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    Red state, blue state: What the election may mean for kids

    The outcome of this year’s presidential election could significantly change the federal government’s role in addressing children’s health.

    One candidate favors reducing the government’s role in healthcare, the other increasing it. One candidate offers broad-brush proposals, the other detailed policy briefs. One candidate has spent years working on children’s welfare, the other has no public track record on it.

    More: Help for kids with complex conditions

    All in all, it’s hard to imagine a more polarizing choice than the one that Donald Trump and Hillary Rodham Clinton will offer voters interested in children’s health in this year’s presidential election.

    “Elections, particularly presidential elections, are often characterized as historic and important,” says Irwin Redlener, MD, president and co-founder, Children's Health Fund, New York. “This one transcends what normally happens.”

    In combination with the results of the congressional elections, the outcome could significantly change the number of children with health insurance and the way pediatricians are reimbursed.

    Neither campaign responded to a request from Contemporary Pediatrics to discuss the candidates’ healthcare positions. However, on their respective campaign websites, Clinton has issued a series of healthcare policy briefs and Trump has posted a concise outline of his healthcare proposals.

    The candidates differ sharply on matters of insurance. The percentage of children without healthcare coverage has steadily declined in recent decades, reaching a historic low of 4.8% in the most recent census, down from 13.9% in 1997.

    Most of the gain in coverage results from the expansion of Medicaid and the Children’s Health Insurance Program (CHIP), which together cover more than a third of US children aged 0 to 18 years. Depending on what voters decide in November, these programs could continue expanding or begin to contract.

    Both programs pay for healthcare costs for children whose families are in poverty, and together they have improved children’s health, says Joan Alker, MPhil, executive director of the Georgetown University Health Policy Institute, Washington, DC. “There’s a lot of research coming out showing the health benefits for kids,” she says, “and the benefits continue to accrue even when they’re adults.” She cites lower blood pressure, less use of emergency departments, better high school graduation rates, and better economic outcomes.


    Medicaid covers about 36.8 million children. The Affordable Care Act (ACA) of 2010 expanded eligibility for Medicaid to 138% of the federal poverty level in states that choose to participate. That level is $20,160 for a family of 3.

    Prior to the passage of the ACA, states set their own eligibility cutoff levels, and eligibility still varies in the 19 states that have declined to participate in the expansion.

    Clinton says on her website that she would work to expand Medicaid in these states by making the federal government pick up 100% of the program’s costs. That won’t affect children directly, says Alker, because CHIP already picks up where Medicaid leaves off, insuring children up to at least 200% of the federal poverty line.

    However, the expansion of Medicaid has indirectly brought healthcare coverage to some children because not all of those eligible for CHIP are enrolled. Sometimes, when parents gain coverage they sign up their children as well, Alker says.

    Trump, on the other hand, proposes to fund Medicaid through block grants. “The state governments know their people best and can manage the administration of Medicaid far better without federal overhead,” his website says. “States will have the incentives to seek out and eliminate fraud, waste, and abuse to preserve our precious resources.”

    In practice, Alker and other analysts interpret this to mean that overall Medicaid funding would be reduced. “[Trump’s] proposal doesn’t have a lot of detail, but there really has never been a block grant proposal that doesn’t include substantial cuts,” she says “and reimbursement for providers would probably be one of the first things on the chopping blocks for states.”

    In an analysis by the nonpartisan Rand Corporation, switching to block grants for Medicaid and repealing the ACA would reduce the number of people with health insurance by 25.1 million. Rand arrived at this figure by assuming that federal funding for the program would drop back to levels from before the ACA passed into law. The Rand report does not say how many of those losing coverage would be children.



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