Hal Andrews | April 3, 2024

A Practical Approach to Health Equity, Part II

In last month’s Counterpoint, I proposed that Congress could do something practical about health equity by authorizing the “Hill-Burton Act of 2024” to encourage the development of healthcare infrastructure in underserved areas throughout the United States. In that post, I also noted that the people whom I have asked to define the phrase “health equity” struggle to do so.  

What may reveal something about my generational cohort is the habit of utilizing a dictionary to understand the meaning of words. According to the Cambridge Dictionary, the meaning of “equity” most closely aligned with the concept of “health equity” is this: 

“The situation in which everyone is treated fairly according to their needs and no group of people is given special treatment.”1 

Applying that definition of “equity” to “health,” I believe that Congress could also enact legislation to deliver comprehensive health insurance for every American child. 

At the outset, I think it is important to note why this proposal is limited to children. Unlike England, America has never had a national conversation about whether healthcare and, implicitly, health insurance are “rights.” Whether Americans are entitled by birthright to cradle-to-grave access to free healthcare is so controversial – and so inimical to the entrenched interests of the healthcare-industrial complex – that it is unlikely to be implemented anytime soon. Whether Congress could do something to provide universal health insurance for America’s children is likely less controversial and relatively easy for the Congressional Budget Office to score. 

What are the baseline facts to consider? 

  • 73.3M Americans are under the age of 18, per the 2020 Census.2  
  • “Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to some…families and children” who lack private insurance.3 “CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid...Each state offers CHIP coverage, [sic] and works closely with its state Medicaid program.”4 
  • “38,317,214 individuals were enrolled in CHIP or were children enrolled in the Medicaid program in the 49 states and the District of Columbia that reported child enrollment data for December 2023 representing 46.1% of total Medicaid and CHIP program enrollment.”5
  • There were 3.6M births in the United States in 2022, per the Centers for Disease Control.6 Annual births in the United States peaked at 4.32M in 2007 and have steadily declined since then.7
  • In 2021, private insurance covered 51.7% of U.S. births, with the rest covered by Medicaid (41.0%), self-pay (3.9%) and other forms of payment (3.4%).8  

Instead of Medicaid’s current hodgepodge of funding programs to provide health benefits for ~52% of American children, the Federal government could provide a comprehensive solution to the healthcare needs of every American child, potentially at a lower cost.  

As a conservative budgeting approach, Congress could assume that there are 4M annual births in the United States, resulting in a persistent cohort of 72M Americans under the age of 18. Applying the Health Savings Account as a framework, Congress could appropriate funding to create a HSA for every child born in America every year in an amount equal to the average annual deductible for an individual covered by employer-sponsored health insurance, which was $1,982 in 2022 according to the Kaiser Family Foundation.9 Alternatively, Congress could appropriate an amount equal to the average annual healthcare spending for children, which was $4,217 for children in 2022.10

For $150B per year, Congress could ensure that every American child could afford basic preventive care; for $300B per year, Congress could underwrite comprehensive healthcare for every American child. In either scenario, the Federal government should also underwrite a catastrophic coverage policy to cover every child diagnosed with a rare disease from the time of diagnosis until adulthood. Moreover, Congress could allow any funds remaining in the child’s HSA to be converted to a 529 plan on the child’s 18th birthday. 

In a proposed Federal budget of $7.3T in expenditures, or even in 2019’s relatively parsimonious $4.45T of Federal spending, spending ~$150B per year to ensure that every American under the age of 18 can afford preventive healthcare is possible and likely widely popular, even evocative of these famous words: “Give me your tired, your poor, your huddled masses…” 

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