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Children’s Health Care Reform:
Thinking Outside the CHIP Box
Ana M. Malinow, MDBaylor College of Medicine Texas Children’s Hospital
Grand RoundsJune 27, 2008
Objectives
• Identify the role of employer-sponsored health insurance and public insurance in children
• Describe the medical consequences of being uninsured
• State sustainable alternatives to the current health care system
“Every system is perfectly designed to achieve exactly the results it gets.”
DM Berwick
Source: Stan Dorn, Bowen Garrett, John Holahan, and Aimee Williams, Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses, prepared for the Kaiser Commission on Medicaid and the Uninsured, April 2008
Impact of Unemployment Growth on Medicaid and SCHIP and the Number Uninsured
1%
Increase in National
Unemployment Rate
=1.0 1.1
Increase in Medicaid
and SCHIP Enrollment
(million)
Increase in Uninsured(million)
&$2.0
$1.4
$3.4
Increase in Medicaid and
SCHIP Spending(billion)
State
Federal
National Health Expenditures1960-2006
0
500
1000
1500
2000
2500
1960 2006Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2004; file nhegdp04.zip).
1960 2006
$28 B
$2.1 Trillion
PNHP.org
No. Nurses per 1000, ’02-’03 Bone Marrow Transplants, ’02-’03
Hospital Inpatient Days, per capita, 2003 Percent Elderly, 2003
U.S.U.S. U.S.U.S.
U.S.U.S. U.S.U.S.
PNHP.org
Life Expectancy, 2003 Infant Mortality, 2002/2003Deaths in 1st Year of Life/ 1000 Live Births
Maternal Mortality, 2002/2003Deaths / 100,000 Births
MRI Units / Million Population, 2004
U.S.U.S.
U.S.U.S.
U.S.U.S.
U.S.U.S.
http://www.kff.org/insurance/7527/upload/7561.pdf
Relying On The Market To Keep Costs Down…
Employee
0 25 50 75 100
Percent of contribution towards premium
$735/mo $273/mo
Annual Premium: $ 12,106
Employer
Minimum Wage: $ 12,168 / yr
Employer Contribution Towards Premiums for a Family of Four, 2007
Health Benefits in 2007, Claxton et al. Health Affairs 2007 (26):1407 and U.S. Department of Labor, 2007
Small or Large:Employees Aren’t Enrolling
U.S.
Small <50 Large >50Firms offering
insurance62% 96%
Employees enrolled in insurance
where it was offered
60% 63%
Source: Analysis of 2005 Medical Expenditure Panel Survey
Percent All Workers Covered by Employment HI in Firms Offering and
Not Offering HI: A 20-year US trend
66%65%
63%
62%61%
60%
59%
2000 2001 2002 2003 2004 2005 2006
Source: http://www.kff.org/insurance/7527/index.cfm
Trend in Employer-Sponsored Health Coverage for Children, 1999-2006
59.7%
60.9%61.4%61.6%
63.4%
64.4%
65.9%65.2%
1999 2000 2001 2002 2003 2004 2005 2006
Source: http://www.census.gov/hhes/www/hlthins/historic/hlthin05/hihistt5.htm
Millions of Children Uninsured, Trend from 1987 to 2006
0
2
4
6
8
10
12
1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Source: http://www.census.gov/hhes/www/hlthins/historic/hlthin05/hihistt5.htm
Trend in Public Health Insurance for Children, 1999-2006
20.9%20.3%
22.7%23.9%
26.4% 27% 26.7% 27.1%
Source: http://www.census.gov/hhes/www/hlthins/historic/hlthin05/hihistt5.htm
1999 2000 2001 2002 2003 2004 2005 2006
Trend in Uninsured Children, Employer-Sponsored HI and Public HI,
1999-2006
05
10152025303540455055606570
Employer-Sponsored
Public
Uninsured
1999 2000 2001 2002 2003 2004 2005 2006
Source: http://www.census.gov/hhes/www/hlthins/historic/hlthin05/hihistt5.htm
Coverage of Recent Enrollees in SCHIP During 6 Months Before
Enrolment, Ten States, 2002
29%
43%
28%
Uninsured
PrivateInsurance
Medicaid
Source: Health A Sommers et al., Substitution of SCHIP for Private Coverage: Results From A 2002 Evaluation in Ten States, Health Affairs, March-April 2007, Vol. 26, No. 2: 532
Major Reasons for Lack of Health Insurance Coverage Among
Adolescents: U.S., 1995Reasons Percent Standard
Error
All main reasons 100
Too expensive, cannot afford HI 72.5 1.8
Job layoff, job loss, reasons related to employment
12.2 1.3
Have been healthy, not needed HI 3.3 0.5
Cannot obtain b/c poor health, illness, age
1.7 0.4
All other reasons 10.4 1.2
Source: P Newacheck et al., Adolescent Health Insurance Coverage: Recent Changes and Access to Care, Pediatrics Vol. 104 No. 2 August 1999
70%60%
30%40%
Medicaid CHIP
State
Federal
Federal and State ContributionTo Medicaid and CHIP
Source: www.kff.org
Income Eligibility for Medicaid in Texas as a %FPL
221%
30%14%
74%
100%
133%
185%
0-12 mos 1-5 yrs 6-19 yrs SSI Non-workingparents
Workingparents
>65 yrs LTA
Source: Kaiser Family Foundation, www.statehealthfacts.org
100%FPL=$20,650Family 4
Income Eligibility for Medicaid in Texas and Massachusetts
185%
133%
100%
74%
14%30%
200%
150% 150%
74%
133% 133%
0-12 mos 1-5 yrs 6-19 yrs SSI Non-workingparents
Workingparents
Texas Mass
Source: Kaiser Family Foundation, www.statehealthfacts.org
Distribution of Total Population by FPL, 2004-05 (state), 2005 (US)
Texas
%
Mass
%
U.S.
%
<100%FPL 22 14 17
100-199% 21 16 19
Low Income
43 29 36
200%+ 57 71 64
www.statehealthfacts.org
Income Eligibility for S-CHIP in Texas as a %FPL
Source: Kaiser Family Foundation, www.statehealthfacts.org
185
133100
0
20
40
60
80
100
120
140
160
180
200
0-12 m 1-5 y 6-19 y
CHIP
Medicaid
200% FPL $41,300Family of 4
Total Annual Household Income and Federal Poverty Level
Texas Mass U.S.
Total Median 2004-06 Annual Household Income www.kff.org
$43,425 $56,236 $46,071
200% FPL family of 4, 2007Dept of US Health and Human Services
$41,300 $41,300 $41,300
100% FPL family of 4, 2007
$20,650 $20,650 $20,650
Minimum Wage $5.85/hr or $7.50/hr
$12,168 $15,600 $12,168
Ave. Annual HI Premiums for Family of 4, 2007
$12,106 $12,106 $12,106
Trend in Percent Uninsured Children in the U.S., 1999-2006
12.1%11.2%11.2%11.4%11.6%11.7%11.9%
13.9%
1999 2000 2001 2002 2003 2004 2005 2006
Source: http://www.census.gov/hhes/www/hlthins/historic/hlthin05/hihistt5.htm
9.4 M
Percent Distribution of Length of Time Since Last Contact with Health Care Provider for Children Under 18 Years
77
167
78
169
51
2227
< 6 mos 6-12 mos > 1 year
Length of Time
Private
Mcaid
Uninsured
Source: National Health Interview Survey, 2006. Estimates based on household interviews of a sample of civilian/non-institutionalized population. Vital Health Statistics 10. 2007 Sep; (234):37
Age-adjusted Percentages of Not Having a Usual Place of Care and
Multiple Visits to the ER
23.5
26.2
6.4
10.47.4
Private Mcaid Uninsured
No usual place of care
>2 visits to ER
Source: National Health Interview Survey, 2006. Estimates based on household interviews of a sample of civilian/non-institutionalized population. Vital Health Statistics 10. 2007 Sep; (234):41
Percentage of Children With Unmet Medical Needs and Delayed Care due to Cost, 2006
1.3 1.9
12.4
2.33.5
16.9
Private Mcaid Uninsured
Unmet Medical Need
Delayed Care due toCost
Source: National Health Interview Survey, 2006. Estimates based on household interviews of a sample of civilian/non-institutionalized population. Vital Health Statistics 10. 2007 Sep; (234):39
Percentage of Children with More than 5 Years Since Last Dental Visit
Source: National Health Interview Survey, 2006. Estimates based on household interviews of a sample of civilian/non-institutionalized population. Vital Health Statistics 10. 2007 Sep; (234):45
27%
14%11%
Private Mcaid Uninsured
Likelihood of Hospitalization After an Injury by Coverage Type
n=1847 injuries in children <18 yrs.
Telephone Call Only Hospitalization
Insurance
Type
Adjusted OR
95% CI Adjusted OR
95%
Private 1.29 0.45-3.72 2.21 0.73-6.63
Medicaid Ref Ref
Uninsured 0.69 0.08-6.33 4.07 1.13-14.66
S Hostetler et al., Health Care Access After Injury by Insurance Type in a Pediatric Population, Pediatric Emergency Care Vol. 21 (7) July 2005 National Health Interview Survey 2000,01,02
Select Population-Based Hospitalization Outcomes by Insurance Status for Children in the U.S., 2000
Measure Rate per 100,000 Relative Risk (95% CI)
Public or None
Private
All hospitalizations 4012.8 2904.2 1.92 (1.91 to 1.92)
Hospitalizations via ER
1948.8 860.9 2.26 (2.25 to 2.27)
Chronic disease 602.6 274.4 2.20 (2.18 to 2.21)
Asthma 227.2 96.0 3.37 (2.34 to 2.40)
Vaccine-preventable disease
30.8 13.9 2.25 (2.18 to 2.33)
Psychiatric disease
328.4 155.9 2.11 (2.09 to 2.13)
Mortality rate 18.7 7.9 2.38 (2.27 to 2.48)
2,378 excess deaths
Ruptured appendix, %* (35.2) (27.6) 1.25 (1.23 to 1.28)
Charges, per insured per year**
(466)
(10,165 M)
(224)
(11,301 M)
2.08
$5.3 billion excess charges
Source: J Todd et al., Pediatrics Vol. 118 No. 2 August 2006, 577-585 •percentage of appendicitis cases ruptured•** Total charges/T # children in each groupKids’ Inpatient Database from the Healthcare Cost and Utilization Project for the year 2000.
Percent of Children with Insurance Discontinuities and Unmet Needs,
2000 and 2001
Source: L Olson et al. NEJM 353:4 July 2005
0
5
10
15
20
25
Delayed Care UnmetMedical Care
UnfilledPrescriptions
Full-Year Uninsured
Part-Year Uninsured
Full-Year Insured,PublicFull-Year Insured,Private
Medical need was delayed for the child because of worry about the cost.The child needed but did not receive medical care because the family could not afford it.The child needed but did not get prescription medicine because the family could not afford it.
Pr
NHIS 2000-01
As Health Care Costs Rise…
• Employer-sponsored coverage (ESC) decreases
• In the past, an increase in public HI has offset negative effects of loss of ESC among children
• Recent loss of ESC has been among those >200%FPL, not eligible for public HI
• Uninsured rates among children will increase
• Lack of insurance among children results in:– Greater rates of unmet
medical needs, delayed care, unfilled prescriptions
– Greater likelihood of hospitalizations
– Greater likelihood of multiple morbidities
– Greater likelihood of mortality
– Greater increased health care costs leading to…
Proposed Reform Measures
• Individual mandates
• Employer mandates
• Expansion of Medicaid and S-CHIP
• Tax credits, CDHP, HSA
• “Medicare-like” public program to compete in the market with private health insurance
• Single payer— “Improved and Expanded Medicare For All”
Support for Governmental Legislation to Establish NHI, 2007 and 2002 by Specialty
Source: A Carroll and R Ackerman, Support for National Health Insurance Among American Physicians: Five Years Later. Annals of Internal Medicine April, 2008
59% Support NHI
If you had $2.1 Trill?
What Health Care System is Worth $2.1 Trillion?
UniversalAffordable
AccountableAccessible
ComprehensiveHigh Quality
EquitableResponsibility of the federal government
“Health care in the Western world has an unprecedented opportunity to improve… for the first time in history, to generate a social consciousness that our precious systems of care are not achieving what they could and should. Daylight has arrived. What we do with that opportunity will depend on the theory on which we act…invest in a workforce of imaginative, inspired, capable, and (dare I say it) joyous people, invited to use their minds and their wills to cooperate in reinventing the system, itself… because of the meaning it adds to their lives and the peace it offers in their souls.”
DM Berwick
