Report: Uninsured Hospitalized Children Face a 6o Percent Increased Risk of Dying

Sometimes the numbers speak louder than words, and the words are just painful to hear: the New York Times’ Prescriptions reports that

Researchers analyzed data from more than 23 million children’s hospitalizations from 1988 to 2005.

Uninsured children who wind up in the hospital are much more likely to die than children covered by either private or government insurance plans, according to one of the first studies to assess the impact of insurance coverage on hospitalized children.

Researchers at Johns Hopkins Children’s Center analyzed data from more than 23 million children’s hospitalizations in 37 states from 1988 to 2005. Compared with insured children, uninsured children faced a 60 percent increased risk of dying, the researchers found.

On a regular basis writers on this blog have discussed health reform as a moral imperative: citing religious doctrine, philosophers, economists and statistics to show that health care, unlike the purchase of automobiles and designer shoes, is not correctly a conventional aspect of a market economy– that the distribution of healing and life itself should not be premised upon who is the best capitalist, or, for that matter, the child of the best capitalist. That uninsured hospitalized children face a 6o percent increased risk of dying says that in a way that I simply cannot add to. Lack of insurance kills.

The Times noted that “Although the research was not set up to identify why uninsured children were more likely to die, it found that they were more likely to gain access to care through the emergency room, suggesting they might have more advanced disease by the time they were hospitalized.”

According to the Times the study showed that “uninsured children were in the hospital, on average, for less than a day when they died.”

Which is to say that it was too late by the time they got there.

The Times noted that “Alison Buist, director of child health at the Children’s Defense Fund, a nonprofit advocacy organization,” said in response to the study’s findings:

If you wait until a child gets care at a hospital, you have missed an opportunity to get them the types of screening and preventive services that prevent them from getting to that level of severity to begin with.

The Times further noted that

The most common reasons for children being hospitalized were complications from birth, pneumonia and asthma. The study found that the reasons did not differ depending on insurance status.

Read the full NY Times article here.
Read the Report here.

Implementing Reform: Children with Special Health Care Needs

The public option took a hit on Tuesday, as the Senate Finance Committee rejected amendments adding it to the Chairman’s Mark of the Baucus bill. As I have written previously, a public plan could improve care for the most vulnerable, including those with chronic illness, who tend to struggle for appropriate care under commercial plans. If the public option is dropped, the implementation of the resulting private plan-based system, including enforcement and regulatory design at the federal and state levels, becomes that much more critical to the task of assuring access to appropriate care.

The bills build on the benefits design of the private insurance market, as did Medicare and SCHIP before them. Those programs adopted familiar, private-sector benefits design and payment methods for political and pragmatic reasons: powerful stake-holders were comforted, and implementation was simplified. The bills build on this lineage. The Baucus bill, for example, requires all plans offered by the insurance exchanges to provide:

preventive and primary care, emergency services, hospitalization, physician services, outpatient services, day surgery and related anesthesia, diagnostic imaging and screenings (including x-rays), maternity and newborn care, pediatric services (including dental and vision), medical/surgical care, prescription drugs, radiation and chemotherapy, and mental health and substance abuse services that at least meet minimum standards set by Federal and state laws.

Pretty standard stuff. But describing a slate of covered benefits, and ensuring that that care is properly delivered by private, mostly for-profit firms, are different things entirely.

Take the example of children with special health care needs (”CSHCN”). The Maternal and Child Health Bureau of DHSS defines CSHCN as “…those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” The Catalyst Center at Boston University identifies these children’s health conditions as including:

chronic illnesses such as diabetes, sickle cell anemia, cystic fibrosis, and heart disease; developmental disabilities such as mental retardation, sensory impairments, and autism spectrum disorders; emotional or behavioral health needs including ADHD and mental health conditions; and physical disabilities such as cerebral palsy, spina bifida, or muscular dystrophy.

Simply providing “health insurance” to children with these conditions is no guarantee that they’ll receive appropriate services. A 2002 study by Harriette Fox and others for HRSA reported that insurers have interpreted contract terms to exclude categorically some conditions such as mental retardation or “inorganic disorders.” Others have limited medically necessary services such as speech therapy or habilitation therapy because they are not curative or restorative, but merely needed to maximize a child’s ability to function.

These contract terms and their interpretations have not often been challenged by state departments of insurance, because those terms and interpretations have the power of custom and industry practice behind them. These customs and practices, however, can deny care that children desperately need to live socially integrated and healthy lives. Amy Davidoff and coauthors in 2004 examined the difference in children’s coverage experiences when covered by Medicaid on one hand, or by private plan-mimicking SCHIP on the other, with respect to denial of access to needed services, including medically necessary ancillary services. They reported that,

Medicaid-eligible children tend not to face these concerns, in part because Medicaid explicitly covers medically necessary services not covered by private insurers. To the extent states pattern their SCHIP programs on private insurance and not Medicaid, the children lose that benefit.

The Baucus bill adds to Medicaid’s strength in this regard. At Title II, Subtitle B of the Chairman’s Mark (after the acceptance of an amendment from Senator Debbie Stabenow), a new Medicaid state plan option will permit states to offer, for children with at least two chronic conditions or one serious and persistent mental health condition,

Comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support; and referral to community and social support services, if relevant…

What of families covered by the private competitive marketplace of health insurance or SCHIP? The bills speak in general terms of the power of federal and state regulators to ensure adequate and appropriate coverage. This enforcement power should be used to ensure that coverage applies to chronic and disabling conditions as it does to run-of-the-mill medical/surgical cases. Future posts will examine some of the specific enforcement language, which will be key to the realization of the promise of reform to CSHCNs and others with chronic and disabling conditions.

Universal Health Insurance for America’s Children - Can It Happen?

It is no secret that America’s health care infrastructure leaves much to be desired.  It spends more on health care than any other country in the world, but is far from achieving the best results.  The extreme cost of care has contributed to increased rates of the un- and underinsured — climbing from 41.2 and 15.6 million in 2003 to  49.6 and 25.2 million, respectively, in 2007.

Most observers agree that the American health care system is badly broken–if it ever was intact–as evidenced by the large number of Americans without health insurance, the high and rising costs of health care, and the relatively poor health outcomes achieved for the money spent.

What might be lesser known is the degree to which lack of health coverage affects children.  In their article, Universal Health Insurance for Children, published in the Journal of Health Care for the Poor and Underserved, Hughes et al. note that despite programs designed to enhance children’s access to coverage like State Children’s Health Insurance Program (SCHIP), about 8.1 million children were a part of the uninsured population in 2007.  Confusion about eligibility is often cited as a reason many children — over 80% of low income uninsured children - who are eligible for coverage do not have it.

Children’s health insurance status helps predict whether they receive needed health care and provides a critical means for identifying and addressing their health problems early in life… Children  who experience unmet health problems are more likely to miss school, to incur high costs for medical care, and to have parents miss work due to caring for an ill child.

Consequences of non-coverage of children start with compromised access to health care and turn into compromises to the American economy.

Lack of insurance coverage for children not only has an immediate impact on those whose access to care is limited, but it also has social implications in terms of potential public health threats due to untreated communicable diseases, higher health care costs for end-stage treatment, and consequences for the economy in terms of productivity and high insurance costs to businesses.

It has been well documented that providing health insurance coverage is cheaper than paying for the consequences associated with the alternative, but America has been resistant to providing universal coverage.  Providing coverage specifically for children, on the other hand, has been met with less resistance.

The social and individual benefit of extending preventive care and health insurance to children, however, is somewhat less contentious [than providing insurance to adults], largely because children are viewed more sympathetically than adults by health care leaders and the American public.

Hughes et al. argue for immediate universal coverage for children, rather than waiting for universal coverage for the country as a whole and note that it would have to occur at the federal, as opposed to state and local, levels.  They make two recommendations for achieving this goal.

One option is to create a Medicare-like federal program under which all children are automatically enrolled in a comprehensive insurance program, regardless of income. By and large, Medicare works well for seniors and is a reasonable model for children. Another option involves modifying Medicaid, SCHIP, and other categorical programs to create a uniform insurance program for low-income and undocumented children that eliminates the confusion and complexity associated with multiple programs. Both options would require sufficient minimization of paperwork and reimbursement to providers to ensure that coverage translates into genuine access to care.

Hughes et al. point out that most Americans support universal coverage, especially for children, despite the added tax burden it may cause.  This is probably a sentiment reflecting the reality of the extreme cost and gross inefficiency of the American health care system.  As children constitute a categorically vulnerable population which affords them the sympathy of the country, it makes sense to begin the road to universal health care in this country with them.  The vast majority of taxpayers are willing to foot the bill and we have an administration ripened to bring about such a change.  If ever there was the time to begin the process of providing universal health insurance to children in America, it would be now.

ABC Special Highlights the Need for Education After SCHIP Expansion

ABC aired A Hidden America: Children of the Mountains last Friday with host Diane Sawyer. Children of the Mountains follows the lives of several children growing up in Central Appalachia.

The special raised several crucial issues, but I was struck by the lack of healthcare available to Appalachian children. Sawyer reported that a diet consisting of high-fat, salty foods and massive amounts of soda pop, particularly Mountain Dew, are responsible for a range of adverse childhood and adolescent health conditions.

One of the most serious health conditions addressed by Children of the Mountains is toothlessness. Sawyer explored how the consumption of large quantities of sugary sodas like Mountain Dew causes extensive cavities and tooth decay. Additionally, Appalachian children experience a lack of resources and health insurance coverage that surpasses that of many other low-income Americans.

The expansion of the State Children’s Health Insurance Program signed into law by President Obama last month requires all states to provide dental care to enrollees. While this is encouraging in light of the serious deficiencies in the availability of dental care to Appalachian children, The Kaiser Family Foundation reports that in 2004, 5.4 million uninsured children were eligible for SCHIP or Medicaid but not enrolled.

Read more

In the Wake of Daschle’s Withdrawal, Obama Signs Bill to Expand SCHIP Coverage

President Obama signed the bill extending health coverage to millions of low-income children yesterday after it the House gave final approval, according to The New York Times. Many see this as a signal of the president’s clear intention to guarantee coverage for all Americans.

Since August 2007, the House has voted at least seven times for legislation to expand the popular State Children’s Health Insurance Program. In a recent blog we explained how Former-president George W. Bush twice vetoed similar legislation. Bush adamantly opposed the legislation on the ground that it would lead to “government-run health care for every American,” reports The Times.

Rep. Henry A. Waxman, a California Democrat said that the bill was “a down payment” and “an essential start” to the ultimate goal of health reform. Speaker Nancy Pelosi proclaimed the passage and signing of the bill as the result of the last fall’s historic presidential election, stating:

“This is the beginning of the change that the American people voted for in the last election, and that we will achieve with President Barack Obama.”

One of the major features of the bill is that it allows states to cover certain legal immigrants, who are currently barred from Medicaid and the State Children’s Health Insurance Program for five years after they enter the United States.

Read more

Bill Before Congress Would Extend Health Insurance to Children of Legal Immigrants Sooner

The New York Times reports that Congress will likely pass a bill to provide health insurance to millions of low-income children. Similar legislation was twice vetoed by President Bush in 2007.

Under the proposed legislation, states would have the option to restore health insurance benefits to legal immigrants under 21 as well as pregnant women. Currently, legal immigrants are barred from Medicaid and the State Children’s Health Insurance Program for the first five years after they enter the United States.

It is estimated that 400,000 to 600,000 immigrant children are affected by the restriction currently in place. The Times notes that:

Among children, legal immigrants are less likely to receive immunizations and routine dental care.

and

[A]mong women, legal immigrants are less likely to receive prenatal care.

Opponents of the bill argue that the original purpose of program-to serve the children of the working poor-has not been fulfilled, raising concerns about extending it to legal immigrants and others groups not originally contemplated.

Others argue that the expected costs of the bill would be too great. The program currently covers about 6.6 million children and costs the federal government $5 billion a year. The Times estimates that the passage of the bill could double the annual expense of the program. The expanded program proposed by the new bill would be financed by tobacco taxes.

President-elect Obama has already expressed his support for allowing states to offer health insurance to legal immigrant children before the five-year waiting period is met.

Generally, the bill is garnering significant support from various sectors. Many people feel that all children should have health insurance. There is great support for this proposition as well. By extending health insurance to more children including legal immigrants, not only will children in need of care be provided for, but by providing greater access to preventive care, states will reduce overall health care costs .

Will Specialist Pay Be a Target of Health Care Reform?

Health policymakers are well aware of the pay differential between primary care and specialist physicians. Given this disparity, it’s important to recognize how the divergence arose. To the extent that training programs are limited for each specialty, that’s a natural barrier to entry that is hard to remedy without a great deal of investment in specialist education–or broadening of medical education generally. However, Ezra Klein quotes a comment on his blog which suggests a more artificial basis for specialist prosperity:

Specialist salaries aren’t just determined– they are based on volume of procedures and payment rates for their procedures. The “best” specialties are fluid, as are the best salaries (with exceptions, like Neurosurgery) primarily because physician payment reform is not keeping up with the changing practice of medicine.

Specialties typically have a couple of bread-and-butter procedures that change based on changes in technology, diagnosis and clinical practice. Typically, these bread-and-butter procedures start small, are paid well per procedure, and physician groups figure out out they do a ton of those procedures to drive salary.

Opthamologists used to make a lot more money than they do now. Why? Because cataract surge[ons] used to get paid a lot more [two to five times more per case than they is paid presently]. These docs figured out how to be more efficient so they could do more cases per day, and it takes a while for payors to say– you’re doing one every 20 minutes instead of every 90? Then we’re cutting back fees accordingly. In the meantime, Ophthalmologists rake it in and are a “top” specialty for medical students.

Eventually, payors and Medicare figures things out and start putting pressures on rates. But it takes a while. The same story is now true for Gastroenterologists, Radiologists and Dermatologists. Radiology was one of the easiest fields to get into 15 years ago. You work in the dark, have little contact with patients, its frankly a weird field for people who went into medicine looking to help people. You used to have a couple of nerdy introvert types who liked being in the dark that chose the field. Now because of the explosion of imaging, and practice efficiency, these guys are reading 3x the images they did 15 years, and making three times as much.

Payments will eventually come down for them too. But in the meantime, Radiology is now one of the hottest fields for medical students. Fixing this perverse dynamic is a key question. PS: General surgeons are the wrong specialty to pick on. What specialty has had vacant spot in the residency matching process the last few years? General surgery. Its a pretty tough life– in terms of lifestyle impact, they deserve the $75-100K more than the P[rimary Care Physicians]. It’s the Radiologists and Dermatologists that have PCP hours but are making 300-400K that are the problem.

This strikes me as a step toward the truth, but it raises as many questions as it answers. After following Medicare’s struggle from 2005 to 2008 to update rates paid for out-patient procedures performed at ambulatory surgical centers, I can attest to the slowness of federal updating. (There may have been a lag from 1990 to 2008 if I am reading the rulemaking documents correctly there.) Meanwhile, private insurers may not have the purchasing power needed for foist an adjustment on thriving specialists. If specialists are coordinated or powerful enough, they can refuse to be part of a network–and that refusal can be more harmful to the network than to the specialists.

But one of the key questions here is how did the specialists increase the volume of the procedures they were able to complete? We can sketch two scenarios schematically. In one, exogenous technological change simply makes it easier to do more procedures more quickly. In another, innovation by specialists themselves makes their practices more efficient. It seems that payment systems ought to reward the latter type of efficiency gains.

Pondering the difficulty of distinguishing between these two types of efficiency gains may make one long for a more normal market determination of the price of physicians here. However, the idea of a “just wage” has to enter into policymaking. Pay should be reasonably correlated with the amount of work the physician puts in each week, the value of the services rendered, and the investment of time and money the physician put into her or his training. But when inequality is pronounced and a large proportion of citizens is dependent on public aid for their care (as in virtually every developed country in the world, including the US), the pay of physicians must reflect that fact as well.

I predict that the specialist pay conundrum will only be solved by carrots and sticks that lead to compression of physician incomes and life chances generally: greatly increased educational aid to physicians (so that they can be debt free at the end of their schooling), balanced by lifelong obligations to either take on a percentage of Medicare, Medicaid, and SCHIP patients, or pay others to take on their share.