The Kid Care legislation in the budget agreement of 1997 can hardly be faulted for its intent. Children who lack health insurance are less likely to see a doctor routinely or seek care for injuries and acute illnesses. They are more likely to receive sporadic care from emergency rooms or clinics. They are less likely to be immunized against serious childhood illnesses. Overall, uninsured children face longer odds of becoming healthy, productive adults.
But federally funded medical coverage for uninsured children may not be the most effective way to reach the uninsured or provide quality care for kids. Over the last decade, privately funded solutions have been bridging the health-care gap for hundreds of thousands of uninsured children. These community-based approaches involve a level of personal care frequently absent from Medicaid mills and other federal programs. The following is a small sampling of the dozens of initiatives evident across the country.
Responding to the economic collapse of Pennsylvania's steel industry in the mid-1980s, which left many children uninsured, Blue Cross-Blue Shield in Pittsburgh launched the first Caring Program for Children in 1985. The Caring Programs blend private insurance with charitable efforts to provide excellent medical care to children of low-income parents who are not eligible for Medicaid.
Children enroll in the insurance plan free of charge and become eligible for such benefits as preventive checkups, routine and emergency medical treatment, diagnostic tests, immunizations, and outpatient surgery. The only cost to families is a copayment of $3 to $5 for prescription medications. The Blue Cross-Blue Shield corporations that sponsor the Caring Programs pick up all their administrative overhead, including the costs of negotiating directly with physicians and hospitals for benefits. The families' claims are paid with charitable donations from local businesses, foundations, religious organizations, civic groups, schools, unions, and individuals-and every dollar donated goes directly to the cost of the children's health care.
Caring program's premiums are 60 to 67 percent lower than those of commercial insurers. "They're so much lower because not every benefit mandated by law for commercial benefits is included in the Caring Program benefits," explains Craig Jeffery, the chairman of the National Coordinating Council of Caring Programs for Children and the director of the Caring for Children Foundation of Texas. For the overwhelming majority of children, this basic benefit package is more than adequate.
"Giving everyone the luxury model effectively locks many people out of health insurance and therefore out of health care," Jeffery says. Most children (like most adults) don't need the "luxury model." Groups such as the Caring Program have found they can provide preventive care, routine treatment, diagnostic testing, and outpatient surgery to all children at an affordable cost. On the other hand, benefits such as speech therapy, ambulance allowances, maternity care for pregnant adolescents, and drug and psychiatric rehabilitation drive up the cost considerably. Fortunately, the majority of children don't need these services; those who do can often find them at community-based organizations. Jeffery notes that children who require hospitalization can get coverage through Medicaid.
The program is open to all children who attend school and live at home with parents who work at least part-time; parents must verify their income level when they apply. Since 1985, 25 programs in 23 states based on the Caring Program model have provided health coverage to 238,000 children; another 111,000 children are enrolled in state health-insurance programs patterned after Caring Programs.
For more information on Blue Cross- Blue Shield Caring Programs for Children, contact Craig Jeffery, P.O. Box 660583, Dallas, Texas 75266-0583. Tel.: 972-766-7190; fax: 972-766-1742.
Free clinics have come a long way since their birth in the 1960s. Kevin C. Kelleher, a family practitioner and the volunteer medical director of the Bradley Free Clinic in Roanoke, Virginia, says the clinics have become "well-respected health-care centers providing outpatient services primarily to the working poor." Most of the clinics serve patients who are ineligible for Medicaid but lack health insurance, because either their employers don't provide it or they find the premiums too expensive.
Private initiatives have been bridging the health-care gap for hundreds of thousands of uninsured children.
The clinics' volunteer nature does not necessarily limit their scope. At the Bradley Free Clinic, more than 40 physicians, 50 nurses, 15 dentists, and other health-care professionals and laypeople offer medical and dental services one morning and two evenings each week. In addition to internists, family practitioners, and emergency-medicine physicians who provide routine care, specialists offer free services either on site or in their own offices. All told, they provide more than $1 million in medical and dental care to more than 11,000 people annually. Local hospitals perform all laboratory work gratis and donate some $45,000 of X rays each year; a private annual donation of $10,000 purchases eyeglasses for children.
The Bradley Clinic also provides more than $500,000 of prescriptions annually and uses donated funds to purchase other medications. "While people may find a physician who will see them without charge, many are unable to purchase prescribed medications and are no better off than before seeing a doctor," says Estelle Nichols Avner, the executive director of the clinic. Although the Bradley Free Clinic doesn't treat Medicaid-eligible patients, it does provide prescription medications to those who cannot purchase their own.
Each year, at least 250 free clinics across America serve perhaps hundreds of thousands of people who can afford neither health insurance nor health care. (There are no reliable estimates of how many people are served.) Most of these facilities receive no federal assistance or local government funding. "Federal money comes with strings attached and can dry up on short notice," says Avner, "leaving programs that depend on it stranded."
According to Kelleher, there are several reasons that free clinics are able to fill some of the health needs of the uninsured. "Free clinics are based in neighborhoods where there is need," he says. "Access and transportation are big problems for the uninsured," who often cannot travel to other medical alternatives. In addition, people feel more comfortable receiving care in their own neighborhoods and may even pay the clinic back by volunteering there. Free clinics prize their ability to meet the needs of individual patients, rather than following some federally mandated program requirements. This flexibility allows them to put community volunteers to work at their convenience, such as at night and on weekends. The result: inexpensive yet efficient care.
The free clinics offer physicians a better outlet for their compassion than performing pro bono treatment at their formal practices. "By centralizing indigent care," says Kelleher, "no one physician carries the burden of the majority of unreimbursed care. Bad-debt patients are fewer and practice overhead is lowered." The clinics' practices also reduce the overuse of emergency rooms and services, he says, saving taxpayer money.
Some argue that free clinics encourage a two-tiered health-care system in which the indigent receive inferior care. "There is no system that is not two-tiered," Kelleher responds. "Under nationalized health-care systems, the wealthier have access to fee-for-service care." Canadians who can afford private treatment, for example, often purchase better care in the United States.
The concept of providing health care with volunteers will continue to work, says Kelleher, "because physicians and other health-care professionals choose their profession because they want to help people-they all have a certain degree of altruism." Free-clinic medicine, he says, is medicine in its purest form, free of interference from health-insurance companies and government mandates.
For more information on free clinics, including how to start one, contact Estelle Nichols Avner, Free Clinic Foundation of America, 1240 3rd St. S.W., Roanoke, Va. 24016. Tel.: 540-344-8242.
After a 1988 survey found that one-third of the 22,000 children in the public schools of Pasadena, California, could not afford proper medical care, a local church convened a coalition of health professionals and community leaders. Rather than wait for a government solution, the coalition chose to respond to the need immediately. An emergency-room physician recruited other health-care professionals to volunteer. In 1990, only 18 doctors volunteered; today nearly 300 health-care professionals provide emergency and preventive care.
Thus emerged the Young & Healthy Program, which annually treats more than 1,000 ailing children without health coverage and offers preventive services to about 2,000 kids-all without federal assistance. The program has become a national model and has spurred at least 80 communities in 36 states to develop similar programs, often with assistance from the Young & Healthy staff.
"We have made a philosophical decision not to accept government funding," says executive director Mary Donnelly-Crocker. Accepting such funding requires too much documentation, she says, and "we're trying to keep ourselves as nonbureaucratic as possible. Also, we don't want to tax the taxpayers any further."
Children in need of medical or dental care are referred to Young & Healthy by school nurses or by alert staff members at homeless shelters, day-care centers, and shelters for battered women. Young & Healthy also dispatches staff nurses to facilities without medical staff to identify medically needy children. Young & Healthy staff members are much like brokers, matching up children in need of care to volunteer providers. Young & Healthy case managers and other staff members assume responsibility for seeing that children who need medical attention actually receive it. For example, Young & Healthy will send a volunteer to take a child to a doctor's appointment if his parents lack transportation. Case managers also refer patients to other, specialized medical services as necessary.
Among the 300 volunteers are physicians, dentists, therapists, and pharmacists who provide a full range of health services. Local hospitals provide outpatient care, emergency-room care, and surgical services free of charge. Similarly, medical laboratories, optometrists, podiatrists, audiologists, and physical therapists donate their services. While the program offers all eligible children treatment for acute problems, some volunteers choose to "adopt" their patients for ongoing care. "Some of our pediatricians, dentists, and therapists agree to take on a certain number of children free of charge each year," says Donnelly-Crocker, "and see them regularly for well-child care as well as for acute consultation."
Young & Healthy runs on about $500,000 a year (including in-kind donations), which it raises from individuals, businesses, community organizations, and foundations. The Pasadena Children's Guild assists the board's fundraising efforts.
For more information, contact Mary Donnelly-Crocker, Young & Healthy, 325 South Oak Knoll Ave., Pasadena, Calif. 91101. Tel.: 818-795-5166.
Other Medical Resources
Children’s Miracle Network • Via 165 hospitals throughout the United States and Canada, the Children’s Miracle Network (CMN) provided $2.5 billion in charity health care in 1996 alone to afflicted children. Funds are generated through community fundraising campaigns. For further information, contact CMN at 4525 South 2300 East, Suite 202, Salt Lake City, Utah 84117. Tel.: 801-278-8900, fax: 801-277-8787.
Shriners’ Hospitals • For 75 years, the Shriners have been delivering free health care to children who have a condition treatable at one of the Shriners’ 22 hospitals and whose family cannot afford treatment elsewhere. Shriners’ hospitals receive no government support nor third-party payments. For further information and treatment applications, call 800-237-5055.
St. Clare Medical Outreach Van • Sponsored by St. Francis Hospital of Wilmington, Delaware, this physician-staffed medical van serves working-class poor and homeless (without Medicare or Medicaid) throughout New Castle County. This service brings medical treatment to about 28 patients per day, 30 percent of whom are age 19 or younger, all without government assistance. Funds come from St. Francis Hospital and private foundations. For further information, contact Dr. Thomas C. Scott at St. Francis Hospital, 7th and Clayton Streets, Wilmington, Del. 19805. Tel.: 302-575-8218.
Nemours Foundation • The Nemours Foundation serves children in four states. From its start at a children’s hospital in Wilmington, Delaware, services have expanded to 10 pediatric primary-care clinics in Delaware and four clinics in Florida. More recently, it has partnered with seven hospitals in Pennsylvania and New Jersey to provide pediatric services. In Delaware alone, the Nemours Foundation facilities service 180,000 children, whether they have private insurance, Medicaid, or neither; a Nemours financial assistance program aids families who could not otherwise afford care. For further information, contact 1600 Rockland Rd., Wilmington, Del. 19803. Tel.: 800-829-KIDS.
Americans have long turned to their churches and synagogues during times of emotional and spiritual need. A growing number now turn to their places of worship for medical needs as well.
In 1984, the Reverend Granger Westberg approached Lutheran General Hospital in Park Ridge, Illinois, with the idea of linking health care to churches. He proposed recruiting "parish nurses" as health counselors, identifying the medical problems of parishioners and connecting them with the appropriate health-care resources in the community. But he also hoped that nurses would help people draw upon their faith to see them through the medical problems and other crises in their lives. The original pilot group of six nurses has swelled to more than 3,000.
"Parish nurses fill health-care gaps in all types of communities," says Janet Griffin, a registered nurse and the director of the Parish Nurse Program at Trinity Regional Health System in Moline, Illinois. Her program serves both urban and rural congregations, tailoring its services to each population's needs. "People often think of the uninsured as being the poverty-stricken in urban areas," says Griffin. "But people who live in farming communities are often uninsured because they must purchase insurance as individuals-which is prohibitively expensive." At best, they can afford only catastrophic coverage, which doesn't include pap smears, mammograms, prostate screenings, and other preventive services, and they cannot pay out of pocket.
For the most part, parish nurses do not provide hands-on, "invasive" treatments. "We try to discover and address health-care issues before they become acute," says Griffin. "In providing wellness care, we hope to prevent major health problems." They offer blood-pressure tests after church services, for example, to uncover potentially dangerous cases of high blood pressure. They also direct parishioners with medical crises to physicians in the parish who volunteer their medical services.
"The parish nurse," wrote Westberg and Ann Solari-Twadell, the director of the International Parish Nurse Resource Center, in Health Progress magazine, "is a health educator, a personal health counselor, a volunteer coordinator and support-group organizer, a community liaison, and a role model for the relationship between one's faith and health." Indeed, parish nurses provide more than pure medical care-they also care for the soul. They offer a "wellness ministry," bringing a pastoral dimension to the treatment of ailing parishioners, including children.
Parish-nurse initiatives follow diverse models. In some cases, a church simply hires its own nurse. Sometimes a foundation or the nonprofit arm of a hospital network initiates the effort. Even then, the nonprofit sponsor typically funds the nurse's salary for one year, but the church assumes the full cost within three or four years. In Trinity's Parish Nurse Program, for example, each church provides 25 percent of the salary during the initial year; within three years, it must assume 100 percent of the cost. Trinity supports 50 nurses in 54 churches within a 50-mile radius.
"We offer a perk that makes the program easier for churches to offer," says Griffin. The nurses are all hired and trained by Griffin's staff, and her office handles all the paperwork for the nurses' salaries and benefits.
For more information on parish nursing, contact the International Parish Nurse Resource Center, 205 West Touhy Ave., Suite 104, Park Ridge, Ill. 60068; tel.: 800-556-5368.