Access is a major problem in the US:
GREENSBORO, N.C. — During the four years that her children were
uninsured, Cassie O. Hall used the emergency room as their
pediatrician. When Tayana had an asthma attack or Darren developed a
stubborn rash, they would head to the hospital and settle in for a
long wait.
Cynthia Neely was surprised to learn that her son, Anthony, was
eligible for coverage.
The children never got physical exams or booster shots. And as the
unpaid hospital bills stacked up, the threshold for a visit grew
higher. “They would have to be half-dead before I would take them,”
said Ms. Hall, a day care operator who could not afford private
insurance.
It was only in May that Ms. Hall learned that her family qualified for
the State Children’s Health Insurance Program, which provides
subsidized insurance to children of the working poor. That she had
never heard of the joint state and federal program made her typical of
countless parents of the estimated eight million uninsured children.
Despite a decade of marketing efforts by governments and private
foundations, nearly 30 percent of children who are eligible for the
health insurance program and are not covered by private plans have yet
to enroll, according to a new government study.
Late last week, the Bush administration published new standards
intended to prevent states from expanding eligibility for the program
to cover children from middle-class families. But a more fundamental
debate over the program has been raging in Washington for months: how
to find and enroll the 1.7 million low-income children who are already
eligible but have not signed up.
That hard-to-reach population is the focus of a showdown over
reauthorizing the 10-year-old program, the largest single extension of
government-subsidized health insurance since the Great Society health
initiatives of 1965.
The challenge of enrolling those already eligible demonstrates how
difficult it will be for states to meet the new standards. The policy
says that states can expand eligibility only if they have first
enrolled 95 percent of those who now qualify. Few states have come
close to doing that; the national enrollment rate in 2004-2005 was 72
percent, according to the study.
The Democratic-controlled House and Senate passed varying bills
earlier this month that would vastly increase financing for the
program, which expires on Sept. 30. Almost all of the new money would
be dedicated to finding and covering children who are already
eligible.
The federal government shares financing for the program with the
states, picking up about 70 percent of total costs. The Senate measure
would add an average of $7 billion a year to the $5 billion currently
being spent. The House version is even richer, adding an average of
$10 billion a year for five years.
President Bush, who proposed a much smaller increase of $1 billion a
year, depicts both measures as a major step toward nationalized health
coverage and has vowed to veto them.
Administration officials warn that the expansion envisioned by
Congress would transform the program into a broad entitlement. Many
families, they predict, would cancel private insurance in favor of
government coverage (one study found that 14 percent of enrollees
did).
Though eligibility varies by state, the 6.6 million children covered
by the program typically come from families between 100 percent and
200 percent of the poverty level (between $20,650 and $41,300 for a
family of four). Another 29.5 million children, most living below the
poverty line, are covered by Medicaid. Studies have found that about
two-thirds of all uninsured children are eligible for one of the two
programs.
There is little dispute among experts that the program has been
instrumental in reducing the rate of uninsurance among low-income
children by almost a third, even as the rate for adults has climbed.
About 16 percent of children from families with incomes below 200
percent of the federal poverty level were without insurance in 2005,
down from 23 percent in 1997, according to a federal government
analysis.
But the persistence of so many children without insurance frustrates
both policy experts and frontline social service workers.
“We’ve beat the bushes every which way but loose to find these kids,”
said Janice G. Cardin, the supervisor here in Guilford County for
North Carolina Health Choice, as the state’s program is called. “But
we know there are still a lot of them out there.”
In this county, as across North Carolina, outreach workers are once
again distributing fliers as school starts. They have used radio
advertisements and refrigerator magnets, and have partnered with
minority groups like Lumbee Indians and Hmong refugees.
They have staffed tables at health fairs and plants that are shedding
workers. They have eliminated waiting periods, simplified application
and income verification procedures, and provided translators to
immigrants.
And yet, the rate of children without insurance in the state recently
reversed course and began rising, to 12.5 percent in 2005 from 10.6
percent in 2004, according to the North Carolina Institute of
Medicine. Though the Health Choice program now covers about 113,000
North Carolina children, the rate of uninsurance today is the same as
in 1999.
Researchers at the Urban Institute, an independent group that studies
economic and social issues, recently calculated that 5.4 million
children nationwide were uncovered at some point each year despite
being eligible for government insurance. The nonpartisan Congressional
Budget Office endorses the calculation.
But the Bush administration has embraced a finding by a different set
of Urban Institute researchers that only 1.1 million children fall
into that category, a figure based on those without insurance for an
entire year.
“My perspective is that all states have been extremely successful,
which is why we have so few left who are eligible but have not been
found,” said Dennis G. Smith, director of the Center for Medicaid and
State Operations.
As it is, administration officials say, the creation of the program,
along with increased use of Medicaid and a decline in employer-based
coverage, has resulted in a significant shift to government insurance.
Forty-five percent of all children were covered by the insurance
program or Medicaid in 2005, up from 28 percent in 1998, according to
the Health and Human Services Department.
They are families like the Neelys of nearby High Point, N.C., a city
still recovering from losses in its textile and furniture industries.
After 15 years as an account manager for American Express, Cynthia L.
Neely found herself laid off last December, and her husband could not
afford his employer’s insurance.
Ms. Neely said she was relieved and surprised to learn this month that
her 8-year-old son had qualified for Health Choice.
“I’ve worked since I was 15 and I never thought I would need this,”
she said. “I always thought if you had any income at all in your
household that you wouldn’t qualify.”
That misconception is among the obstacles to signing up children of
working parents. For Hispanic parents, there may be barriers of
language and immigration status. In other instances, parents may
struggle with the stigmatizing perception that they might be taking
welfare.
The Bush administration complains that many states have distorted the
original intent of the program by raising eligibility limits to as
high as 350 percent of poverty (New Jersey, with New York seeking
federal approval to go to 400 percent).
Enrollment in the program grew rapidly in its early years, but slowed
in 2003 and dipped briefly in 2004 before recovering the next year.
Various studies have blamed state budget cuts for the slowdown, which
prompted some states to restrict eligibility and make enrollment
cumbersome. In North Carolina, budget-cutters temporarily froze Health
Choice enrollment in 2001. In Texas, where one of every five children
is uninsured, officials began requiring parents to requalify for the
program every six months rather than annually.
But as fiscal pressures eased in the last two years, states have
revived efforts to increase enrollment through measures like allowing
applicants to mail in forms and requiring less documentation of
income. |