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Report documents importance of parents to children's health coverage
As members of Congress considered whether to expand the SCHIP program when it is reauthorized, the George Washington University Medical Center School of Public Health and Health Services and First Focus, a bipartisan advocacy organization for children, released a report demonstrating that children benefit greatly when their parents have health care coverage.
According to report authors Sara Rosenbaum and Ramona Perez Treviño Whittington, the enrollment of parents in public insurance programs such as SCHIP results in greater participation by their children, as well as improvements in the continuity of the child's health coverage. The report also says parental coverage appears to be associated with a more effective use of the child's health care coverage.
"Offering coverage for parents, especially low-income parents who are extensively uninsured and who may have significant unmet health needs, appears to operate as an incentive for families to both seek and use coverage," the authors said. "Low-income parents who are uninsured have significantly reduced rates of health care use and coverage of parents appears to offer an important strategy for increasing access to and use of appropriate health care. Like other parents, low-income parents who enroll in coverage also seek benefits for their children."
The report analyzed research published since 2000 that explored the relationship between public health insurance coverage of parents and the rate and effectiveness of coverage among children.
The authors said that the 10.9 million parents who were uninsured in 2005 comprised nearly 25% of the more than 46 million uninsured persons that year. Among 20.4 million low-income parents, 37% lacked coverage, 36% had employer-sponsored coverage, and 27% had coverage through Medicaid or another source of public financing.
"There is broad agreement that diminished health insurance coverage among nonelderly adults is a cause for concern," they wrote, "in view of the individual and communitywide effects of high uninsurance rates."
The report says the line between direct coverage and coverage subsidies has become increasingly blurred, and what remains is a clear desire across the political spectrum to improve coverage of adults. Given that desire, the authors said, the fundamental policy question appears to be not whether to publicly subsidize coverage for low-income parents but instead how to finance and structure the subsidy, whether through tax expenditures or direct financing. Another policy question is how high up the family income range public subsidies in whatever form should reach.
The report said Medicaid and SCHIP offer parallel pathways to expand public insurance coverage of low- and moderate-income children. In the context of SCHIP reauthorization, it said, the question is whether to carry the parallelism where children are concerned into the parental coverage arena. "The answer to this question," the authors said, "lies at least part in a decision as to whether covering parents actually represents sound child health policy. Some have argued that coverage of parents is not only good for parents, but furthermore that extending coverage to parents promotes not only coverage of children but also the more effective use of coverage in terms of increased access to care and a greater use of appropriate care. It is because of this assertion regarding the beneficial pediatric effects of family coverage that the case for creating parallel coverage flexibility under both Medicaid and SCHIP has arisen."
The authors report that all studies they examined showed positive coverage effects on children from parental coverage. There were no studies suggesting that covering parents diminishes coverage for children. Because the proportion of eligible but unenrolled low-income children is so high, the authors contended, the issue is the significance of the coverage gains for children, not whether states that cover parents do so by diminishing coverage for children.
The authors said one approach under SCHIP might be to allow states that meet child coverage milestones to apply their remaining SCHIP allotment funds toward parental coverage. In that way, children would remain the principal beneficiaries of reform, while states that wish to do so could apply the balance of their allotments toward expanded coverage of parents at a preferred federal rate. Another possible approach would be to permit use of SCHIP allotments for parental coverage by states that achieve national children's coverage benchmarks through Medicaid expansions at the regular federal matching rate.
Universal participation essential
Meanwhile, Commonwealth Fund assistant vice president Sara Collins testified at a June Senate Budget Committee hearing on the need for universal health insurance.
"The U.S. health care system performs poorly relative to other industrialized nations and relative to achievable benchmarks for health outcomes, quality, access, efficiency, and equity," Ms. Collins said. "In addition, where you live in the United States matters greatly in terms of access to care when it is needed, the quality of that care, and the opportunity to lead a healthy life. A major culprit in the inconsistent performance of the nation's health system is that we fail to provide health insurance to nearly 45 million people and inadequately insure an additional 16 million more. Universal coverage is essential to placing the system on a path to high performance."
Referring to the Commonwealth Fund's National Scorecard on U.S. Health System Performance, that preceded the just-released state scorecard, Ms. Collins reported that out of a possible 100 points based on benchmarks that have been achieved here or in other countries, the United States received a score of 66, a full one-third below benchmark levels of performance. The United States scored particularly poorly, she said, on indicators of efficiency, with wide variation in cost and quality across the country and with much higher spending levels than other countries.
Thus, the United States ranks 15th out of 19 countries on mortality from conditions "amenable to health care" and ranks last on infant mortality.
"Universal participation is essential for dramatic improvement in health care outcomes as well as overall performance of the U.S. health system," she said.
According to the testimony, universal coverage is essential to achieving a high performance health system. It is critical, Ms. Collins said, that the entire population be brought into the health care system in a way that ensures timely access to care across the full length of people's lives. Uninsured and underinsured patients and the doctors who care for them are far from able to obtain the right care at the right time in the right setting, she declared. Uninsured patients are more likely to receive wasteful and duplicative care because of a lack of care coordination. Quality and effectiveness measurements will not be meaningful, she cautioned, unless those measures reflect the experience of a fully and continuously insured population and the work of providers who care for them. And it will be impossible to realize efficiency in the operation of provider institutions and financing arrangements in the presence of billions of dollars in uncompensated care now paid for through pools of federal, state, and local government revenues and a highly uncertain amount of cost-shifting to other payers.
Evaluating reform proposals
Ms. Collins told the senators that key questions to consider in evaluating health reform proposals include:
"The majority of recent proposals at both the federal and state levels build on the current system by connecting public and private insurance to ensure more coherent and continuous coverage over a person's lifespan," Ms. Collins testified. "A framework for such an approach would create a new group insurance option similar to the Federal Employees Health Benefits Program, with income-related subsidies for the purchase of coverage; expand Medicaid and SCHIP for lower-income families; and expand the Medicare program for older adults. It would require employers to offer coverage or pay into a fund and require individuals to obtain coverage."
An alternate framework, she said, might include a more substantial role for Medicare. All uninsured people, people with private individual coverage, and most Medicaid beneficiaries would enroll in Medicare. Employers would pay 80% of their employees' premium, and workers would pay 20% of the premium. Employers could opt out if they elected to provide an actuarially equivalent benefit. Individuals could not opt out. The program would subsidize both premiums and cost-sharing for families living below 500% of the federal poverty level.
"Ultimately what is needed to move the health care system to high performance is a coherent set of policies with goals and properly aligned incentives that move all participants in the system in the same direction—toward improving access, quality, equity, and efficiency for everyone," Ms. Collins concluded. "It is critical that all adults and children are able to fully participate in a health care system that is well organized and is based on incentives that ensure that everyone receives the right care, at the right time, and in the right setting over their lifespan. It will not be productive in the long run if we focus overly on the impact of reform policies on the federal budget, or on the budgets of major corporations, or even the impact on our families' budgets. Instead, we can only move forward when we keep our eye on the number that really matters: the $2 trillion that we spend as a nation on health care each year. This ultimately determines the size and growth of all participants' budgets and should be the focal point of our collective energies as we develop coherent, consistent, and equitable health care policy."
Download the GWU report at www.gwumc.edu/sphhs/healthpolicy/chsrp/downloads/Parental_Health_Insurance_Report.pdf. Download the testimony at www.commonwealthfund.org/publications/publications_show.htm?doc_id=494551.