, our current system of vaccine financing has resulted in a gap for underinsured children.

http://jama.ama-assn.org/cgi/content/full/298/6/638

Comment:

By Don McCanne, MD

The crisis in the affordability of private health insurance can only result in an expansion in the current epidemic of underinsurance. If insurers are to maintain a market for their products, they must continue to find innovative methods of not paying for health care.

Vaccines for children are so important that we have in place public policies that ensure that children covered by public insurance programs and children without any health insurance at all will still receive their immunizations. Our public policies also presume that vaccines will be provided on a private basis for privately insured children. The response of the private insurers confirms that this latter assumption is not valid, especially considering that the cost to fully vaccinate a child in the public sector is $1170.

There is a fundamental difference between public insurance and private insurance. Public insurance is founded on policies that help to ensure that people receive the health care that they need, when they need it. That includes vaccines for children. Private insurance is founded on policies that ensure success in a competitive marketplace that trades off lower insurance premiums for limiting access to care that people need. That includes limiting affordable access to childhood vaccines.

Leaving policy decisions under the control of the private stewards of a competitive market of underinsurance will result in adverse outcomes such as the preventable deaths of untold numbers of children for lack of vaccines. Isn’t it time for us to dismiss the private stewards and hire our own public stewards who really do care about the health of our children, and the health of the rest of us?