For Kids, Being Uninsured Can Be A Killer

It’s easy to get lost in the dismal statistics coming out of the new study on children and health insurance: there are 7 million uninsured kids in America; they’re 60 percent more likely to die in the hospital than insured kids are; basic insurance could have saved 17,000 of them from dying over the last two decades. But let’s step back from the numbers for a minute. Let’s say you’re the parent of a 5-year-old boy.

One day you notice that your son’s breathing is ragged, that he can’t run around for long before he starts to gasp for air. You take him to the pediatrician’s office, where he’s diagnosed with asthma. You live just below the poverty line, and your son is insured by Medicaid, which pays for the inhaler he needs.

The next year, your son needs a refill on his inhaler. But now, he no longer has Medicaid because you didn’t fill out the raft of paperwork required to re-enroll him every year. You work two jobs that pay under the table, and you couldn’t pull together all the pay stubs and birth certificates and other documents the government requires for your kid to remain eligible. You can’t afford the inhaler on your own. Your son can probably scrape by without it for a few months, you think. He’ll have to.

Three months later, he’s doing worse. He wheezes; sometimes he can’t breathe at all. But without insurance, you can’t take him to the pediatrician, and there’s no nearby free health clinic. Finally, one night, your son collapses, and you rush him to the emergency room. It’s too late. He’s so sick that the hospital can do little for him, and he dies.

Now multiply that story by 17,000, and you’ll have an idea of what the numbers mean.

In the age of Medicaid and SCHIP, amidst political promises to get every child insured, why are there still 7 million children without health insurance? And why are these kids so much more likely to die when they land in the hospital? Most problems in health-care reform are complex; they don’t have clear-cut answers. But these two questions do, and the fact that we still have to ask them is “heartbreaking,” says Dr. Fizan Abdullah, the new study’s lead author and a pediatric surgeon at Johns Hopkins Children’s Center.

The reason 7 million children are uninsured is simple: the bureaucratic government apparatus that should be helping them has failed them. Medicaid and SCHIP (now sometimes called CHIPRA, after recent legislation that expands the program) do manage to cover millions of children—two million more today than they did in 2006. But they still don’t reach all the kids who are eligible. And there are still a swath of children whose parents make too much to qualify for programs like SCHIP but can’t afford family health insurance.

Why? Some families simply never hear about the programs because “outreach is so poor,” says Dr. Paul Wise, director of Stanford University’s Center for Policy, Outcomes, and Prevention. “There’s also a large number of these families who have been beneficiaries at some point but fall off the programs or are kicked out, because some states make it very difficult for families to remain enrolled.” Many states require families to prove, either every six months or every year, that they’re still eligible—a process that requires them to furnish dozens of documents while filling out paperwork so complex that “you need a lawyer just to understand it,” says Laura Shone, a pediatrician at the University of Rochester who has studied the issue extensively.

Families with two working parents or only one parent often can’t keep up with the requirements. They lose track of time or papers. They move around and change jobs. They may not even realize their kids have lost their insurance until long after it happens; the break in coverage is “in most cases entirely unintentional,” according to a 2007 study in Health Affairs. The re-enrollment process could be simplified to help these parents out, says Wise, but “state budgets are under enormous pressure, and one way to put a cap on spending is to create administrative barriers to families staying enrolled.” In other words, it’s cheaper not to pay for insurance for kids who need it.

Without insurance, these kids and their families can’t manage their health properly. The lucky ones find care at free clinics, although it’s not necessarily as good as what they’d get with insurance: “People who are funneled to facilities specifically set up to take care of poor patients don’t always get high-quality care,” says Wise. The really unlucky ones don’t get any care at all. Shone’s work has found that children who are uninsured for a year are twice as likely to go without any medical help the entire time—preventive care, acute care, or prescriptions—as children who have insurance all year.

Here lies the answer to the second question, why are uninsured kids more likely to die in the hospital? By the time they show up in the ER, they’re often too sick to be saved.

The new study is explicitly about correlation, not causation: it doesn’t say that kids are dying specifically because they lack insurance. But if you look closely at the data, it might as well. Kids who show up in the hospital with complications that might have been warded off by preventive care, like chronic diseases such as asthma and diabetes, or once-mild colds that have devolved into pneumonia, are much more likely to die if they don’t have insurance. But among kids hospitalized because of trauma (say, from car wrecks), having insurance or not doesn’t make much of a difference; the death rates are the same. That means the health effect of not having insurance is “occurring in a pre-hospital setting,” says Abdullah. These kids need preventive care, and if they don’t get it, they become critically ill.

And they do show up sicker than kids with insurance: they die more quickly, with shorter and less expensive hospital stays. “You’d think the hospital would spend more money on them because they’re sicker,” says Abdullah. “but the hospitals don’t even get that opportunity to provide the care. The kids are already too far gone.”

Abdullah is a doctor, not a policymaker, and his study is written in the measured, data-heavy language of science. But he sees young patients every day who live out the numbers he’s analyzing, and he’s very, very angry. “Our civilization and our nation will be judged by how we treat our most vulnerable,” he says. “For us, with all the societal resources and wealth we have, to not prioritize children’s health care is almost unforgivable.”

Wise, too, is worried about the kids behind the numbers. “Everybody in the child-health world has applauded the progress that’s been made with this administration and this Congress,” he says. “Nobody’s 'for' infant mortality. My concern, however, is that when the bare-knuckle political fighting over health-care reform gets going, children’s issues may go unprotected. They’ve already been largely marginalized.” It will take more than studies, however troubling, to put children’s health where it belongs—at the forefront.