Negotiating the system of publicly financed pediatric health care

December 1, 2005

First of three parts: Who is eligible? What are the benefits?

First of three parts

Dr. Fine is a hospitalist, pediatric gastronenterology, and clinical instructor at Children's National Medical Center, Washington, D.C. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Who is eligible? What are the benefits?

Pediatric health policy can become explosive politics!

Medicaid, the State Children's Health Insurance Program (SCHIP), and Community Health Centers (CHCs) form the crux of the national public health-care safety net for low-income children. Each program represents part of the ongoing efforts of federal and state governments to provide children, and other vulnerable populations, with adequate health-care coverage and access. And each program faces challenges and unprecedented obstacles to its effectiveness that have made front-page headlines in recent months.

How eligibility is determined

Michael, 5 years old, lives with his single mother and two siblings. To enter kindergarten, he needs a full check-up and to be up to date with immunizations. He hasn't seen a doctor since he was 1 year old, however, because he has no health insurance. His mother makes $30,000 a year at a job that does not offer health insurance as a fringe benefit. Is Michael eligible for Medicaid or the State Children's Health Insurance Program?

For most of the 20th century, poor children had few health-care options. When ill, they were forced to seek care at an emergency room or from a fractionated system of municipally-run charity and philanthropic programs.1 Preventive services-if offered at all-were for the wealthy. Efforts to establish large-scale, federally-supported health-care alternatives for these children were often derailed by lack of support from legislators or intense opposition from interest groups who fought any notion of "socialized" medicine.2

Only when the enabling legislature for Medicaid was drafted in early 1965 did the federal and state governments acknowledge that ensuring the well-being of children and other vulnerable, low-income populations is, at least in part, a societal obligation.

Medicaid. This is a jointly funded program in which expenses are shared by the federal government and the states. The program is administered almost entirely by the states. As designed, each state has great latitude in determining eligibility criteria-in essence, creating 51 different Medicaid programs. The federal government has minimum eligibility requirements for recipients of benefits, but states are otherwise free to shape their program to meet regional needs.