Rationing without justice: children and the American health system.

• Author: Rosenbaum, Sara
• Position: The Law and Policy of Health Care Rationing: Models and Accountability

INTRODUCTION

Of all the hardships and inequities in the United States caused by the absence of a reasoned approach to health care resource allocation, perhaps none is more stark or poignant than the nation's treatment of children. The United States stands virtually alone among western industrialized democracies in failing to assure at least minimum health care for all pregnant women and children.(1) The voluntary employment-based health insurance system, the central health care financing mechanism for working age Americans and their families, leaves out forty percent of all children.(2) Medicaid, the largest source of public health care financing for children, covers less than half of all children without employer benefits;(3) moreover, the federal government and some states, responding to the growing economic burdens created by the program, frequently aim their budget cutting knives at expenditures on women and children, who are without the political defenses needed to fight back. The United States offers children no floor of health care decency as it does for the elderly through the Medicare program. There is no body of case law, no constitutional guarantee, that assures all children access to comprehensive, basic health care regardless of ability to pay. Instead, children who today are the poorest Americans are also among the most likely to be medically underserved.

The consequences of this cumulative, national neglect of children are found in neonatal intensive care wards, hospital emergency clinics, special education programs for disabled preschool and school age children, and on the faces of death certificates for thousands of American children who die each year from preventable causes. The ultimate paradox of this failed policy toward children is that it not only needlessly claims so many young lives but that it also helps perpetuate our costly health care system. This paradox makes adoption of a national child health policy central to any new approach to allocating health resources, whether by price, quantity, health outcome, or some combination of the three.

This Commentary reviews the health status of American children and presents information on children's insurance coverage and access to health services. It argues that much of the poor health among children today can be traced to their lack of access to even basic health services. Finally, it sets forth overall national health reform recommendations for children.

1. THE HEALTH OF AMERICA'S CHILDREN

   Good health is one of the basic hopes that all parents have for their children. For far too many American children, however, the chances of being born healthy and growing up healthy approximate those of children who live in countries far less wealthy than our own. In the case of certain key child health indicators, many U.S. communities measure poorly compared to third world nations. In the nation that spends more per capita on health care than any other, black infants die at rates higher than those for babies born in Jamaica or Trinidad and Tobago;(4) immunization rates for infants and toddlers in the nation's capital rival those of Haiti.(5)

   Health care is crucial for all children, but it is by no means the only factor that influences child health status. It is nearly impossible to discuss the health of children today without considering their poverty. In 1989, 12.6 million American children-one in five-lived below the federal poverty level, a twenty percent increase over a ten-year period.(6) Nearly one in four young children under age six and two in five black and Latino children were poor;(7) overall, children were almost twice as likely as adults to be poor.(8)

   Poverty affects child health in two ways. First, poverty significantly elevates children's risk of death and disability by exposing them to environmental and social conditions that nonpoor children are far less likely to face.(9) Second, poverty robs children of access to health care: poor children are significantly more likely to lack health insurance, and poor families frequently live in isolated inner city and rural communities, far from sources of either affordable or accepting care.(10)

   When poor children finally do obtain health care, it is far too often provided in severely overcrowded emergency rooms. Moreover, it is all too often delayed for reasons of cost, distance, or fear of treatment by the health care system, until a health need has escalated into a crisis. A baby's fever becomes meningitis; a strep throat becomes rheumatic fever; a woman's pregnancy becomes a medical emergency. The reason for these disasters is not that parents do not care: incessantly overcrowded waiting rooms in the relative handful of good community health clinics that are available to poor and medically underserved families with children are a testament to the effort these families will make to get care for their children. These disasters happen mainly because of the absence of a basic health care system for children.

   No family can afford a fundamental human necessity as expensive as health care on its own. Virtually all families need sizable economic subsidies in order to pay for care. Thousands of communities need economic assistance to attract, support, and retain an adequate supply of health care providers. But the nation has managed to develop a system that supplies adequate health care to only a portion of all American children and that leaves millions uninsured and underserved.

   Regardless of whether interventions beyond or in addition to medical care affect the health of children, all children need medical care. Were childhood poverty to disappear tomorrow, some of the most blatant health status and health care access problems would abate, but they would by no means disappear. Employment-based health insurance, which for the last five decades has been the central mechanism for distributing health resources to working families with children, shows widespread signs of crumbling, particularly in the case of coverage of minor dependents. Without aggressive intervention, the health problems reviewed below (which are frequently associated only with the poor) will confront ever greater numbers of children. Thus, although childhood poverty is intimately related to poor child health, the threats to child health transcend simple measures of poverty.

   1. Measures of Child Health

      There are certain basic indicators that most health researchers consider key measures of child health. This Commentary reviews data on five of these basic indicators: infant birthweight; prenatal care; infant and child mortality; infant mortality by cause; and childhood immunization status.(11) These are bellwether indicators that provide a sentinel picture of the health of children. Each is measurable, and each can be improved with known, relatively inexpensive, and highly cost-effective interventions.

      1. Infant Birthweight

         In 1988, over 270,000 infants-6.9% of all U.S. infants born that year-were born at low birthweight (weighing less than 5.5 pounds at birth).(12) Infants born at low birthweight account for two-thirds of all neonatal mortality (deaths within the first twenty-eight days of life) and are twenty times more likely than normal weight infants to die during the post-neonatal period (twenty-eight days to one year).(13) Low birthweight infants are also at significantly greater risk for such lifelong disabilities as cerebral palsy, autism, and retardation.(14) Poverty and access to health care are the major determinants of low birthweight.(15)

         America has one of the lowest rates of birthweight-specific infant mortality in the world. This phenomenon is attributable to the relatively widespread(16) availability of advanced (and extraordinarily expensive) neonatal intensive care technology, which can keep extremely small infants alive and significantly reduce both death and severe disability.(17)

         Among all nations, however, the United States has an extremely high incidence of low birthweight. It is this excessively high frequency of low birthweight births (the nation ranked twenty-eighth selected countries over the period 1980-1988)(18) that underlies our elevated infant death rates. Although seven percent of all births are low birthweight, sixty percent of all infant deaths annually occur among low birthweight infants.(19)

         As with other key measures of child health, data on low infant birthweight are collected by race and ethnicity, not by family income. Because of the lack of direct economic measures, health researchers commonly use race as a proxy in examining the health status of low income children.(20) Black children as a group are exceedingly poor, and thus their health indicators are particularly instructive.(21)

         In 1988, thirteen percent of all black children were born at low birthweight. The disparity between black and white low birthweight rates that year stood at 2.32:1--the widest gap since birthweight data by race were first collected in 1969.(22) The elevated rate of low birthweight which affects one in every eight black infants born in the United States is a primary cause of the high U.S. black infant mortality rate.(23)

      2. Prenatal Care

         Prenatal care has a significant impact on the incidence of low birthweight and, consequently, on infant death and disability.(24) Infants born to women who receive comprehensive prenatal care that begins early (by or before the third month of pregnancy), and that continues throughout pregnancy, are significantly likely to be born at full term and at normal birthweight. Pregnancy care permits health care providers to detect and treat the many conditions that can lead to infant (and maternal) death and disability.(25) It is also highly cost-effective. Savings to the health care system resulting from reducing the incidence of low birthweight (and thus the high long- and short-term costs associated with treating low birthweight infants) have been estimated at more than...