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Reversing the Rising Rates of Uninsured Children


Karla Fredricks, MD, MPH, FAAP
December 2, 2019

At a mobile clinic designed to care for uninsured children, a 12-year-old boy sat on the exam table and gingerly cradled his clearly deformed right forearm with his left hand. His mother stood beside him, recounting to me how her son, Jose*, fell off his bicycle two weeks earlier and injured his arm. However, they did not have any health insurance and Jose told her, “It doesn’t really hurt.” She kept hoping that the deformity was only swelling that would improve over time because she could not afford to take him to a doctor.


I explained that Jose’s clinical examination showed that his forearm was broken. Unfortunately, due to the delay in accessing care, his bone had started to heal improperly. Now, instead of a simple cast, he would require surgery to re-break and repair the bone.


With tears in her eyes, Jose’s mother stated that she had stopped his Medicaid out of fear that it would cause problems for his father, who is not a citizen of the United States. She never thought this action might lead to harm for her son.

With a growing number of children without health insurance, Dr. @KarlaFredricks says pediatricians can help #KeepKidsCovered by dispelling fears about using Medicaid and the Children’s Health Insurance Program (CHIP). #ProtectFamilies #AAPvoices

More than 4 million U.S. children lack health insurance
According to a recent report by the Georgetown University Center for Children and Families, U.S. Census Bureau data show an upward trend in uninsured children over the past two years. By the end of 2018, the total number of children in the United States without health insurance coverage surpassed four million. According to analyses of the data, much of the decline in children’s insurance coverage can be attributed to decreasing enrollment in public health benefits such as Medicaid and the Children’s Health Insurance Program (CHIP).


Why is it so incredibly important that children utilize Medicaid/CHIP? These programs currently insure more than one-third of all children in the United States who, without these benefits, would likely lack coverage. Compared to uninsured children, those with Medicaid/CHIP see a health care provider more regularly for routine preventive care, go to the emergency room less, have higher rates of high school graduation, and contribute more to the economy as working adults.


The chilling effect of “public charge”
Among other factors, fear and confusion over the proposed “Inadmissibility on Public Charge Grounds” (aka “public charge”) rule have caused many families to avoid the use of Medicaid/CHIP. Although the “public charge” rule was blocked by two temporary injunctions on Oct. 11, 2019, concern remains high in immigrant communities that use of Medicaid/CHIP might lead to detrimental outcomes for the family.



"Compared to uninsured children, those with Medicaid/CHIP see a health care provider more regularly for routine preventive care, go to the emergency room less, have higher rates of high school graduation, and contribute more to the economy as working adults."


While the battle over this rule plays out in the judicial system, there are some practical ways that individuals can take a stand for the youth of the United States:

  1. Understand the “public charge” rule and what it does and does not include. If the “public charge” rule were to ever be implemented, it would change considerations on which certain individuals are judged likely to become a “public charge” or “depend on public resources to meet their needs.” The public charge determination would only apply to non-U.S. citizens who are seeking to obtain a visa to enter the country or adjust their status to lawful permanent resident (for example, to obtain a green card) from within the United States. In the past, only the use of cash assistance–such as Temporary Assistance for Needy Families or Supplemental Security Income–or long-term institutionalization paid for by the U.S. government was counted against the non-citizen applicant. Should the new rule end up going into effect, it would add the use of some types of Medicaid for adults, the Supplemental Nutrition Assistance Program, and certain government-supported housing subsidies to the list of benefits that negatively impact an individual’s application.

    However, even if the “public charge” rule is implemented in the future, it will affect very few people and will not be retroactive. In addition, it is important to note that the use of Medicaid or CHIP by any youth under the age of 21 is not included; public health insurance for children will not be counted against any applicant or their family/household members. This means that no child should forego Medicaid/CHIP because of this rule. NOT ONE.

  2. Work with community members that know the eligibility requirements for Medicaid/CHIP for your state. Since income limits and immigration status requirements differ from state to state, incorporating staff familiar with these regulations into pediatric practices, hospitals, and social service organizations can be very useful. Their expertise in Medicaid/CHIP, combined with their rapport with patients and families, can improve uptake of public insurance coverage.

  3. Develop talking points on the importance of Medicaid/CHIP usage. Each individual patient will have their own set of benefits derived from having public health insurance coverage, such as the receipt of free or low-cost medical visits and prescriptions. Beyond emphasizing patient-specific positives, population-level data can also be helpful to show the improved long-term outcomes of children with Medicaid/CHIP.

  4. Provide accurate resources for information about legal policies. It is important for non-legal professionals to stay within their scope of practice and share recommendations related to their area of expertise only. If legal information is needed, families should be referred to trusted sources such as Protecting Immigrant Families, the National Immigration Law Center, and/or local organizations that have been verified as reliable. Any specific questions about a family or patient’s application for a green card or visa should be answered by an immigration attorney.

We have the ability right now to alter the rhetoric surrounding Medicaid/CHIP and effect positive change in our communities. We can educate and inform, so everyone understands that Medicaid and CHIP for children under 21 years of age are not to be feared; they are the same beneficial programs they have always been. Our efforts to spread this critical information are essential to reverse the alarming decline in children’s insurance coverage, thus protecting the health of millions of children and ensuring that no Medicaid/CHIP-eligible child will needlessly suffer medical delays like Jose.

 

   *Name and some identifying details changed to protect patient privacy.
* *The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.


About the Author


Karla Fredricks, MD, MPH, FAAP is a member of the AAP Council on Immigrant Child and Family Health and the director of the Program for Immigrant and Refugee Child Health (PIRCH) at Baylor College of Medicine/Texas Children’s Hospital.