By Christopher Lee
Washington Post Staff Writer
Tuesday, September 5, 2006
For the better part of a decade, fewer and fewer American children have gone without health insurance each year, a trend that diverged sharply from the seemingly inexorable rise in the number of adults without coverage.
For the first time since 1998, the number of children younger than 18 without health coverage ticked upward last year by 361,000, along with the overall increase in the ranks of the uninsured, according to census figures released last week. Of the nation's nearly 74 million children, about 8.3 million, or 11.2 percent, lacked coverage in 2005, up from 10.8 percent the year before.
The discouraging development surprised some health experts, who attributed the change to budget crunches that led some states to curtail enrollment of children in government-subsidized plans and steady declines in the number of people who receive health insurance through their jobs.
Children without health coverage are three times as likely as insured children to lack a regular doctor, according to a report released last month by the Robert Wood Johnson Foundation. Research from the American College of Physicians in 2000 found that uninsured children were less likely to be up to date on immunizations and to receive treatment for sore throats, earaches and other common childhood illnesses. A University of Texas study found that kids with insurance tend to have fewer school absences.
The uptick in the number of uninsured kids could play a major role in next year's debate in Congress over whether to renew the State Children's Health Insurance Program (SCHIP), a nine-year-old federal-state effort to provide health coverage to children of the working poor and near poor.
"There is a message in these numbers," said John R. Lumpkin, a physician who is a senior vice president at the Robert Wood Johnson Foundation. "The only reason that number [of uninsured children] isn't worse is because we have Medicaid and SCHIP. . . . We continue to have a crisis in this country with kids who have no health insurance."
Congress created the popular SCHIP program in 1997, directing tens of billions in matching funds to the states over 10 years. The goal was to provide health coverage for children whose families do not qualify for Medicaid but cannot afford insurance on their own -- generally those with incomes as high as twice the poverty level, or $39,942 for a family of four last year.
In the first six years, about 3.9 million children were signed up for coverage, but enrollment has flattened since 2003. In part, that is because an economic downturn led some states to raise premiums, reduce outreach efforts and impose enrollment limits and new administrative hurdles, said Genevieve M. Kenney, a health economist at the nonprofit Urban Institute.
"There's no question that we don't have the same momentum nationwide," she said. "Some of it is natural as the program matures. But I think the recessionary period and the state budget crunch were real factors in interrupting the momentum. And I don't think states have recovered from that."
Enrollment limits or freezes lasting six months or longer took effect in Alabama, Colorado, Florida, Maryland, Montana, North Carolina and Utah, Kenney said. Mississippi stopped accepting applications by mail. In Texas, where more than 20 percent of children are uninsured, the highest percentage in the nation, officials in 2003 imposed new premiums, eliminated dental coverage and began requiring families to re-enroll their children every six months rather than yearly.
"There was a $10 billion [state] budget shortfall," said Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission.
After peaking at 529,271 kids in May 2002, enrollment in Texas's children's health insurance program plummeted nearly 44 percent to 298,731 by June of this year, state figures show. Goodman said the decline was more than offset by increases in Medicaid enrollments, but the two programs serve different populations.
The most potent force behind the recent increase in uninsured children, experts said, is the decline in employer-sponsored health insurance as rising costs prompt businesses to raise premiums or cut coverage.
The latest census figures show that a record 46.6 million Americans had no health insurance in 2005, up from 45.3 million in 2004. Among those who did have coverage, fewer were receiving it through their jobs. In 2001, for instance, 62.6 percent of Americans had employer-sponsored coverage. By last year the figure was 59.5 percent, census figures show.
Katherine Swartz, a professor at the Harvard School of Public Health, said a trend toward trimming business payrolls and hiring contract workers has made things worse. More than a quarter of 25-to-34-year-olds do not have health insurance, said Swartz, author of "Reinsuring Health." For 35-to-44-year-olds, the uninsured rate is 19 percent.
"Those are the prime ages for having kids," she said. "These are unheard of percentages of those age cohorts that are uninsured. And, of course, if they have kids, their kids are not going to have health insurance either."
Corralling rising health care costs is one way to boost the number of insured children, said Diane Rowland, executive director of the Kaiser Family Foundation's Commission on Medicaid and the Uninsured. A more immediate step is better education and outreach because studies show that at any given time about seven in 10 uninsured children are eligible for low-cost or publicly subsidized coverage, she said.
"We lose some people because they are not aware that they might be eligible or they don't know how to go down and apply," she said.
Pride also is a factor, with some families reluctant to accept government help, said Lumpkin of the Robert Wood Johnson Foundation. "Part of our campaign is to convince them, 'You know, you pay your taxes, you might as well get the benefits,' " he said.
Researcher Madonna Lebling contributed to this report.