The Journal of Pediatrics
Volume 153, Issue 3 , Pages 301-302.e3, September 2008

Health Insurance for All Children and Youth in the United States: A Position Statement of the Federation of Pediatric Organizations

  • Peter G. Szilagyi, MD, MPH

      Affiliations

    • Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester. NY, and the Academic Pediatric Association (APA)
    • ,
  • Tina Cheng, MD, MPH

      Affiliations

    • Department of Pediatrics, Johns Hopkins Medical Center, Baltimore, MD, and the APA
    • ,
  • Lisa Simpson, MBBCh, MPH

      Affiliations

    • Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, OH, and the APA
    • ,
  • Jay E. Berkelhamer, MD

      Affiliations

    • Children's Healthcare of Atlanta, Atlanta, GA, and the American Academy of Pediatrics (AAP)
    • ,
  • Theodore C. Sectish, MD

      Affiliations

    • Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA, and the Federation of Pediatric Organizations

Article Outline

 

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FOPO Position Statement 

All children and youth in this country deserve health insurance coverage. This nation provides health insurance coverage for every American 65 years and older through the Medicare program. Moreover, our nation has provided universal services for a variety of sectors such as education, social security, and public safety. We assert that the health of children is essential to our nation's future and should be viewed in the same way. The Federation of Pediatric Organizations (FOPO), which represents the voice of 7 of the leading national organizations within the pediatric community, believes our nation's children and youth deserve the same guarantee of health insurance coverage.

Health insurance for our nation's children and youth also must be adequate to meet the health care needs of all children. These needs include preventive and developmental services; acute, emergency, specialty, and inpatient care; comprehensive services for children with special health care needs; dental care; and mental health care. Studies by FOPO members have demonstrated that inadequate health insurance in any of these essential areas of child health care results in poor health outcomes and preventable morbidity that can extend into adulthood. Studies have also shown that adequate health insurance improves the health and quality of life of children, helping to prepare them for productive lives.

Health insurance for children is far less expensive than is health insurance for adults. It is economically feasible and sound public policy to provide health insurance to all children. The FOPO calls upon the members of the United States Congress to enact legislation that will ensure that all children and adolescents living in the United States are provided broad and adequate health insurance coverage, thereby improving our children's and nation's health outcomes.

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Discussion 

FOPO recently articulated its strategic initiatives for the next 5 years.1 FOPO offers a unified voice for the pediatric community on issues and policies that broadly affect child health care. This commentary provides the context, rationale, and next steps for FOPO's Position Statement: Health Insurance for All Children and Youth in the United States. A list of FOPO Member Organizations is available at www.jpeds.com and www.fopo.org.

The American Academy of Pediatrics (AAP), founded in 1930, has steadfastly advocated for the health and well being of America's children. Legislative advocacy to ensure that all children living in the United States have access to health care has been a central focus since the organization's inception. The Maternal and Child Health Program, Medicaid, Early and Periodic Screening, Diagnosis and Treatment Program, and the State Child Health Insurance Program (SCHIP) have been some of the most important incremental steps in a very long journey to achieve this end. During the past 10 years, the AAP has advocated for a new program called Medikids to fill the gaps that still exist for the 9 million children who are uninsured. As part of the AAP's efforts, access principles (Figure; available at www.jpeds.com) have been developed to benchmark any existing health insurance program or new proposal that provides health insurance for children.

FOPO Position Statement asserts that health insurance must be adequate to meet the health care needs of all children, a particularly relevant element as health insurance plans are increasing co- payments, premiums, and cost-sharing in an attempt to limit the rapidly rising costs of health care. Multiple studies have demonstrated that cost-sharing on children's health services affects utilization of care, with higher cost-sharing leading to lower utilization.2, 3, 4 Lack of coverage for services such as mental health, developmental, or other comprehensive services leads to lower use of those services. Thus children's health insurance must be designed to cover age-appropriate services that children need, in a way that promotes the appropriate use of such services. Minimal health insurance with an inadequate benefit package will lead to under-utilization of necessary services.

The question then becomes—how does one define “adequate?” One strategy is to consider what children need and what services truly benefit children.5 Children need preventive and primary care services including dental care.6 All children and adolescents need a medical home that provides care that is “accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective.”7 In addition, children need acute care services because injuries and acute illnesses are common in children. Finally, chronic care services are essential. An estimated 14% to 18% of children have special health care needs, including chronic physical, developmental, behavioral, or mental health conditions.8 Children with special health care needs have a greater burden of illness, poor health, and use a large share of pediatric services. They frequently need specialty or hospital services, long-term medications, and care coordination in a medical home. For these children, comprehensive services are particularly important, including educational, developmental, social, nutritional, and other services that contribute to a child's overall health status.9

Thirty years of scientific studies have convincingly demonstrated that lack of health insurance leads to suboptimal utilization of needed services, lower quality of care, and in many cases poorer health outcomes.10, 11, 12 Conversely, studies have demonstrated that provision of health insurance improves their health care, resulting in better access to health services, utilization of needed services, quality of care, and in many cases improved health outcomes.13, 14, 15 Thus health insurance directly contributes to the good of society. Although health insurance is not always the ticket to good health, because much is needed beyond health insurance, lack of health insurance often leads to poor health. Most recently, studies of the SCHIP have demonstrated that provision of health insurance to previously uninsured children improved their care,16 for children in general,17 for children of varying ages including adolescents,18, 19 and for children with special health care needs,20 such as asthma.21 Furthermore, studies have found that children with newly acquired SCHIP health insurance have greater access to and utilization of primary and preventive health services;22 and these services in turn lead to improved health outcomes. Finally, studies have even revealed that preexisting health disparities are in part due to lack of health insurance coverage and that provision of health insurance partially mitigates racial and ethnic health disparities.23

A robust body of literature indicates that improving the health of children results in improved health of adult populations. For example, most adult chronic diseases and high-risk or unhealthy behaviors have their antecedents in childhood. Retrospective studies of adult populations have demonstrated that childhood factors have substantial impact on adult health outcomes, presumably because of the downstream accumulation of morbidity resulting from childhood insults.24, 25 Thus, if health insurance for children improves the health of child populations, it will ultimately result in improved health of adult populations.

Economist and Nobel Laureate James J. Heckman has demonstrated that early investments in the well-being and skill formation of disadvantaged children pay off.26 His work shows that as a society we overinvest in remedial skill programs at later ages and underinvest in the early years. Healthy and productive children have much greater odds of being healthy and productive adults. If we don't invest now, we pay much more later.

An important point in the Position Statement is that the provision of health insurance to children is much less expensive than the provision of health insurance to adults. Although children 0 to 18 years comprise 26% of the US population, they consume only about one-tenth of the healthcare dollar. Even among publicly funded programs including Medicare, Medicaid, and SCHIP, the pediatric portion represents only 9% of publicly funded healthcare costs.27, 28 Because 88% of US children do have health insurance,29 providing universal health insurance to the remaining 12% of children would only minimally increase the total healthcare budget. Thus in terms of “dollars per individual covered, ” provision of health insurance to children is a good value.

Finally, the FOPO Position Statement is a rallying cry for adequate health insurance coverage for all children. The United States has made the conscious decision to provide health insurance, including quite comprehensive coverage, to all elderly residents, but not to children. Scientific evidence clearly demonstrates that provision of health insurance to children improves their health and that adequate health insurance is important for both child and adult health. Because the cost of health insurance for children is relatively low, and the benefit is great, FOPO strongly advocates for health insurance coverage for all children and youth in the United States.

The FOPO Position Statement represents an important milestone in the journey to provide health insurance to all children and youth in the United States. The strong endorsement by FOPO of this position at this point in time builds on decades of efforts of pediatricians, politicians, legislative staff, and advocates led by the AAP and members of the US Congress. It is not a coincidence that this Position Statement is being publicized in a presidential election year to make the argument about the need for health insurance for all children and youth. We intend to make this Position Statement and other critical issues part of a major media event this fall to draw attention to the issues and stimulate responses from the presidential candidates and the public. Health insurance for all US children and youth is both the right thing to do and the scientifically prudent choice, and it is too long overdue.

References available at www.jpeds.com.

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Appendix 

The Federation of Pediatric Organizations (FOPO) Member Organizations 


Academic Pediatric Association (APA)

American Academy of Pediatrics (AAP)

American Board of Pediatrics (ABP)

American Pediatric Society (APS)

Association of Medical School Pediatric Department Chairs (AMSPDC)

Association of Pediatric Program Directors (APPD)

Society for Pediatric Research (SPR)

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References 

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 The opinions expressed herein by the authors do not necessarily reflect the official endorsement of The Association of Medical School Pediatric Department Chairs, Inc.

PII: S0022-3476(08)00483-6

doi:10.1016/j.jpeds.2008.05.052

The Journal of Pediatrics
Volume 153, Issue 3 , Pages 301-302.e3, September 2008

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