Children: The real victims of our nation’s insurance crisis

MGMA Connexion, Vol. 2, Issue 6, July 2002

By Jeanan Yasiri, FACMPE, MGMA member and Vice President for Service Innovation , Dean Health System, Madison, WI

Thomas H. Blinn, CMPE, MGMA member and Vice President, Sutter Physician Alliance, Sacramento, CA

"If we raise a generation of insured children, they will see health insurance in the same way that we see public schools: It will become part of the social fabric. They will never have been without insurance."

These sage words from Steve Freedman at the Institute for Child Health Policy, University of Florida, suggest that by developing methods to ensure access to health insurance and health care, we will truly invest in our future. That's why it's tragically ironic that children are one of the populations most eligible for health benefits - but are not obtaining them.

Knowledge of programs 

The survey on the uninsured found that most Americans don't know about programs to help expand insurance coverage. It also found that people would enroll in these programs if they are eligible.

Half of Americans are familiar with Medicaid and about a quarter (24 percent) are familiar with the Children's Health Insurance Program (CHIP), two initiatives that provide medical assistance to low-income families. However, even without knowing much about them, more than half (52 percent) of Americans overall and 84 percent of uninsured adults with children say they would enroll their child in CHIP if they had more information. 1

Complexities keeping families out 

Because of the complexity of public assistance efforts and employer-sponsored health insurance benefits, many people simply do not enroll in the programs for which they are eligible.

Children represent the largest portion of the uninsured in the United States. Among the 12 million children who are uninsured, 62 percent are eligible for Medicaid or CHIP but not enrolled. Nearly 70 percent of uninsured children come from families with incomes less than 200 percent of the federal poverty level. 2

Access to insurance unquestionably affects children's health. Uninsured youngsters are three times as likely as privately insured children and twice as likely as publicly insured children to lack a regular source of health care.3In response to this, Congress established CHIP in July 1997, which provides $20.3 billion in federal matching funds as block grants to states (1997-2002) to help children. In some cases, the parents of eligible children also get access to these benefits.

The current economic downturn poses the risk that even more uninsured families - technically eligible for CHIP benefits - may face increasing hurdles to obtaining those benefits as states struggle with blossoming caseloads.

Because CHIP is guided by individual state public policy, CHIP efforts vary widely from state to state. Disturbingly, in May 2000, three years after passage of this measure, the Department of Health and Human Services (HSS) reported that states had not used hundreds of millions of dollars set aside to promote CHIP efforts. The states simply had not claimed the money. Of the $500 million appropriated to the national CHIP effort, $383 million remained unspent after three years. The figures showed that 21 states had spent less than 10 percent of the money they were allocated to help preserve Medicaid for people leaving welfare. HHS reported that Texas, Georgia, Hawaii, Louisiana, Nebraska and Tennessee had not spent any of their money.

Children of noncitizen parents

The other group often forgotten in health insurance includes children born in the United States to mixed-status families. Because they are citizens, these children are eligible for benefits regardless of their parents' citizenship status.

It is estimated that nearly one in 10 families with children is a mixed-status family or a family in which one or more parents is a noncitizen and one or more children is a citizen. Mixed-status families make up at least 9 percent of U.S. families with children. Further, mixed-status families are themselves complex - they may comprise any combination of legal immigrants, undocumented immigrants and naturalized citizens. And because the composition of the family often changes frequently as undocumented family members legalize their status and legal immigrants naturalize, the picture for securing benefits becomes even more complex.4

Also significant:

  • Mixed-status families constitute 14 percent of all such families with incomes under 200 percent of the poverty level; and
  • Twenty-one percent of all uninsured children nationwide and more than 50 percent of California's uninsured children live in mixed-status families.

Others who are eligible but unaware 

Bobby Peterson is executive director of the Madison, Wis.-based ABC for Health, a not-for-profit public interest law firm that helps patients obtain access to public and other health insurance benefits for which they are eligible. Peterson points to health care providers as an obvious entrée to benefits counseling - but one of the weakest links in providing that very service.

"(Health care providers) think they are doing it, but they aren't to the level of sophistication that they really need to be in order to serve their customers," Peterson says. "You really need to have sophisticated training and understanding of the nuances of these public benefits and insurance programs to make sure patients are getting what they need and deserve in the health care financing system."

ABC for Health, with the help of a Covering Kids grant from the Robert Wood Johnson Foundation, provides training to health care providers, public health representatives and others who frequently come in contact with families and individuals who are uninsured or underinsured.

Peterson has worked with numerous providers who assume that their business offices are already exhausting outreach efforts, when the reality is far different. "I've actually gone to court in situations where an institution has provided charity care up to a certain level and then sued the family for the balance when the entire bill could have been covered under Medicaid," Peterson says. "It's the disconnect between what the [organization's] administrators think is going on between their staff and patients and what is actually happening. What's worse is that organizations are making donations to help uninsured families get their health care, and it's being wasted to a certain degree because it could have been covered elsewhere."

Such efforts in comprehensive training of health providers have proven successful in various practices, including Dean Medical Center, a multispecialty group practice serving a 17-county market area in south-central Wisconsin. Dean's health benefits counseling efforts serve hundreds of patients annually, including many children, and recoup just under $1 million in public assistance reimbursements that otherwise would have been considered bad-debt accounts.


  1. Survey on the Uninsured conducted by "The NewsHour with Jim Leher" and the Kaiser Family Foundation January-February 2000
  2. Kavanaugh LD, Carpenter MB. Outreach to children: Moving from enrollment to ensuring access. National Center for Education in Maternal and Child Health, 1998.
  3. Weinick R, Weigers M, Cohen J. Children's health insurance, access to care, and health status: New findings. Health Aff March/April 1998.
  4. Fix M, Zimmerman W. All under one roof: Mixed-status families in an era of reform. The Urban Institute, June 1999.