Needy children need answers

By Henry Tomes, PhD
Executive Director for the Public Interest

What's happening? No, this is not the neighborhood greeting of years gone by, but rather a real question about changes needed in access to and availability of health services for children and their families.

Of the more than 40 million Americans who have little or no access to health care, 10 million are children. However, these are not the children that one thinks of when unmet needs are discussed. Rather, they are children of working families who can't afford to buy health care or whose employers have failed to provide care as a benefit. These families, often described as the working poor, are unable to qualify for Medicaid benefits because their incomes are above federal poverty levels, but are not high enough to enable them to purchase health insurance or purchase it out of pocket.

There continues to be a shameful lack of mental health care for children considering the overall wealth of the nation. Mental health services are available to poor children through Medicaid programs jointly funded in partnerships with the states and federal government. However, most states have received waivers that enabled them to manage care for Medicaid eligible children-which probably has the effect of making service access more problematic.

These programs, while important, provide only limited coverage for children in need. While inadequate to meet the needs, these programs nevertheless represent significant increases over past efforts. However, there is considerable room for growth. APA is continuing to advocate full coverage for all children.

Mental health and health care

Since 1994, the Center for Mental Health Services has administered the Comprehensive Community Mental Health Program for Children and Their Families. It began with an appropriation of $35 million; it has been increased to $78 million. In 1997, the last year for which data were available, 22 communities received grants that enabled them to augment other funds and provide a wider array of services to 22,000 children and their families.

While hailed by mental health advocates as a significant step ahead, the program makes only the smallest dent in the overwhelming need for community-based services to children with serious emotional disturbances. The 1997 data revealed that slightly more than a third of children served received a primary diagnosis of conduct or adjustment disorders, while only 2 percent were diagnosed as experiencing a psychotic disorder. A fuller evaluation of services to children and families, of course, must take into account other services provided from states' resources as well as those supported in state-federal partnerships such as Medicaid.

It is said that the longest journey begins with the first step; clearly this is the first step on a very long journey.

For children and their families, the passage of the State Child Health Insurance Program (CHIP) in 1997 represented an important step in improving access to health care. CHIP, Title XXI of the Social Security Act, provides access to health care for children who are not covered by Medicaid, Title XIX of the Social Security Act or employer purchased benefits such as Blue Cross-Blue Shield. This program a wide range of health services including mental health care.

Congress, at the urging of the Clinton administration, has authorized $24 billion for the program's first five years. While the funds authorized appear significant, it is likely that only a quarter an estimated 10 million children and youth will be given access to previously unavailable services. Although modest in terms of the number of children ultimately to be reached, CHIP has made it possible for some families to get more preventive care for their children rather than to access care in stressful crisis or emergency situations.

What's really happening?

I have highlighted these programs because they are recently authorized and address significant needs. Few people oppose health care to children, poor or otherwise. Yet children continue as one of the most underserved groups, primarily, some say, because they lack political clout-i.e., they are too young to vote.

These programs represent the real happening, an alternative to the massive, ill-fated comprehensive health-program proposed early in the Clinton administration. The alternative to big cost, big bureaucratic scheme is incrementalism. Address some unmet needs here, some there and soon there are enough patches to make a quilt. A weird quilt, but one that nevertheless may ultimately provide coverage for all. First an incremental quilt to cover children, then perhaps there will be the political courage to initiate a women's quilt, then.who knows?



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