Archives for March 2017

Healthcare Reform Must Prioritize Children and Avoid Fixed Payments

Shetal Shah, MD, FAAP

Shetal Shah, MD, FAAP

(As healthcare reform continues at a fast pace, Chapters have been working to highlight the potential impact proposals within the American Health Care Act will have on children.  Given Medicaid’s vital role in providing health insurance to children, protecting its budget from policies that would result in restricted enrollment or decreased services has become a national American Academy of Pediatrics’ priority.  Here, two active AAP members from neighboring chapters, Drs. Shetal Shah and Heather Brumberg, outline how measures to “Block Grant” or instill “Per-Capita Caps” on the Medicaid program will affect children.  This blog post was originally published as an Opinion-Editorial piece in Tulsa World, a prominent newspaper in Oklahoma.  It is available here.)


At a time when national healthcare can change with a tweet, politicians seeking to “Repeal and Replace” the Affordable Care Act (or Obamacare) are proposing to weaken our children’s healthcare safety net.  President Trump aims to convert Medicaid to a Block Grant System which gives states a fixed dollar limit to fund their entire Medicaid program.  Features of this plan also appear in House Speaker Paul Ryan’s proposal, “A Better Way.”  Auditions for potential replacements of healthcare reform have also included these provisions.

We experience the Affordable Care Act each day.  As pediatricians who care mostly for infants in the Medicaid program, this fiscal maneuver will hurt children, decreasing their access to preventive care.  It also ignores the intangible benefits children experience when they have stable health insurance.

Children in the Medicaid program receive advantages aside from better health.  Rates of child poverty are epidemic, and include 1 in 5 children.  Poverty impacts the brain development of growing children, leading to increased rates of distractibility and longer times to learn new tasks.  Studies illustrate impoverished children have differences in parts of their brain which affect emotions, decision-making, and language.  As a strategy to elevate kids out of poverty, Medicaid yields significant benefits.  Data from the Georgetown University Center for Children and Families shows children with Medicaid grow up to be healthier adults, and achieve greater economic success than if they had periodic coverage.

Medicaid is the nation’s largest child health insurance program.  Expansion of Medicaid under the Affordable Care Act means the program now covers almost 30 million children.  This has led to the lowest rate of uninsured children (4.8%) EVER.  Children are over-represented in the Medicaid program, comprising only 20% of the population but almost 50% of Medicaid beneficiaries.

Though popularly conceived as a social handout, the parents of our infant patients often work 2 jobs apiece as janitors, waiters and daycare attendants, but still can’t earn enough to phase out of the program.  Since children are healthier than adults, pediatric Medicaid recipients incur only 20% of Medicaid costs, mostly in preventive care like immunizations, lead and autism screening.

A key factor of Medicaid is its economic adaptability.  States share the costs of new enrollees with the federal government, so they are encouraged to enroll as many children as are eligible, including my newborn patients.  During the “Great Recession” 3.7 million people moved to Medicaid.

However if converted to a Block Grant system, or per-capita cap program, states will bear the costs for new enrollees or increased children’s healthcare on their own.  Unlike the federal government, 45 states have balanced budget amendments, which mean they cannot take on debt to provide children with healthcare in times of economic recession.

This backward step for children’s health insurance leads to reduced coverage, unnecessary obstacles meant to deter families from enrolling their children in Medicaid and limited physician payments – all of which reduce access to care and literally sicken a third of our nation’s kids.  Practically, that means “addicted” babies born to opiate-exposed mothers don’t get home visits by nurses to ensure they are thriving.  It means new mothers won’t see lactation consultants to support breastfeeding.  A Block Grant program would mean premature babies, at risk for cerebral palsy, won’t be able to see a neurologist.  It will mean long waits for parents of autistic children to see specialists.

Even if you don’t receive Medicaid, cuts could affect you.  The School Superintendent’s Association notes that should block grants be implemented, services benefitting all children will be cut first.  These include school-based vision and hearing screening and fewer nurses in schools.

How much funding are states expected to lose?  Block Grant programs are not new, and had those proposals been implemented, states would have had to cut $76.6 billion dollars over a 10-year span by slashing child enrollment and refusing necessary services.

Why are children especially vulnerable to Medicaid funding cuts?  Despite being the most cost-effective population to insure, children suffer excessively in times of fiscal crisis.  Since children are 0% of the vote, and their lost preventive care is less visible than reducing payments for adult acute care like health attacks and strokes, our newborn infants are the main course on the financial menu.

One night in our unit slept 2 babies.  One infant’s mother was a professional from a wealthy suburb, the other baby’s mother cleaned rooms in a local hotel and took 2 buses each night to be with her ill newborn.  A well-funded Medicaid program gives each of these babies a chance to reach their full potential.

Obamacare has flaws.  It made no improvements in malpractice reform, did not curtail the unconscionable costs of prescription drugs, fails to provide universal coverage to all children, does not substantially fund comparative outcomes research which could save billions and increased taxes in certain income brackets.  Efforts to “Repeal and Replace” would be better spent in addressing these issues instead of jeopardizing healthcare for 30 million children.

The babies need us, but are we there for them?

(Dr. Shetal Shah is the Legislative Secretary and Secretary for the American Academy of Pediatrics, District 2, Chapter II.  Dr. Heather Brumberg is Vice-President of the American Academy of Pediatrics, District 2, Chapter III.)