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......._---'T;..;;.;;H....;;E STATE OF AMERICA'S CHILDREN YEARBOOK 1998 and 10 million in 1975 to 20 million in 1996. The decline in private coverage for children, however, has begun to overshadow the Medicaid expansions. As a result, the number and percentage of uninsured children have risen to historic levels. Changes in Medicaid. In 1973 Medicaid coverage was largely tied to whether a family received cash assistance. In most states, children and pregnant women were denied Medicaid if their family income was too high to qualify for Aid to Families with Dependent Children (AFDC), even when that income was substantially below the federal poverty line. Dramatic changes occurred in the mid-1980s. The federal government fIrst permitted and then required states to extend Medicaid to large numbers of previously uninsured children and pregnant women from low-income, working families, and many states went beyond the minimum federal requirements. Medicaid eligibility was also expanded in many states to include numerous children with disabilities, including those from moderate-income families. Currently Medicaid covers one in four American children, including a large proportion of newborns and children with disabilities. The benefIts provided under Medicaid also expanded considerably (at least on paper) with the 1989 enactment of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements that children covered by Medicaid must receive any medically necessary health care. The 1989 provisions require states to provide children with services that may not be covered for other age groups under state Medicaid programs. The move to managed care. The country's basic health care delivery system has undergone fundamental change over the past 25 years. In the 1970s most Americans received health care through feefor-service insurance. They could seek care from any provider, and insurers reimbursed for services provided. In recent years increasing numbers of families have been enrolled in managed care plans, which offer more limited choice of providers and often reimburse for set fees regardless of the services provided. The era ofmanaged care has brought new challenges. Instead ofreceiving care from solo or group physician practices or from nonprofIt community hospitals, many families must now rely on forprofIt corporate entities of increasing size. In the • In 1996, 11.3 million children through age 18 had no health insurance-the highest number ever recorded by the Census Bureau. Seventy percent af all Americans added to the ranks af the uninsured that year were age 18 or younger. • Ninety-two percent of uninsured children have at least one working parent; 66 percent have a parent who warks full-time and year-round. • In 1996 more than 40 percent of Medicaid beneficiaries were enrolled in managed care plans; as recently as 1991, fewer than 10 percent were enrolled. • By 1996, 78 percent of all 2-year-olds were fully immunized, up from 55 percent in 1992. • Infant mortality is at its lowest level ever (7.6 deaths per 1,000 live births in 1995). Although maternal and child health indicators have impraved among Black children since 1991, their infant mortality rate (15.1 per 1,000) remains disturbingly high. 22 CHI L D R EN'S D E FEN S E F V N D
CHILD HEALTH past, advocates for low-income children and children with disabilities worried that too few providers participated in Medicaid. The new concern is that Medicaid managed care may not always furnish accessible, high-quality care and may deny essential services and referrals. Other developments. Shifting patterns ofillness have also created new challenges, while new approaches have helped curb old problems. Infant mortality has declined radically and today is less than half the 1973 level. Still, the vast majority of industrialized countries have lower rates than the United States. Moreover, troubling racial disparities continue to characterize infant mortality rates and other key indicators of maternal and child health (see table 2.1 and later discussion). Teen birth rates, associated with low birthweight and similar problems, rose during the mid-1980s and early 1990s, but they have declined steadily in the past several years (see chapter 7). Rates of vaccine-preventable childhood illnesses have fallen dramatically, thanks to new vaccines and greatly improved immunization rates since the early 1990s. This extraordinary improvement follows an immunization initiative begun by the Clinton Administration in 1993, which included the creation of the Vaccines for Children (VFC) program. VFC provides free vaccine to doctors immunizing uninsured children and children covered by Medicaid. Before the program was established, the price of all required vaccines for preschool children had risen from $28 in the early 1980s to $270 in 1994. VFC is now used by more than 80,000 providers in all 50 states, and the majority ofstates have committed their own funds to extend the program to additional children. The national vaccination effort also expanded immunization clinic hours, created registries identifying children with incomplete immunizations, educated providers about missed opportunities for immunizations, and educated parents through Table 2.1 Maternal and Infant Health Indicator., by Race of Mother, 1995 Asian or All Native Pacific Indicator races White Black American Islander Hispanic a Percentage of births Early prenatal care b 81.3% 83.6% 70.4% 66.7% 79.9% 70.8% Late or no prenatal care c 4.2 3.5 7.6 9.5 4.3 7.4 Low birthweight d 7.3 6.2 13.1 6.6 6.9 6.3 Very low birthweight e 1.3 1.1 3.0 1.1 0.9 1.1 Bi rths to teens 13.1 11.5 23.1 21.4 5.6 17.9 Births to unmarried mothers 32.2 25.3 69.9 57.2 16.3 40.8 Births to mothers who have 22.6 21.6 28.7 33.0 16.1 52.1 not completed high school Deaths before age 1 per 1,000 births Infant mortality 7.6 6.3 15.1 6.1 - Data nat available. a. Persons of Hispanic origin may be of any race. b. Care begun in the first three months of pregnancy. c. Core begun in the last three months of pregnancy or not at all. d. Less than 2,500 grams (Sibs., 8 oz.). e. Less than 1,500 grams (3 Ibs., 4 oz.). Source: U.S. Deportment of Health and Human Services, National Center for Health Statistics. CHI L D R E 'S D E F ESE F U D 23
Page 2 and 3: About CDF he Children's Defense Fun
Page 4 and 5: Copyright © 1998 by Children's Def
Page 6 and 7: Acknowledgments Susanne Martinez, d
Page 8 and 9: THE STATE OF AMERICA'S CHILDREN YEA
Page 20 and 21: _____T...:H_._E... S T ATE 0 F AM E
Page 22 and 23: .... T...-HE STATE OF AMERICA'S CHI
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THE STATE OF AMERICA'S CHILDREN YEA
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106 CHI L D R EN' S D E FEN S E FUN
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THE STATE OF AMERICA'S CHILDRE YEAR
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THE STATE OF AMERICA'S HILDREN YEAR
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