The Evidence for Expanding Health Care Coverage for All Children Peter G. Szilagyi MD MPH PastPresid

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The Evidence for Expanding Health Care Coverage
for All ChildrenPeter G. Szilagyi MD
MPHPast-President, Academic Pediatric
AssociationProfessor of Pediatrics, University
of Rochester

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Goals of my talk

• Respond to key points in Jays talk
• Present some evidence
• Challenge ourselves

No conflicts or disclosures
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I agree with everything that Jay said
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First a Quiz Who is this man?How does this
relate to healthcare coverage?

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First a Quiz Who is this man?How does this
relate to healthcare coverage?

• Hold that thought

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What is the evidence about healthcare coverage?
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Is it that bad to be uninsured?
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Consequences of Being Uninsured

• Poorer access to care (all types)
• More unmet needs, more foregone care
• Lower utilization of most health services
• Poorer quality of care across the board
• Poorer health outcomes in some cases
• Summary of many studies

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Has SCHIP Reduced the number of uninsured?
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SCHIP The good news

• 4 million children enrolled

All Americans Children
Uninsured
SCHIP
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Does health insurance really improve care?
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SCHIP in New York Improves Access and Continuity
Szilagyi et al. Pediatrics 2005
Jun115(6)e395-404
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SCHIP in New York Improves Access and Continuity
Szilagyi et al. Pediatrics 2005
Jun115(6)e395-404
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Utilization for Asthma
Szilagyi et al. Pediatrics 2006
Feb117(2)486-96
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Impact of Health Insurance (SCHIP) On the Health
of Children

• Improves receipt of care
• Preventive, acute, chronic, specialty
• Receipt of medications
• Reduces unmet needs for care
• Improves quality of care
• Children in general
• Children with special needs (chronic conditions)
• Improves some outcome measures (but not others)
• For healthy children and those with chronic
  conditions
• Reduces some disparities in healthcare

Summary of many studies
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Does it make sense to expand the upper income
limit of SCHIP?
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Does it make sense to expand the upper income
limit of SCHIP?

• Are children above 200 FPL also as needy?

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US Children Care All Year by Insurance Status
Insured all year
Odds Ratio
Uninsured all year
Referent
Unadjusted
Income Category (as Percent of FPL)
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Shone LP et al. Upper income limits for SCHIP
and foregone care among uninsured US children.
JAMA. 2008300(16)1882-1884.
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US Children Care All Year by Insurance Status
Insured all year
Odds Ratio
Uninsured all year
Referent
Unadjusted
Income Category (as Percent of FPL)
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Shone LP et al. Upper income limits for SCHIP
and foregone care among uninsured US children.
JAMA. 2008300(16)1882-1884.
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What is needed beyond health insurance?
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The Cascade of Voltage Drops From Insurance to
Quality Health Care
Potential to Receive High-Quality Health Care
1. Insurance Available 2. Enrolled in
Insurance 3. Providers and Services
Covered 4. Informed Choices
Available 5. Consistent Source of
Primary Care Available 6. Referral
Services Accessible
7. High-Quality Care Delivered
Quality of Received Care
Eisenberg, J. M. et al. JAMA 2000, Chung
Schuster, Health Affairs. 2004
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The Cascade of Voltage Drops From Insurance to
Quality Health Care
Potential to Receive High-Quality Health Care
1. Insurance Available 2. Enrolled in
Insurance 3. Providers and Services
Covered 4. Informed Choices
Available 5. Consistent Source of
Primary Care Available 6. Referral
Services Accessible
7. High-Quality Care Delivered
Quality of Received Care
Eisenberg, J. M. et al. JAMA 2000, Chung
Schuster, Health Affairs. 2004
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The Cascade of Voltage Drops From Insurance to
Quality Health Care
Potential to Receive High-Quality Health Care
1. Insurance Available 2. Enrolled in
Insurance 3. Providers and Services
Covered 4. Informed Choices
Available 5. Consistent Source of
Primary Care Available 6. Referral
Services Accessible
7. High-Quality Care Delivered
Quality of Received Care
Eisenberg, J. M. et al. JAMA 2000, Chung
Schuster, Health Affairs. 2004
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Most Uninsured Children are Already Eligible for
Health Insurance
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Eligible But Not Enrolled
Source 1999 National Survey of Americas
Families, using July 2000 SCHIP eligibility rules.
Uninsured
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Eligible But Not Enrolled
Source 1999 National Survey of Americas
Families, using July 2000 SCHIP eligibility rules.
Uninsured
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The Cascade of Voltage Drops From Insurance to
Quality Health Care
Potential to Receive High-Quality Health Care
1. Insurance Available 2. Enrolled in
Insurance 3. Providers and Services
Covered 4. Informed Choices
Available 5. Consistent Source of
Primary Care Available 6. Referral
Services Accessible
7. High-Quality Care Delivered
Quality of Received Care
Eisenberg, J. M. et al. JAMA 2000, Chung
Schuster, Health Affairs. 2004
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Benefits of a Medical Home

• Improved quality
• Some quality and safety measures
• Patient and family satisfaction
• More effective use of health resources
• Reduced health disparities
• Improved satisfaction by professionals

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The Cascade of Voltage Drops From Insurance to
Quality Health Care
Potential to Receive High-Quality Health Care
1. Insurance Available 2. Enrolled in
Insurance 3. Providers and Services
Covered 4. Informed Choices
Available 5. Consistent Source of
Primary Care Available 6. Referral
Services Accessible
7. High-Quality Care Delivered
Quality of Received Care
Eisenberg, J. M. et al. JAMA 2000, Chung
Schuster, Health Affairs. 2004
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SummaryThe Evidence for Health Care Coverage

• Uninsured children are suffering
• Healthcare coverage does improve care
• But is not sufficient for good outcomes
• All children would benefit from coverage
• Even higher income brackets
• Health care coverage is just the first step along
  the cascade

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Who is this man?How does this relate to
healthcare coverage?

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Who is this man?How does this relate to
healthcare coverage?

• Charles Darwin
• Wrote Origin of Species
• 150 years ago (1859)

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US Health Care Coverage

• Can be likened to a case of natural selection,
  with survival of the fittest.

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US Health Care Coverage

• Can be likened to a case of natural selection,
  with survival of the fittest.
• But children are not the fittest.

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US Health Care Coverage

• Can be likened to a case of natural selection,
  with survival of the fittest.
• But children are not the fittest.
• We need healthcare coverage for all children.

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The reason for it all
Remember, its all about children