Guillory

Editor's Corner

Government's role in healthcare

by Charleta Guillory, M.D.
Associate Professor of Pediatrics—Neonatology

Future healthcare for our children will be greatly influenced by choices we make today. Traditionally, financial responsibility for health insurance, such as Medicaid and CHIP, for low-income children has rested on the government. A concern is that public health funding for children is suffering and is driven more by political concerns and macroeconomic trends than by fairness or the needs of this vulnerable population. Physicians have been entrusted with the enormous responsibility for and privilege of our children’s healthcare and must work in conjunction with legislators vigilantly protecting children’s equal access to healthcare.

Consider the following timeline of legislative actions and their affects for the millions of children with limited access to healthcare:

• 1977: An estimated 11 million children in the United States are without health insurance. The Balanced Budget Act created a state Children’s Health Insurance Program (sCHIP) and provided $24 billion over 5 years and $48 billion over 10 years to expand health coverage to uninsured children.
• 1999: Texas legislature created CHIP—more than 500,000 children enrolled from April 1, 2000, to September 1, 2003.
• 2003: Devastating budget cuts caused 175,000 Texas children to lose CHIP coverage; remaining participants lost dental, vision, and hospice services. Medicaid enrollment increased but provider rates were not restored.
• 2004–05: U.S. federal courts rule that states (Cook County, IL, and Oklahoma) violated the equal access provision of Medicaid law.
• 2005: Texas legislature restored key aspects of CHIP to 2003 levels. Other restrictive cuts remain. No funding for enrollment growth.
• 2006: Proposed presidential budget would slash $60 billion from Medicaid over 10 years, potentially jeopardizing the healthcare safety net for millions of children; in April, congress limited the cuts to $10 billion over 5 years.

The need is neither denied nor ignored. Three articles in Pediatrics (2004–2005) touted the effectiveness of sCHIP, associating enrollment with improved healthcare access, decreased use of emergency rooms, fewer unmet needs, and improved continuity and quality of care. As evidenced by the U.S. federal court rulings in 2004 and 2005, federal officials realize the inequities. So, too, do states, which are struggling with the economics of financing equal access to healthcare resources. Perhaps, the federal rulings will help to elevate the value of children in society so appropriate funding is earmarked. But efforts are needed on all fronts.

Today’s physicians are caught in a global ethical dilemma. The morality of beneficence and autonomy govern at the bedside; patients and their families expect the best that modern technology can offer. But grave injustices occur daily—uninsured children in the emergency room, victims of no medical home, late diagnosis and interventions, and poor outcomes.

A key ethical principle is justice—the fair and equitable distribution of benefits to everyone, universal access to basic medical care. Distributive justice recognizes that resources are limited and should be fairly allocated among the population. In the United States, most people hold the belief that healthcare should be allocated according to need. When money and resources become scarce, justice takes on a new meaning. The dilemma is the ethical issue of setting limits and distribution of high-cost medical care so others can receive basic medical care. Constraints of cost control have thrust the topic of rationing to the forefront of health policy debates and made the justice principle a core ideal of medical ethics.

Physicians must be proactive in identifying problems and developing solutions. Participation in professional societies and child advocacy organizations, such as the March of Dimes, allows pediatricians to speak in one loud voice to communicate and negotiate access to healthcare for all children.