Below, a guest post from HealthBeat reader and blogger, Dr. Chris Johnson. Formerly the head of the pediatric intensive care unit at the Mayo Clinic, Johnson is the author of Your Critically Ill Child and blogs at www.chrisjohnsonmd.com.
When you read his post, it is worth remembering that a larger share of U.S. children live in poverty than in any other nation in the developed world.
We have known for a long time that poverty is associated with illness. Tiny Tim did not die at the end of Dickens’ Christmas Carol. The reason he lived was because, just in time, Scrooge had an epiphany and raised the Cratchit family’s standard of living. That Christmas goose brought more than good cheer to the Cratchits — it brought good health, too. Some historical studies, such as those of Thomas McKeown, have linked the long population rise of the past century to improved nutrition. Experts still debate if this is true or not, but either way it is old news.
It may be old news, but for today’s Tiny Tims it is still very much current news. The furious debates over what to do about health care reform are often about choice — what choices Americans should have selecting their health care, what choices doctors should have in providing it, and what choices society has in paying for it. I take care of children, so that is the lens through which I see the issue. And children have no choice at all in this matter, because the family they are randomly born into determines everything, even if they will live or die. Across America we have constructed what are, in effect, a series of laboratories to test the results of what happens when different sorts of children get severely ill. These laboratories are pediatric intensive care units.
Poor children are far more likely than affluent children to end up in a PICU. The simplest indication of this is to look at the proportion of children in PICUs who are on Medicaid: it is generally at least half, often more. Yet the proportion of children in the general population who are on Medicaid is roughly a third. Why is this? Why are poorer children more likely to become critically ill or injured?
One reason is that pregnant woman who are poor are more likely to deliver prematurely, and former premature infants have a high prevalence of residual medical problems, things which often lead to future PICU admissions. Thus more premature births equals more PICU admissions. Another reason is that, because of low reimbursement rates for providers, it is often hard for a child on Medicaid even to find a doctor. So children with chronic problems, such as asthma or diabetes, often cannot get the kind of good routine care that would keep them out of the PICU. These reasons are straightforward, ho-hum, so obvious we have become inured to their implications. (Though we should not be.)
If we dig deeper, though, we find other disturbing possibilities. For example, a study by Evans and Kim on the physiological effects of poverty found that poor children have chronically high levels of stress hormones that correlated with the length of time they were in poverty. Adolescents who were recently poor did not show these findings; what mattered most was the duration of poverty. We know childhood poverty is strongly associated with poor health as an adult, and this may be one of the reasons. Even if a poor child somehow later breaks through to affluence, the health effects linger on.
Thankfully, evidence shows that once children on Medicaid who need a PICU get there, they get the same level of care and have the same outcomes as children with private insurance. That is reassuring; poor kids on Medicaid do not get second-class care and have the same risk of mortality as the affluent ones. However, the research uncovered a very disturbing finding — children without any insurance at all were more likely to die. Why? Because they were sicker when they first arrived in the PICU, undoubtedly because their parents feared to bring them to the doctor. Because of our current dysfunctional on-system, the parents waited, and their children died as a result. Personal anecdotes are not research, but I have thirty years of them saying the same thing — uninsured kids are sicker when they get to the PICU. This is entirely predictable. Of course the prospect of a massive, bankruptcy-inducing medical bill makes even the best of parents equivocate and delay when they should not.
It is fair to debate how many adults without health insurance are in that situation owing to their own choices, although I think that argument is a straw man, as is the notion that many homeless adults choose to live in boxes under bridges. But it is not fair to inflict this debate on children, who are stuck with their birth situation. Childhood poverty carries life-long health care risks, but at least Medicaid generally gets the poorest children the care they need. Denying children health care insurance, however, kills them. I find this to be obscene.
Denying children the right to exist in the first place, for usually nothing more than convenience is even more obscene.
hi all,
We all know currently more people live below poverty line compare to other country because government’s most of the package are given to big banks or financial organization but no package is given to poor people yet.
This article addresses the most obvious problem facing health care in the US: the negative effects of lack of access to health care. This is most often, but not always, related to economic status. Even conservatives concede that this needs to be changed.
In particular, in addition to providing insurance for everyone, we need to provide good insurance. High deductibles and co-pays are an important factor in making people delay health care in ways that not only harm themselves, but cost society huge amounts of money when patients present only when health problems reach a crisis. We can save billions in ICU and ER costs by making it possible for people to seek low tech intervention early in disease processes, rather than waiting until they have to seek help or die.
The comments about the impact of Medicaid programs in causing health crises for patients are also important. Medicaid as it exists needs to end. Medicaid patients should be incorporated in universal insurance reforms and get insurance through a federal insurance option or through private insurance that offers good coverage and reasonable payments to providers so that the patients can reliably access care.
but wait, don’t we already offer health insurance to these children? figures consistently show that better than 95% of kids legally in the US have access to health insurance — either employer-linked or public. so is this really about immigrant kids with status problems? or does it reflect those who have access but still lack coverage, in which case liberalizing the rules wouldn’t help very much.
It reflects the fact that for many people Medicaid does not provide access to good outpatient care because many providers won’t accept Medicaid patients, that SCHIP and other associated programs are underfunded in many states and are closed to admission and again underpay providers, blocking access, and that there are a lot more kids out there who don’t get health care than people think.
The data collected by the Pediatric Society and the experience of people like Dr. Johnson say a lot more about the real state of affairs in children than the data collected by the Bush administration. In my own state, the governor effectively has blocked the expansion of health care to kids that SCHIP is supposed to provide by failing to provide the state funding required. In years past he actually looted the fund for low income health care — in the process losing nearly $100 million in federal matching dollars — in order to provide extra money to stop from having to raise taxes on high income people.
By coincidence, this is the same “liberal” state where Dr. Johnson worked. Conditions are actually much, much worse elsewhere — for example take a look at the latest go round in Texas, where the governor has pushed for cuts in what is already a poor state program for kids.
In the end, if you are poor in the US, most of the health care access you get is through the ER.
Jim:
In my experience it is usually a child in a family in which the parents make too much money to qualify for Medicaid. The eligibility rules vary from state to state. States are required to enroll children in families at the federal poverty line. Many states allow enrollment if a family makes more than that, but the threshold varies — some states are more generous than others.
The examples I’ve seen lately are from families in which the parent(s) lost a job with benefits and COBRA is far too expensive for them.
Sometimes families just don’t know about Medicaid. We can get these kids enrolled after they are admitted to the PICU and then they are covered for the whole illness. But there are plenty of times we can’t.
Here are some data from the US Census Bureau about numbers of uninsured children from families at twice the poverty line or lower, although of course one can’t tell the reason from the table why they have no insurance.
http://www.census.gov/hhes/www/hlthins/liuc07.html
Jim–
Florida, among other states, capped SCHIP enrollments and put a huge number of children who quaified for SCHIP on a waiting list.
When the media publicized this fact, Florida agreed to cover the kids on the list at the time–and then abolished the list, so that, in the future, no one would know how many kids who qualified weren’t covered.
At the same time, Florida made it much, much more difficult to apply for Schip–narrowing the fime frame when new applicants to apply, and forcing them to re-apply every year, coming up with new documentation each time.
Pat S. is right– the Bush administration’s numbers on children who have access to insurance are bogus.
Jim Jaffe: ….figures consistently show that better than 95% of kids legally in the US have access to health insurance…
a) what figures? can you refer me to some?
b) how many kids “with access to health insurance”, actually have health insurance? What does “access” mean in this statement?
c) for how many of the kids who actually have health insurance, does that insurance reasonably cover both routine and emergency or catastrophic care?
I “have access to” a truly fine steak and seafood restaurant. Funny, I don’t seem to be buying a lot of steaks lately…
Noni
have you gotten involved in http://www.speaknowforkids.org... you should!
Noni-
You are right– there is insurance and there is insurance.
Many families are covered by cheap high-dedcutible policies that they can’t afford to use.
And many policies don’t cover the things kids need. . .
“Having insurance” and “having healthcare” are not synonymous.