The Vote: Helping Children for over a 100 Years

A few weeks ago, I spoke at a pediatrics residents’ symposium about politics, civic engagement, the health of our patients and families, and how voting is critical in tying all of these together.  At the end of my talk, I shared three images with my fellow child advocates, encouraging them to exercise their right to vote, and to see it as yet another form of child advocacy. 

The first picture is an iconic photograph from the women’s suffrage era, taken in 1920, of Alice Paul and a group of women holding a banner with a quote from Susan B. Anthony, “No self respecting woman should wish or work for the success of a party that ignores her sex.”  These words are still true today as they were over 90 years ago, and the image itself is a powerful reminder of how valuable the right to vote is.  However, it is also worth remembering what these women wanted to do with the right to vote:  increase safety at the workplace, adopt a minimum wage, and better the lives of children.  Women like Florence Kelley understood how voting could address the atrocities of child labor.  In 1905, recognizing that women did not yet have the right to vote, she gave a speech encouraging male workers in factories to use their vote to urge legislatures to pass policies protecting children from the dangers and abuses of the workplace: 

“We can enlist the workingmen on behalf of our enfranchisement just in proportion as we strive with them to free the children. … For the sake of the children, for the Republic in which these children will vote after we are dead, and for the sake of our cause, we should enlist the workingmen voters, with us, in this task of freeing the children from toil!” 

The second picture is one of many photographs taken during the civil rights movement of the 1960’s.  It is of African-American protestors carrying signs with various messages, all connected in their call for dignity:  “Unrestricted Voting Rights,” “Labor sat down for the right to strike, Students sit in for treat men alike,” and on the far left, “End school segregation, Endorse Supreme Court decision.”  These are ordinary men and women, all of who sacrificed so much in order to have the precious right of the vote for themselves and for the generations that followed.  Septima Poinsette Clark was a schoolteacher who had witnessed the devastating effects of discrimination on children, their teachers, and their societies.  She taught adults how to read and write so they could pass the literacy tests that were used to stop African-Americans from voting in many parts of the South.  Her students learned how voting contributes to the health of their democracy and the dignity of their children. 
 
The third photo was of a button from the American Academy of Pediatrics saying, “I care for kids and I vote,” next to the Academy’s advocacy icon, AAP Charlie.  The men and women in either of the two photographs described above could have worn this button.  As I cast my ballot today, I felt the weight and pride of this badge of honor.  There is an under-appreciated history of child advocates who sought the right to vote so they could use the ballot as one of many tools to improve the lives of children.  This election season, there are many decisions to be made across the country for candidates and ballot initiatives that can impact the lives of our children.  Our votes will determine issues ranging from Medicaid, education, health care funding, reproductive health, and marriage, just to name a few.  We owe it to our voting rights champions of our past, the children we care for today, and our common future to make the tough decisions and vote.  




(Images used in this blog post can be found at Wikimedia Commons, Common Knowledge, and http://www.aapgotv.org/)

Governor, Will You Stand in the Clinic Door?

“Segregation now, segregation tomorrow, segregation forever!” George Wallace said this now infamous line on January 14, 1963 to thunderous applause at his inaugural address when he became Governor of Alabama.  Wallace won the election because of his defiant views towards the federal government’s efforts at racial integration, including the Supreme Court’s unanimous decision in 1954 regarding Brown vs. Board of Education, that made segregation unconstitutional.  Almost fifty years after Wallace’s speech, we once again find governors putting politics before civil rights.  In Texas, Florida, Louisiana, South Carolina, and many other states, governors have declared their defiance of the Affordable Care Act, which seeks to extend the basic human right of health care to millions of poor, working-class Americans, many of whom belong to minority communities. 

Governor Rick Perry of Texas, Governor Nikki Haley of South Carolina, Governor Bobby Jindal of Louisiana, Governor Rick Scott of Florida, and Governor Scott Walker of Wisconsin have all issued statements and made speeches against the Supreme Court’s upholding of the Affordable Care Act.  They are perpetuating misinformation about the health reform law, but what is more dangerous is the fidelity these governors have for misinterpretations of “states’ rights,” like their predecessors from the 1950’s and 1960’s.  This ideology contributes to inequities in our current health care system, and we are morally overdue in establishing health justice for all. 

With the recent Supreme Court decision to uphold the Affordable Care Act, we can begin to remedy some health disparities among low-income and minority Americans.  Currently, African Americans are twice as likely as whites to lack health insurance, and Latino Americans are three times as likely to be uninsured.  If the Affordable Care Act is fully implemented, the rates of uninsurance are expected to drop from 22% to 10% for blacks, and from 33% to 21% for Latinos, according to the projections of a study done by the Urban Institute and published in Health Affairs this past May.

To be clear, much of this progress will depend on the expansion of Medicaid eligibility in 2014, and this is where leadership (or lack thereof) at the state level will matter.  The Affordable Care Act seeks to expand Medicaid to include individuals and families earning up to 133% of the federal poverty level (that’s $14,500 a year for an individual, and $30,000 a year for a family of four).  But, according to the recent Supreme Court decision, the federal government is now not allowed to force states to expand Medicaid.  If a state wants to continue denying access to Medicaid to a working parent (with two children) making say, $5,000 a year, (which is Texas state policy, that sets the upper eligibility for Medicaid at 26% of FPL for parents), then the federal government must follow the previous rules on funding that state’s Medicaid program. 

However, if a state opts to participate in the Affordable Care Act’s expansion of Medicaid in 2014, then the federal government will provide 100% of funding for the state’s Medicaid program from 2014 to 2016.  Then the federal support gradually decreases to 90% in 2020 and stays at that level for every year after that.  Many health policy analysts have argued that states will take the deal, which is too good to refuse in light of rising uncompensated health care costs.  While I see reason to share in this optimism, there is plenty of evidence from the current condition of the uninsured that should make advocates cautious and vigilant. 

Sadly, under the current federal-state partnerships on Medicaid, many states are falling short when it comes to enrolling eligible patients and families.  Of the 8 million uninsured children in our country today, almost 2/3 of them are eligible for Medicaid but are not enrolled in the program because states either fail to reach out to the families and/or states make the enrollment process unnecessarily difficult.   The Affordable Care Act seeks to rectify these issues, but states are not obligated to cooperate. 

Indeed, where a child lives can impact his/her access to health insurance.  In six states (Maine, New Hampshire, Vermont, Massachusetts, Wisconsin, and Hawaii), the uninsured rate for children is 5% or less.  That rate increases to 15% or more in four states:  Florida, Texas, New Mexico, and Nevada.  Over a third of all of our country’s uninsured children live in just five states:  New York, Georgia, Florida, Texas, and California.  Most of these variations in coverage can be attributed to how state policymakers use (or misuse) their “states’ rights” to determine which families qualify for Medicaid/CHIP and how they are enrolled. 

The disparities between states’ Medicaid eligibility standards and enrollment procedures plays a part in the disparities in uninsurance between different ethnic groups.  With over half of all American children now being born to minority families, it is worth considering that 1 in 9 black children and 1 in 5 Latino children lack health insurance (that’s compared to 1 in 13 white children).

In June 1963, six months after Governor Wallace promised to defy federal policies and to keep Alabama segregated, he physically stood in a doorway at the University of Alabama to stop two qualified black students, James Hood and Vivian M. Jones, from enrolling.  This ugly episode of American history became known as the “Stand in the Schoolhouse Door.” Local law enforcement was unable to convince the Governor to step aside and allow the students to enter.  Resolution of this conflict ultimately required President Kennedy to federalize the Alabama National Guard, who ordered Wallace to step aside and allow the students to enroll. 

I do not anticipate Governors Perry, Haley, Jindal, Scott, Walker, or others doing anything cruel like standing in the doorway of a community clinic, blocking eligible patients from entering.  Nonetheless, their political stance against the Affordable Care Act, and their apathy for the seriousness of health disparities, will deprive families of their right to the highest possible state of health.  The Affordable Care Act offers a starting point for building a better health care system, but real progress will depend on policymakers in every state abandoning the obsolete ideologies and misinterpretations of “states’ rights” held by their predecessors.  Real progress will require state and federal policymakers deploying their political will and resources to promoting a new age of health justice for all.

Block Grants for Medicaid: The Pink Slime of Health Policies

Over the past two months, we have learned about the beef industry’s supposed attempts to reduce bacterial contamination in our meat through the use of “pink slime,” a filler made with the trimmings of cow parts and treated with ammonium hydroxide.  Some have argued that the use of this processed paste demonstrates the meatpacking industry’s commitment to addressing food safety.  But consumer advocates, pointing towards findings that bacteria remain in these meat products, argue that pink slime provides just another way to cut corners and turn over a profit.  The pink slime controversy raises serious questions about allowing industries to develop and distribute consumer products with the expectation of complacent consumption, regardless of the products’ risk or potential harm. 

Sadly, over the past two months, I have had similar concerns about federal policymaking regarding Medicaid, where pink slime is being pushed on the public in the form of substandard health policies.  Both the “Ryan Budget” plan passed by the House last month and the budget proposal pushed by Senator Pat Toomey call for repealing the Affordable Care Act and turning Medicaid into a system of block grants.  Under these proposals, federal support for Medicaid would be frozen to a fixed amount of money allocated for each state, regardless of whether the state were to suffer a natural disaster, economic downturn, or other unforeseen catastrophe.  Medicaid would also lose $810 billion and one third of its federal funding by 2022.  To make matters worse, there is a proposed cap on federal spending for Medicaid, which means there would be less and less support to cover the costs of health care services for poor working families. 

These supposedly “safe and sound” products of budget policymaking are disastrous for our children’s health. A block grant system coupled with spending caps erodes federal support for Medicaid, thus leaving states to their own devices on determining who is eligible for health care, what benefits to provide, and how to fund health care for poor working families.  While proponents may trumpet these changes as “flexibility” for states, block grants and spending caps are really just federal pink slime products that would give rise to even more pink slime at the state level. 

Currently, Medicaid and the Children’s Health Insurance Plan (CHIP) provide access to health care for about 30 million children, who represent just over half of those enrolled in Medicaid.  Under a block grant system, the 4.6 million children who received health insurance through Medicaid/CHIP at the beginning of the current recession would have no coverage because there would not have been federal funding to support them.   The current system of federal funding for Medicaid allows states the flexibility to continue offering health care to eligible families, during good times and bad.  Block grants would allow states to deny health insurance to needy working families.  During times of trouble, more children and families will be left out in the cold, without health care, because of eligibility restrictions.  Under the Ryan Budget, the Urban Institute estimated that somewhere between 14 million and 27 million people would be dropped from Medicaid by 2021.  Because that proposal also repeals the Affordable Care Act, an additional 17 million people would no longer get health insurance coverage through the expansion of Medicaid. 

Even for the few families that still qualify for Medicaid in a block grant system, budgetary restrictions will reduce the quantity and quality of the health benefits available to their children.  Currently, Medicaid and CHIP are required by law to offer comprehensive coverage for children as laid out by the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) rules.  This means Medicaid coverage currently includes vaccinations, developmental screenings (including screening for autism, speech delay, learning disabilities, and other manageable conditions), preventative check-ups, sub-specialist and hospital care, and chronic disease management.  For poor working families, like the ones I care for in southeast Washington, DC, this broad range of services is vital because low-income children have more complicated health care needs and are more vulnerable than higher-income children with private insurance.  Under a block grant system, states would not be required to provide high quality, comprehensive care, and many states would reduce their Medicaid/CHIP benefits to a pink slime of services in order to cut costs.  Many states are already cutting Medicaid reimbursements to health care providers to “pink slime” rates, and this trend would worsen under a block grant system.  Altogether, these policies will lead to millions of children suffering unnecessarily because their health problems, (like asthma, autism, birth defects, sickle cell disease, and so on), receive insufficient preventative care, inadequate chronic disease management, and unreliable access to primary care and sub-specialists. 

A block grant system for Medicaid is supposed to alleviate the federal deficit and give states greater flexibility in reducing their health care costs.  However, block grants would create more lingering problems than solutions.  Just because children and families are restricted from joining Medicaid, and just because those who would still be eligible are restricted from comprehensive services, it does not mean all of those healthcare needs disappear.  If anything, the healthcare needs of poor American families will grow and become more expensive for the country, because families will use emergency rooms for problems that could have been more effectively managed (and prevented) by better primary care.  Every child who lacks health insurance costs an average of $2,100 more per year to a local community than a child with Medicaid or CHIP.  Every child with insufficient coverage is similarly expensive.  These facts should cause alarm for child health advocates and deficit hawks alike. They demonstrate that block granting Medicaid is an ineffectual health policy solution being passed off as a good one, leaving states with more fiscal challenges than they currently face.   

When the meatpacking industry sells us pink slime, what really angers American consumers is the feeling of being cheated:  that the corporations’ profit is more important than the quality of their product.  We are left with a feeling of being deemed unworthy of better treatment or more dignified consideration.  We should be similarly outraged when our members of Congress try to cut corners in policymaking, especially when it comes to the health care of our fellow Americans struggling in (or near) poverty.  Turning Medicaid into a block grant system is an inadequate policy product for addressing our country’s federal deficit, and would be disastrous for the health care of millions of children, seniors, and the disabled.  Pink slime is intolerable, whether it is in our children’s school cafeterias, our grocery stores, or in the halls of Congress.

10 Ways the Health Reform Law is Helping My Patients Right Now

As the Patient Protection and Affordable Care Act’s reaches its 2 year anniversary, there has been much speculation about how the law will effect Americans as we await its fate before the Supreme Court and its full implementation in 2014.  Those conversations are important, but let’s not miss the health reform law’s important accomplishments, many of which are going on right now.  My patients and their families in southeast Washington DC are among millions whose health and peace of mind have benefited through several provisions in the Affordable Care Act.  As a pediatrician, I am obviously partial to those provisions impacting child health, but as an American I am also proud of how the health reform law helps my patients’ parents and grandparents.  Thus, this is list of ACA accomplishments from the past 2 years, in no particular order. 

1. Insurance companies are now prohibited from denying coverage to children with pre-existing conditions.  Though the insurance companies may argue this used to be done for the sake of moral hazard, it was morally reprehensible to deny health insurance to any child, including the four to 17 million children with conditions like asthma, obesity, or other chronic conditions such as cerebral palsy.  Thanks to the Affordable Care Act, this shameful practice became a thing of the past in 2010, and 2 million children have gained coverage since then.  The law will protect adults with pre-existing conditions in 2014.  
2. Young adults can be covered by their parents’ health insurance up to age 26.  Approximately 2.5 million Americans are now covered through this provision.  Having cared for the survivors of childhood cancer, birth defects, and organ transplants, I can only imagine the peace of mind millions of parents must be experiencing, knowing their sons and daughters will continue to receive necessary medical care.  
3. Free preventive health services are now available in our health insurance plans (with no co-pays), and around 54 million Americans have already made good use of these services, which include immunizations, pap smears, mammograms, and colon cancer screenings, just to name a few.  Pediatricians across the country are adopting the excellent screening standards established in the Bright Futures periodicity schedule, through which we can better detect developmental disabilities (including autism, speech delay, and others).  As a physician, it is a relief to know more patients and families can take action to reduce their risk of serious illness and disability.  
4. Another ACA accomplishment in preventive health care is the establishment of the Prevention and Public Health Fund, which supports programs to help more communities avoid tobacco use, obesity, and cancer.  To fully realize these goals, this fund needs to be protected from cuts during debates over the budget and deficit.  
5. Insurance companies can no longer rescind coverage from people who make simple errors on their initial applications.  They are also prohibited from imposing lifetime limits on a patient’s coverage.  This is particularly important to patients like the ones I mentioned earlier:  cancer victims, premature infants, and children with developmental disabilities and rare diseases, all of whom can have health care expenses that exceed an arbitrary lifetime limit.  
6. Between 2010 and 2011, through a provision to help seniors trapped in the Medicare Part D “doughnut hole,” 3.8 million elderly Americans each received $250 in rebates.  As of August 2011, a 50% discount was given to 900,000 Medicare beneficiaries for their prescription drugs.  That is real relief for my patients’ grandparents. Under the ACA, the "doughnut hole" will continue to shrink and ultimately disappear in 2020.   
7. If you have recently thought twice about what you bought at a fast food restaurant because you saw some helpful nutrition facts on the menu, then you are benefiting from a little-known but widely-seen accomplishment of the ACA.  Chain restaurants and vending machines are now required to disclose nutritional information on standard menu items.  Having this information is a small but important step in reversing America’s obesity epidemic.  
8. Federally qualified health centers (FQHC’s) and the National Health Service Corps (NHSC) broaden access to health care for millions of Americans living in rural and inner-city communities where there are few health providers.  This mission, which is all the more important during tough economic times, has been supported through the health reform law’s increased funding for NHSC and its health centers.  
9. Through the ACA, the healthcare workforce is getting guidance from a newly established National Health Care Workforce Commission, which provides important recommendations on how doctors, nurses, dentists, and other health professionals are recruited, trained, and distributed among different communities.  Also, the Graduate Medical Education (GME) program is being reformed to increase the supply of health care workers, especially in primary care (which includes pediatrics, geriatrics, and family practice).
10. Given the concern most Americans have for the rising costs of health care in our country, it important for us to get the most bang for our buck.  Under the medical loss ratio (MLR) provisions of the health reform law, for every dollar given in premiums to an insurance company, 80 to 85 cents must be used for health care, not administrative expenses or executive bonuses.  If they fail to follow through, the insurance companies will have to send rebates to their customers. Though several states have been given a waiver on implementing this rule, it puts insurance companies on notice to spend our premium dollars on our health, not their wealth. 

From my perspective as a physician and advocate for health policy, the Affordable Care Act is off to a strong start, and I look forward to more of the provisions to be implemented in the years to come.  I encourage fellow Americans, including members of Congress, to really look past the melodramatic hype and familiarize themselves with the health reform law.  The ACA has the potential for us to get more bang out of our health care bucks and build a 21st century health care system that delivers high quality care to every American, regardless of where they live, what they look like, or how much they earn.