• What the New Brain Research Tells Us: How Everyday Experiences Affect Children
• What the new Brain Research Tells Us: Implications for Child Care in Maine
• Start ME Right
• Child Health Care Access Project: Maine's Crisis In Access To Dental Care
• Child Health Care Access Project: Who are the Uninsured in Maine?
• Infant and Toddler Language Development

Issue Papers

Child Health Care Access Project: Who are the Uninsured in Maine?

Laurie, Bill and Brandon live in a small coastal community. Laurie sells real estate. Bill is a commercial fisherman whose primary income is from lobstering. Brandon is 11 years old and has a chronic asthma condition. Although both Laurie and Bill work full-time, their incomes are seasonal. Their net income in 1996 totaled $21,000 after taxes. They recently sold their mobile home and built a small house on family owned land. They have learned the hard way that health insurance makes sense and enrolled Brandon in a health insurance plan. The plan, however, refused to pay for Brandon's asthma related health care needs, as the condition was considered preexisting. Trying to get ahead was difficult for this family of 3, with house payments, and over $300 a month for Brandon's health insurance, asthma related medications and visits to the doctor. To make ends meet, Laurie and Bill had to take Brandon out of the health insurance plan. In order to decrease the likelihood of asthma attacks that might create a need for more medication and trips to the doctor, Brandon was forced to quit basketball, his only after school activity.


Ann and her 9 year old daughter, Caitlin, live in a small apartment in Augusta. Ann had worked as an Administrative Assistant in State government for 3 years before being laid off in November 1995. Ann has only been able to find part-time work since she became unemployed and currently works 30 hours a week at a large department store in the area. She is unable to afford health insurance for her and her daughter. Caitlin was involved in a bicycle accident over the summer. Although she did not seriously hurt herself, she was in need of some dental work, estimated to cost approximately $600. Ann had hoped she could pay a small amount towards this bill every month, but the dentist office told her that she could not have an outstanding balance for more than 3 months. They referred her to a "health credit company", which would pay the bill and allow Ann to pay back the amount with interest over the course of the next year. Although Ann was outraged at having to have pay more for her daughters health care because she was unable to pay for it all upfront, she agreed to do so, as this was the only way she could access the dental care her daughter needed.

Kirk works as an independent logger in northern Maine. Both his daughter's and son's teachers have indicated that his children may have eyesight problems and suggested that he take them to an optometrist. Kirk doesn't have the money he needs to bring them to the eye doctor and get them glasses. Kirk is worried that he probably will not have enough money at the end of the month to pay the rent, provide the food his growing children need or to deal with their health care needs.

• Between 1977 and 1987, the percentage of children without any form of health insurance in the United States rose by 40% and between 1988 and 1993 there was a 15% increase in the number of uninsured children, while the number of children rose by only 9% during that period
  
• From 1991 to 1995, the average percentage of Maine children who lacked health insurance was 10.8%.
  
• In 1995, over $29,000,000 in "charity care" services was provided by Maine hospitals without the expectation of payment to individuals and families without health insurance.
  

Although the United States has one of the highest quality and most sophisticated health care systems in the world, a large segment of Americans do not have access to the medically necessary care they need to live healthy lives. As health care costs continue to rise in Maine, the number of people unable to afford health insurance for themselves or their families also increases.

Generally, the uninsured tend to be sicker than those with insurance coverage, but they see a physician less often and will delay or forego medical care. Typically, they do not seek preventive screenings or prompt medical treatment, and they are more likely to experience avoidable hospitalizations. A recent national survey conducted by the Harvard School of Public Health indicates many of the uninsured face major barriers to needed health care services and suffer health and economic consequences because of these barriers. Prior research has documented that the uninsured and underinsured experience decreased access to health care services, and decreased health status that is more likely to lead to increased burdens of economic hardship, ill health, and mortality. While many barriers to health care exist, without insurance, many simply go without care.

The Harvard survey negates the view that the uninsured are not denied health care. Because of the inability to pay upfront for health services, many of the surveyed uninsured delayed seeking treatment for illness, and described themselves as being sicker and more likely to have higher out-of-pocket expenses for health care. It strains our image as a just and humane society when significant portions of the population endure avoidable pain, suffering and illness because of an inability to pay for health care.

It appears that nationally, children make up on of the fast growing segments of the uninsured. Between 1993 and 1994, approximately 36,000 Maine children under age 18 were uninsured. Many are children of working parents who are not eligible for, or not offered, health insurance where they work. In fact, the largest portion of the uninsured appear to be low income adult workers who do not qualify for Medicaid, and cannot afford insurance. Between 1991 and 1993, 26% of the uninsured in Maine had income below the poverty level and 41% had income between one and two times the poverty level. In 1992 the federal poverty level for a family of four was $14,335. Many of these are hard working parents who lack the resources they need to provide their children with routine preventive health care services. Without such services, their children are more at risk of becoming sick. As a result, they are unable to attend day care or are more likely to miss school. Consequently, parents are often forced to miss work. Continued health problems can lead to a whole array of other social and economic problems for uninsured families.

During the period 1998 to 1993, loss of employment based insurance was the single greatest contributing factor in the decline in the number and proportion of children with health insurance. Of all children in working poor families in Maine that were not receiving public assistance, just 41 percent had employment-related health coverage in the early 1990s. As the percentage of payroll towards health insurance increases, more employers are finding it difficult to offer health insurance to their employees and dependents.

Despite a substantial expansion of Medicaid to poor children, 18 percent of children in working poor families in Maine lacked any health insurance, from public or private sources, during that same time. Many people assume that Medicaid finances health care services for all of the poor. However, many low income families are ineligible for Medicaid, due to categorical and state program eligibility requirements. Also, many low wage earning parents are unaware that their children may be eligible for Medicaid while they work. Many of these uninsured working parents pay taxes which help to provide health care to the disadvantaged through Medicaid. Many others may pay health care bills "out of pocket" that help to cover the costs of uncompensated care or charity care for others who cannot or do not pay. At the same time, they earn too little to purchase insurance for themselves and their children. Thus the working poor are obviously the least able to pay for care directly, and they are more likely to be without either Medicaid or private insurance.

Low income families continue to be the focus of public controversy, where welfare reform centers on moving welfare recipients from welfare to work. The reality regarding poor children in Maine is that many live in families where the parent(s) do work. Only 81% of jobs available in Maine in 1994 paid a livable wage. The average hourly wage paid to working women in Maine is about 76% of that required to meet the basic needs of a single parent household with two children. The economic shift in Maine that has led to the growth of low-wage jobs, only provides an opportunity for increasing the number of working poor rather than promoting financial independence.

The many physicians and other health care providers, clinics and hospitals that try to assist the uninsured are also experiencing strain. Demands in certain areas of the state typically exceed available time and resources. There are some areas in the state which experience increased access problems due to economic burden. Strain is continuously felt by the local governments in those areas of the state whose communities include many uninsured persons, because certain hospitals and health centers inevitably incur major financial deficits. As the number of uninsured continues to grow in Maine, and with the increases in the use of managed care where those with insurance are required use participating providers within their plan, some public facilities that have traditionally been the source of last-resort care in Maine are in jeopardy of closing, thus intensifying the stresses on area providers and the uninsured.

As economic trends and federal and state policies continue to contribute to the increasing numbers of children without health insurance, Maine must explore solutions which will not only enhance our health care system, but will also increase access to health care. Policies which allow for state earned income tax credits and increases in the minimum wage, for example, would enable more families to rise above the Federal poverty line. Other policies which would allow low wage working families in Maine to receive health insurance will encourage such families to keep working and become less dependent on public assistance in the long run.

Policies that devote more resources to prevention of avoidable health problems might be one of the most cost-effective uses of Maine's health care dollars. In addition to improving the quality of life, preventive care is often much more cost-effective than treatment. For example, vaccines provided annually in the United States prevent nearly 7 million cases of measles, mumps and rubella, saving $14 in medical costs for every dollar spent on immunization. Providing insurance to children that promotes and pays for preventive care is one the most cost-effective mechanisms in increasing child access to health care.

Expanding health insurance coverage to children of the working poor will not only encourage parents to keep working, but will also provide the preventive care necessary to reduce the overall health care expenditures for this population now and as it reaches adulthood. Medicaid, for example, is a critical component of the preventive health care safety net for children. It is most often associated with poor pregnant women and children, and indeed, 75 % of its beneficiaries are people who fall into those categories. But most of Medicaid's money - about 60% - goes to finance care for the elderly, blind and disabled. Because our health care system has the most to gain from providing preventive care to Maine's children, it makes sense that expansions in health insurance coverage for children be promoted. Once such expansions are promulgated, it is critical that those who are eligible are made aware of such expansions and are enrolled at once.

Policies that encourage and enable businesses and employers to provide insurance coverage should also be explored. Providing incentives that would encourage low wage employers to provide coverage to employees and their families create a more stable work force, decrease the number of uninsured and improve access to the preventive care necessary for reducing overall health care costs in Maine.

Maine also needs to take a closer look at other changes currently occurring in its health care system. Specifically, changes in the manner in which services are chosen, provided and paid for are occurring rapidly statewide. The movement from the traditional fee-for-service system to managed care is expected to have a tremendous impact on consumers and providers of health care throughout the state. While it is unclear whether managed care controlled costs will generally increase access to health care in Maine, the state needs to carefully monitor these changes while they occur. For example, while there is some evidence that managed care has slowed the pace of growth in health care costs and premiums, the number of people who are unable to afford insurance and are uninsured, continues to increase in Maine. Maine needs to develop policy that regulates the implementation of managed care, insuring that savings result in increased access to coverage and care for the uninsured and underinsured.

Finally, improving children's access to health care in Maine will require more than economic solutions. Physicians and other health care providers are in a unique position as advocates for children to identify specific personal and structural barriers to care and to devise strategies to overcome non-financial barriers. Possible approaches include:

• developing community and home based services to address the environmental and personal factors associated with poor health outcomes among uninsured and disadvantaged children,
  
• improving the organization of practice to provide preventive services and patient education more efficiently, and
  
• promoting active efforts on the part of physicians, health institutions and organizations to share resources, i.e. sharing resources among physicians, other health professionals and health institutions to meet the specific needs of local communities.
  

Maine needs to encourage and provide support to providers who share their ideas and combine local resources to improve services for uninsured and underinsured children. By doing this, Maine will improve upon the existing structure of its health care system, rather than replace it. Combining policy efforts which address economic barriers with other nonfinancial approaches is critical to enhancing our existing health care system. In doing so, Maine will be in a better position to improve access to health care and ultimately, health outcomes for all Maine children.

September, 1996

This publication is brought to you by the Maine Children's Alliance, 303 State Street, Augusta, ME, 04330, (207)623-1868 as part of the Maine KIDS COUNT Project funded by the Annie E. Casey Foundation.

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