Today, at a White House summit on fiscal responsibility, President Obama made it clear that health care reform will remain at the top of his domestic policy agenda. But this wasn't his first move to repair some of the more grotesque flaws in the nation's dysfunctional "system" of medical care. Earlier this month - with enthusiastic participation of Congress - the president reauthorized the State Children's Health Insurance Program - or SCHIP. With a stroke of his pen he approved an appropriation of $32 billion over the next four and a half years making it possible for some 4 million children currently without health insurance to get the coverage they need. This new legislation goes a long way toward fulfilling one of the president's major health care campaign pledges: a promise to make mandatory health insurance for children one of the first steps toward reforming the nation's tattered health care system.
But a new report from the Center for American Progress undermines part of the progress just highlighted by the SCHIP expansion. According to the Center, the on-going economic and unemployment crisis is throwing millions more Americans into the ranks of the uninsured. This may well translate into as many as one million additional children now without coverage. Two steps forward, one step back - a bad situation about to get a great deal worse.
SCHIP, originally passed in 1997 has been a life-saver for low income families who earned too much to qualify for Medicaid, but too little to afford private coverage. And - not surprisingly - kids without insurance are 3-4 times more likely to not have a regular primary care doctor, and much more likely to have poorly managed chronic conditions like asthma or diabetes.
That said, neither the president, nor Congress, should consider the job of securing access to health care for children to be a done deal. At least two pieces of unfinished business will remain on the table:
First, there will still be several million children uninsured, even after implementation of the newly expanded program. And with more parents out of work we can anticipate a rapidly growing number of children losing health insurance coverage. And there is the persistent challenge of children who may, in fact, be eligible for SCHIP or Medicaid, but live in states where bureaucratic hurdles make it extraordinarily difficult to sign up or renew participation in these programs.
Second, elected officials may need to be reminded that health insurance coverage does not necessarily equal access to health care. Many people with health insurance face significant barriers to actually getting health care in a timely and effective manner. For starters, the distribution of physicians, nurse practitioners and clinics in the U.S. is uneven and unpredictable.
In fact, the federal government tracks physician distribution and has assigned a special designation, "Health Professional Shortage Areas," to communities where there is less than one practicing primary care doctor for every 2,000 people. As of September 2008, the federal government declared more than 6,000 communities in the U.S. to be official HPSAs. In other words, some 64 million Americans - including 15 to 16 million children - live in rural and urban physician shortage areas where health insurance is not enough to assure timely access to medical care. In other words, the supply and distribution of primary care physicians and other providers is insufficient to meet the public's need, irrespective of insurance status.
It is clear that expanding coverage for kids is a critical first step. But there are many challenges that will need to be addressed before we can be confident that health care for all children is assured. Next steps should be:
1. Fulfill President Obama's commitment to make sure every child in the U.S. has appropriate health insurance.
2. Expand federal and state efforts to make sure we have sufficient numbers of physicians and clinics in all communities. This would mean significant expansion of one of the nation's most effective resources, the federally-funded community health centers.
3. Create new incentives for medical school graduates to enter primary care. This can be accomplished by expanding highly successful programs like the National Health Service Corps, which provides medical school tuition relief for students who commit to entering primary care fields.
4. Streamline health care in ways that will reduce the crushing paperwork experienced by many primary care physicians. Investing in a 21st Century electronic health care records system would be a good start.
So kudos to the Congress and the President for passing SCHIP. But fully meeting the challenge of getting all children the health care they need, will still need resources and the persistent focus of elected officials.
Irwin Redlener, MD, Professor, Population and Family Health, Columbia University Mailman School of Public Health & President, Children's health Fund
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