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Hush little baby, don't get sick.

With many working poor families unable to afford a doctor for their children, some states have taken the lead in this special area of health care.

It's the pediatrician of forced choice for those who don't have a family doctor. Ear infections, sore throats and coughs are as common in today's hospital emergency rooms as chest pain, head injuries, gunshot wounds and overdoses.

It's symptomatic of the nation's most pressing problem--a lack of affordable health insurance that would allow those parents who don't qualify for Medicaid to take coughing children to a family doctor instead of a local emergency room. In all, Americans made 50 million visits, many for children's ailments, to hospital emergency rooms in 1992 for nonemergency medical treatment.

Those costs are passed on to other patients and to insurance companies as hospitals and medical centers attempt to recoup uncompensated emergency costs.

"Emergency rooms have become the family doctor for too many Americans," noted U.S. Health and Human Services Secretary Donna Shalala. "Emergency rooms are not intended to deliver routine medical care; patients don't get the timely, preventive services. And the cost is three times higher than visits to a doctor's office."

Another regular service a family doctor provides is vaccinating children against disease. But there were 2,237 measles cases in the United States in 1992 and 160 cases of rubella, both diseases that can be easily prevented by immunizations given in early childhood. And the danger of allowing rubella to spread is that it causes serious birth defects if pregnant women are exposed to it. Because there are some parents who are unaware that vaccinations are necessary, some who don't find the time to take their children in for immunization and some who cannot afford it, there were about 9,000 cases of contagious diseases in the United States in 1992 that would never have struck had all children been immunized. (A little less than half, 40 percent, of all American preschoolers are not fully immunized.)

As Washington continues to debate national health care reform, some states have come up with prescriptions for what ails uninsured children and pregnant women and are helping to keep them from slipping through the gaps in medical care.

Pennsylvania Insures Children

Pennsylvania, for example, subsidizes medical insurance for children of low-income families. Those with an income between 185 percent and 235 percent of the federal poverty level pay half the cost of coverage. The plan, financed by a 2-cent-per-pack tax on cigarettes, covers about 30,000 children and offers preventive as well as general medical care.

"This program was designed to help children," says Diana Donovan, Pennsylvania Department of Insurance. "It reaches children from families who have an income that disqualifies them from any other medical assistance but who still can't afford insurance."

The state contracts with insurers for the program. This year, it was able to offer four Blue Cross plans and also had contracts with U.S. Health Care and Geisinger, two health maintenance organizations (HMOs).

New York, Connecticut, Hawaii and Massachusetts also subsidize private insurance coverage for low-income children.

Florida Keeps Kids Healthy

In a pilot project, the Florida Healthy Kids Corporation provides health insurance coverage through participating public schools with families paying a sliding fee based on income. Healthy Kids covers children and youths, ages 5 to 19, who attend participating schools and are not enrolled in other public assistance programs. Siblings, ages 3 to 5, also may enroll.

The Florida Legislature created the Healthy Kids Corporation in 1990 to help phase in health insurance for uninsured school children and to find health care services for them. The Legislature authorized four pilot sites, which were expanded to 10 in 1991. School administrators, school board members, educators and physicians serve on the Healthy Kids Corporation board of directors. The corporation determines eligibility and premium amounts, hires administrative staff, contracts with health care providers and school boards, and publicizes the program.

The first pilot site was Volusia County (Daytona area), where Rose Naff, executive director, estimates 13,000 kids needed help. Over the last three years, 10,000 youngsters have participated in the program, she adds. Healthy Kids was expanded this year to Highlands and Okeechobee counties.

Four more Florida counties are to be added to the program, and there are "16 more who want in," Naff says.

A federal grant and state match kick-started the program in 1990, but Naff said the goal is to have the communities gradually take on full financial support. "We start with a minimum local contribution of 5 percent of the cost," she explains. "That amount is increased each year, and, at some point in the future, the programs should be completely locally supported."

New Hampshire recently passed legislation modeled on the Sunshine State program.

Minnesota Cares

Minnesota adopted a major health reform program in 1992 that helps provide primary care for children and their families who do not qualify for Medicaid or general assistance medical care. Children with family incomes up to 275 percent of the federal poverty level (a family of three with an income up to $32,640) can become eligible for coverage on an income-based sliding scale.

MinnesotaCare is funded from a 5-cent increase in cigarette taxes to 48 cents a pack, a 2 percent tax on gross patient hospital revenues and a 2 percent tax on gross revenues of other health care providers. A 1 percent premium tax on nonprofit health services corporations including Blue Cross and Blue Shield will begin in January 1996.

Taking a slightly different tack, Iowa has a joint public-private insurance program for eligible children. Blue Cross and Blue Shield of Iowa donated $3 million over six years to support the plan and established a foundation for tax-deductible contributions to the program. Participating doctors and hospitals have given substantial discounts for children covered by the program. This year, the Iowa Legislature allocated $75,000 in state money to the $1 million program.

Iowa's Caring Program took care of about 2,400 children this year. "We serve the people who need help, but who don't qualify for Medicaid or medical assistance," reports Molly Kurtz of the Caring Foundation.

The other 22 Caring programs established across the nation by Blue Cross and Blue Shield cover about 115,000 children.

Preventing Childhood Plagues

An estimated 40 percent of American preschoolers are susceptible to such childhood diseases as mumps, rubella and other ailments that could be prevented if they were vaccinated. According to the U.S. Public Health Service, every dollar spent on childhood immunization saves $10 in later medical costs for treating the diseases that vaccines can prevent.

In some states--Colorado, Florida, Georgia and Maryland--welfare benefits are directly tied to whether or not children in the family have been immunized. If children do not get their vaccinations, recipients lose benefits.

Rhode Island and at least 14 other states buy vaccines in bulk for free distribution to children.

Oklahoma took another approach, using a multimedia advertising blitz to convince parents that children should be given all necessary vaccinations by age 2. During its "Due by Two" Campaign, children received free immunizations at community and public health centers.

Before the campaign, only about 33 percent of Oklahoma 2-year-olds were immunized. After the three-month advertising blitz and free vaccines at community clinics, there was a 31 percent increase in immunizations. Older children also benefited; the vaccine rate rose 11 percent for children under 5.

Before They Are Born

The need for good medical care does not begin with a child of 2 or 3--it begins before birth.

Estimated costs for treating a sick baby in a neonatal intensive care unit are $20,000 to $400,000. Hospital costs for a healthy newborn average about $4,300 for delivery and care. One of the critical factors in a newborn's good health

is the mother's health. Pregnant women need good prenatal care and education about keeping themselves and their babies healthy.

It costs the private sector about $5.6 billion annually through higher insurance premiums to treat ailing newborns. It costs an additional $4 billion annually to cover the costs of babies whose families do not have private insurance.

Washington state developed a model program in 1989, First Steps, that coordinated services for pregnant women from low income families and helped them obtain crucial prenatal care. First Steps expanded Medicaid eligibility for pregnant women and infants under age 1, increased Medicaid reimbursements for doctors, included a statewide media campaign and toll-free number where women could find maternity care providers in their communities, and assigned case managers as needed through the mother's pregnancy and infant's first year. The program also includes counseling for alcohol and drug abuse.

In an evaluation of the program in the Seattle area, the results were a significant drop in infant mortality for African Americans (nationally, the ethnic group with the highest infant death rate) from 23.6 per 1,000 live births in 1989 to 17.7 in 1991.

In Utah, a program that combines a media campaign to help educate women about pregnancy and special services for poor women at risk of having unhealthy babies has also resulted in falling rates of infant mortality--from 8.8 per thousand live births before the program to 6.2 in 1991.

 Number of Percent of
 Children Children
State Uninsured Uninsured

Alabama 204,382 18%
Alaska 17,322 11
Arizona 155,762 17
Arkansas 130,275 19
California 1,437,220 17
Colorado 107,889 12
Connecticut 41,630 5
Delaware 23,503 13
D.C. 28,262 21
Florida 556,536 18
Georgia 200,513 12
Hawaii 19,285 7
Idaho 49,326 15
Illinois 292,629 10
Indiana 167,304 12
Iowa 42,150 6
Kansas 78,253 11
Kentucky 122,405 14
Louisiana 211,133 19
Maine 30,272 10
Maryland 147,668 13
Massachusetts 87,768 7
Michigan 159,256 6
Minnesota 60,615 5
Mississippi 136,407 17
Missouri 182,725 13
Montana 29,996 12
Nebraska 33,260 7
Nevada 48,493 16
New Hampshire 23,314 9
New Jersey 162,035 9
New Mexico 100,838 22
New York 423,052 9
North Carolina 209,604 14
North Dakota 10,653 6
Ohio 224,029 8
Oklahoma 166,169 20
Oregon 114,685 15
Pennsylvania 251,675 8
Rhode Island 12,627 6
South Carolina 139,705 15
South Dakota 19,911 10
Tennessee 147,906 12
Texas 1,100,963 23
Utah 54,812 9
Vermont 10,613 7
Virginia 229,804 14
Washington 108,357 9
West Virginia 64,017 14
Wisconsin 86,745 7
Wyoming 13,277 10

High infant mortality rates spurred the North Carolina General Assembly to expand the state Medicaid program and to provide better health care for poor pregnant women and young children. Legislators initiated Baby Love, a statewide public education and outreach program, and streamlined the Medicaid eligibility process. Other improvements included increasing Medicaid fees for obstetrical services and developing a statewide system for managing maternity care.

In the first year of the program, legislators phased out the state's maternal and child health program, transferring $6 million for expansion of the Medicaid program, where the money could be used to leverage matching federal funds.

Evaluated in 1991, the program resulted in decreases in infant mortality and the severity of sickness in newborns, saving the state approximately $2.02 in expenses for newborns within the first 60 days of life for every dollar it invested in maternity care.

"For kids, the public is saying yes to immunization, yes to well-baby [preventive] care," notes Delaware Representative Jane Maroney, who has devoted her time to state and national health care issues. "And our public, at least, has indicated they would spend taxes to help young children."

No matter what national reform path is taken, states have managed to prescribe a number of remedies aimed at keeping children healthy. A national plan that allows states the flexibility to continue to design their own programs will ensure the better health of children, infants and pregnant women.


When and if Congress adopts a major national health care reform plan (and the president accepts it), that time won't be too soon for Texas.

Right now, the second largest state in the union is grappling with a monstrous dilemma. Texas has more than 1 million children who do not have health insurance. Costs of care for emergency treatment of illegal immigrants are skyrocketing, and there aren't enough primary care doctors to even begin to answer the needs of residents.

"For us, health care reform is a great big beacon of possibilities," says Representative Leticia Van de Putte. "Our state has what you would call frontier spirit--a wonderful legacy of self-reliance--but that just doesn't cut it when it comes to health care. We're going to need national help."

The Lone Star State has a particularly bleak portrait when it comes to meeting the health care needs of its children.

In Texas, about one in every four children lives in poverty; about 3.2 million employees are uninsured themselves, much less having insurance for their families. "We have, basically, a service sector economy of small employers who cannot provide health insurance for their workers," Van de Putte explains. And, if they do provide employee insurance, many cover the working parent, but not the children or spouse.

The result? People can't afford to take themselves or their children to doctors--even if they can find one. In Texas, 154 of 200 counties have been declared medically underserved. "If every one of our state medical school graduates were primary care physicians, not a specialist among them, it would still take 20 years to provide enough family doctors for all the underserved areas in the state," Van de Putte says. Add that to the fact that about 40 percent of the state's general practitioners are within 10 to 15 years of retirement, Van de Putte explains, and "that's real scary."

And then there are those vast distances of the American West. "People just can't understand the distances. In some areas, even if you fly, you will still have to drive another four hours to get to an urban center," Van de Putte explains. She talks about one family who had a choice when their child became sick--drive 35 minutes to a New Mexico facility their insurance did not cover or gamble on the hour it took to make the nearest Texas emergency room. Van de Putte believes universal coverage, on a national scale and valid across state and regional lines, would help solve dilemmas like that.

Considering the cost, the distances, the lack of primary care physicians and the fact that the state is facing a $1.3 billion deficit, according to Van de Putte, Texas policymakers have tried to provide medical care for their citizens.

The state has helped establish federal community clinics and migrant health clinics. Legislators expanded the nurse practitioner act, allowing them more leeway in treatment, and are in the process of expanding the nurse midwifery program.

"We also have a concept we call Southern Exposure [in deference to the television series, Northern Exposure] that will pay off loans of medical school graduates if they serve in rural or underserved urban communities."

Van de Putte adds that any federal measure must address the problems and costs of undocumented workers. Right now, she points out, no one--whether they possess a green card or not--is turned down for treatment in a Texas emergency room. The cost of those unable to pay, including migrant workers or undocumented aliens, is borne by the state taxpayers.

The state is also involved in three managed care pilot programs for its Medicaid patients-but "our best possible chance, the best possible opportunity for us, is a national program," Van de Putte says.

Dianna Gordon is an assistant editor for State Legislatures magazine.
COPYRIGHT 1994 National Conference of State Legislatures
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1994, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:includes related article; children and health care reform
Author:Gordon, Dianna
Publication:State Legislatures
Date:Sep 1, 1994
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