Medical Examiner

Insurance Access Is Just a Fraction of Our Health Care Problem

Almost all American kids have health insurance, thanks to CHIP and Medicaid. Why do they still have such different outcomes?

External view of an emergency department ambulance bay.
Birkus-Viktor/iStock/Getty Images Plus

I race down the hospital stairs, skipping the last one as I rush into the emergency department. The patient is a 10-year-old boy living in public housing in Harlem. As usual, I start by collecting the patient’s history, this time from his mother; she pulls her coat around her and responds to my questions in an almost rehearsed voice. It’s clear that she has been here many times before. This is the third time the patient has come into the ED for an acute asthma exacerbation over the last year. He is slightly small for his age, with a baggy Yankees shirt that drags over his knees.

I already know how this story is going to play out. Asthma impacts about 1 in 12 American children, but a child’s demographics go a long way in predicting disease severity, and even survival. I can predict, based on where my patient lives, that his asthma will not be well-controlled. I can predict, based on his socioeconomic status, that he’s going to have more ED visits and hospitalizations. I can predict, based on his race, that his likelihood of dying from asthma is much higher than it should be.

The United States is ranked No. 43 in life expectancy worldwide, one of the worst among developed countries (the infant mortality rate is even more abysmal, coming in at No. 55, below countries like Cuba and Poland). And yet, we spend more on health care than any other country in the world: We spend, on average, twice as much per person as other wealthy countries while still experiencing worse outcomes. The problem with our health care system, the reason why we spend so much and yet still have such bad outcomes, is that it’s unequal.

When many people hear “inequality,” they think about the millions of people who are uninsured. That’s certainly a critical issue, but it doesn’t explain the poor and unequal outcomes among children. Thanks to programs like Medicaid and the Children’s Health Insurance Program, 95 percent of children actually do have health insurance. So why is it possible for me to predict a child’s health trajectory based only on their race and socioeconomic status?

The first contributor is the intersection of social conditions and health. In addition to the high infant mortality rate, the U.S. also has one of the highest child poverty rates in the developed world. Poverty directly impacts health, especially for children. The asthma rate is much higher in poorer urban neighborhoods, partly due to substandard housing conditions: Mold and plumbing leaks, as well as cockroach and rodent feces, are major asthma antigens. In one rat-infested public housing structure in Boston with high asthma rates, housing officials started the Healthy Pest Free Initiative aimed at reducing the number of rodents and cockroaches in public housing. The asthma rate fell by almost 50 percent in a four-year period (in this instance, the decline was thought to be related to both decreased pests and decreased pesticide usage in the building). An improvement in housing conditions alone would decrease the rate of asthma and other childhood illnesses like respiratory infections. Furthermore, studies continue to show that health disparities early in life result in increased disease and shorter life expectancy into adulthood. Thus, low socioeconomic status and early childhood disparity impact an individual’s health throughout their entire life, beyond childhood.

Second, we must acknowledge that we have a two-tiered health care system. Even among the insured, the type of insurance that you have determines which clinics, medications, and sub-specialists you are able to access. Many children with asthma end up at clinics with fewer resources, leaving them overcrowded and underserved. Higher-resourced clinics, with pulmonologists, specialty asthma clinics, and auxiliary support (like nutritionists and social workers), tend to be congregated in wealthier areas, despite the fact that asthma rates are higher in poorer neighborhoods. In fact, children with public insurance have lower rates of controller medication usage, a key factor in controlling asthma, with one study showing that almost half of Medicaid-insured children with asthma reported no controller usage at all.

Race is also a major predictor of outcomes, with data from 2015 showing that African American children were four times more likely to be admitted for asthma and 10 times more likely to die from the disease as compared to white children. Our health care system, because it is dependent on who can pay what, is segregated by both income and race. This means a child’s access to health care differs widely by ZIP code. It has created an apartheid medical system that is inherently unequal.

Although the political debate focuses on access to insurance, if we really want to improve health outcomes in this country, the entire system needs to be restructured, and the inequality needs to be addressed. Insurance—and what kind of insurance you have—doesn’t just influence who gets coverage: It affects how the whole system is set up. It is no longer enough for politicians to only discuss access to coverage—they should be discussing improving the entire system. A “Medicare for All” system would allow for the restructuring of the entire health care system. Under “Medicare for All”, all Americans would have the same insurance, thus getting rid of private insurance and the two-tiered health care system that segregates individuals based on the type of insurance they have.

It would allow the government to change the payment structure so that doctors are incentivized to take on more lower income patients and improve outcomes. It would also allow for more preventive care and pediatric screening, key factors in identifying early childhood disparities and disease triggers. Versions of a “Medicare for All” plan also provide clinicians with health disparities training while increasing funding to recruit more minority physicians. It is much harder to see how a public option, which is essentially an expansion of Medicare that retains the private insurance model, would sufficiently restructure the system enough to address the inequality. The public option would provide more patients with coverage, but unless it is meant as a bridge towards a single-payer system, it would retain the currently unequal two-tier system.

As a pediatrician, one of the hardest aspects of my job is the fact that inequality often determines how a child will fare long before I meet them in the emergency department. I place the oxygen mask on my 10-year-old asthma patient, noticing his long Yankees shirt has a small hole in it. I wonder how many older brothers wore it before he did. I know very little about his past and his life, but I can still predict so much about his future.