Will noble sounding promises actually be fulfilled by the
Imagining the Next American Century: Children, the 110th Congress, and Beyond
-- Evan Fieldston, M.D., M.B.A.
The most basic - and the most humane - treatment of children calls upon society to protect them from poverty, to maximize their potential through education and access to appropriate and complete health care, and to prepare a society in which they can grow, develop, and ultimately work in a productive and meaningful manner. This is where the next Congress should start as it lays a foundation for child policy in the 21st century. Given the right circumstances, the 110th Congress holds much promise for children, though competing domestic and international needs and constraints will prove challenging.
Not only is appropriate spending on children morally correct and supported by voters, it carries an impressive return on investment. This article will outline a variety of ways in which Congress can properly invest in children, increase several forms of security, and maximize the chance that they, and the United States, will prosper in the century to come. You can help by continually reminding your elected officials that you expect them to address the needs of children. There are many places to turn for information and means to connect to politicians, including websites like the Children’s Defense Fund
That American children, surrounded by a $13 trillion GDP ($43,500 per person), have a 20--25 percent poverty rate is a national embarrassment and the root cause of many of the social ills faced by children and their families. In the last century, the federal government made a commitment through Social Security, Medicare, and Medicaid that senior citizens would not live in poverty; today, less than 10 percent of them do. No similar commitment has been made to children. Congress should address this most basic security interest by helping America’s lowest wage earners have incomes that truly cover the cost of living. This could be done by raising the minimum wage or implementing a negative income tax. One example worth considering is Singapore’s new Workfare system, whereby the government pays people in low-wage jobs a bonus (part cash, part credit to a savings account) for staying employed. This negative income tax promotes employment and productivity. The incentive is structured to help low-income earners, helps companies stay competitive with global businesses, and narrows widening income inequality gaps - gaps thought my some social scientists to be worse than a whole nation being less wealthy.
Congress must also maintain and strengthen Temporary Assistance for Need Families (TANF), the nation’s program that provides states with funds to support children and families in need. Work-to-welfare rules and children’s interests can align, but children should not suffer for the failings of parents.
A child’s growth and development is tightly linked to health, which in turn is linked to wealth. Governments have a role in securing the least well-off (either in terms of health and/or wealth) a chance to maximize potential by insuring them access to health care. A government can do this in a number of ways, including: access to care for those who cannot afford it or those who need more than a private system can provide; supporting research the private sector does not yet deem worthwhile; and regulating the marketplace to protect patient-consumers from those who would put profit over clinical performance. Depriving children of good health care today only leads to higher costs in the future, so we all have a vested interested in seeing that good investments are made in medical care.
Medicaid is the most important health safety net for children, people with disabilities or chronic illnesses, and low-income senior citizens. 26 million children are covered by Medicaid, representing one-third of all American children and more than one-half of Medicaid enrollees. But, children represent less than a quarter of Medicaid spending. More than just low-income children are the beneficiaries; for many children with chronic diseases and disabilities, their only access to coverage is through the Medicaid program, regardless of their parents’ income or insurance. Medicaid combines federal and state funds, with states determining eligibility and coverage details. An important component of the program is the Early, Periodic Screening, Diagnosis, and Treatment (EPSDT), which is meant to assure that children are regularly screened for conditions that threaten their health and well-being. Medicaid has suffered significant cuts in nominal and real funding, despite clear evidence that Medicaid funding for children has a multiplier effect well in excess of outlays. Children’s access to care suffers as payments to physicians and hospitals are so low in some cases, they do not cover the cost of care. Minority children continue to suffer significantly higher rates of infant mortality and traumatic injury. Congress needs to restore funding, rationalize eligibility and coverage, and reduce state-to-state variations in a program purported to provide equal coverage to all children.
Congress must also reverse a 2006 Deficit Reduction Act provision, added without debate, that a child must prove citizenship to apply or remain on Medicaid. This means that newborns, children in foster care, and victims of natural disasters may be denied coverage if they cannot produce an original passport or birth certificate. Up to 1.6 million children who legally qualify for Medicaid may find themselves without coverage, with parents fearful of seeking care, or with pediatricians unable to be reimbursed for services provided.
The State Children’s Health Insurance Program (S-CHIP), a federal-state program for families who earn too much to qualify for Medicaid but too little to purchase health insurance, is up for reauthorization this year. The program has been one of the most successful in covering children. As more families lose employer-based benefits, the S-CHIP program is a lifeline for keeping children insured and its reauthorization is a national necessity.
Over 46 million Americans (almost 1 in 6) lacked health insurance at some time in 2006. Among children younger than 18, 11% lacked coverage (9 million); among young adults, aged 18-24, 31% were without coverage. Of all uninsured, 21.5 million full-time workers were uninsured; and 88% of uninsured children had at least one parent working. Published evidence shows that when children’s parents lack coverage, even if the children have coverage, they may go without needed preventative and acute care. Thus, insuring children is as much about providing a plan to those children as it is to their parents.
Funding from the National Institutes of Health (NIH) is a critically important component of medical progress and generates a great deal of support for children and their families with health conditions. After many years of growth, the President’s budgets have frozen growth and cut programs of importance to children, child development, and substance abuse.
The Maternal and Child Health Services Block Grant supports direct and indirect health services to 27 million children and their mothers. In particular, the program is of special importance to children with special needs and low-income families, as well as a program, Health Start, that seeks to reduce low-birth-weight pregnancies and lack of prenatal care. The MCHSBG has been frozen and cut for several years.
The Bush Administration has aggressively pushed an abstinence-only education campaign for the country’s youth, despite the clear evidence that such programs do more harm than good. Congress should act to reverse this ill-conceived requirement and fund evidence-based, pragmatic programs that teach the truth and empower young men and women to make smart decisions about their bodies and reproductive health. In addition, Family Planning support for 4,500 clinics across the nation has been frozen. Ideological restrictions on services should be lifted and funding restored.
Behavioral and mental health has been considered different from physical health for many years, and its funding pales in comparison. Large numbers of Americans suffer from acute or chronic mental illness, but research and clinical resources are lacking. The Surgeon General called for increased programming in this area, including child, adolescent, and adult treatment options and substance abuse programs.
Congress must be attentive to the rolling trend of consumer-directed health care. These plans, with high deductibles and copayments, are intended to make health-care consumers have “skin in the game” when it comes to paying for services. But, the danger is that such plans will need patients to avoid necessary and cost-saving preventative and primary care, as well as skip prescription drugs to save money, only leading to worse health and more costly outcomes. Children are particularly vulnerable to parents putting decisions about wealth before health, and no parent should be put in the position of choosing to use cash for health care versus other family needs. At least 3-4 million children are deemed to be “underinsured,” as their plans do not provide comprehensive coverage.
Beyond the immediate fiscal year, Congress must commit to universal coverage of the nation. We must recognize that we already have “national health care” given the fact that the government pays for more than two-thirds of spending. As we seek universal coverage, we can start with the children. The American Academy of Pediatrics and many other groups have been calling for a MediKids program equivalent to the current Medicare program to ensure that all children have access to comprehensive health care through a basic health insurance package. Universal coverage need not mean socialized medicine, and creative solutions can mix (but temper) the power of the market and the scope of the federal government to provide children with appropriate, complete, and cost-beneficial coverage. Importantly, economic realities dictate that states are neither in the financial position - nor competitively able - to provide this coverage on their own. One attractive model would be to provide all families vouchers to purchase private health insurance for children, or for all family members for that matter. In fact, the U.S. could convert from an employer-based health insurance system to an individual-based system by giving all Americans actuarially-adjusted vouchers that can be used to buy a basic health plan. Insurers could offer additional benefits for supplemental fees on top of the voucher value, but all Americans would gain coverage (and would be required to do so). Employers would end their role as middle-men and would regain international competitiveness. Take-home cash pay would rise for employees, and subsidization of high-income earners’ luxurious health plans would end. Finally, a government safety net for chronic illnesses, which defy the economic principles of insurance, should be created and based on evidence-based reimbursement of services, emphasizing secondary prevention and high-quality care. A reinsurance model is one option, whereby the government reimburses insurers for costs deemed to be part of chronic disease maintenance.
After economic and health security, education is among a child’s most basic needs. The Founding Fathers noted that governments are instituted among men to secure “Life, Liberty and the pursuit of Happiness.” Education is the cornerstone of maintaining and enhancing these aims at a societal and individual level. Liberals and conservatives should find common ground in the notion that educating the next generation is among a government’s most basic duties. Congress has a number of means by which it can meet this obligation.
The Head Start program is a decades-old commitment of the nation to its youngest and most-vulnerable people and provides at-risk children the needed social, developmental, and educational supports needed before school so that achievement can be maximized. Despite compelling evidence that the Head Start program works, Republicans have continually frozen or cut funding. As a result, more and more children lose eligibility, and salaries for Head Start staff remains inadequate. Congress should immediately reinvigorate this program with an infusion of needed funds to increase pay, attract new teachers, and expand eligibility.
The President and Congress have under-funded child care programs, and the 110th Congress should take steps to address this issue. Finding appropriate child care options is very difficult, and the cost is often excessive. The work requirement of welfare reform must be coupled with more-than-adequate opportunities for parents to find high-quality and affordable child care. Special supports for children with medical needs are also needed so that parents can work, while their children are at safe and supportive programs that attend to the special health needs of these children.
The No Child Left Behind legislation has been an unfunded mandate on states, that in many cases redirected educational efforts from productive pedagogy to a need to meet testing criteria that may or may not have anything to do with good education or long-term outcomes. A Congressionally-backed, independent investigation of the benefits of the program, needed reforms, and required funding for states to meet goals deemed worth keeping should be explored. The President has not even fully funded the program in his own budget. The President has also cut funding to community and after-school programs, which should be restored.
The Individuals with Disabilities Education Act (IDEA) requires states to provide children with disabilities free, appropriate education in the least restrictive environment. The Early Intervention Services Program is federal support to states for the EI program for infants and children with special needs. The program has suffered cuts and spending-freezes. EI has proven benefits to ameliorate or even eliminate the effects of prematurity and disabling conditions and represents one of the nation’s most compassionate and wise investments in its future. Congress must increase funding of this critical program.
Linked with funding increases should be requirements for programs to deliver results and not waste funds. Careful attention must be paid, however, to how these outcomes will be measured. Failing to meet goals should not result in punishing cuts, but high-performance should be recognized, publicized, and rewarded.
The Bush Administration’s lack of robust support for student loan programs means that real support for higher education, in spite of staggering rises in tuition at public and private colleges and universities, means that young Americans have less support than in the last several decades. Congress should restore funds to the student loan programs and make all interest on student loans tax deductible.
Environments, whether homes, schools, playgrounds, beaches, city streets, or farmlands impact child health and development. The nation has too many homes laden with lead paint, play areas contaminated with toxins, and regions swathed in pollution-filled air. High rates of asthma in inner cities are likely due to daily insults to developing lungs and studies have shown that asthma exacerbations are significantly reduced by acute changes in pollutant quantities in the air. Lead from paint, for example, once in a child’s bloodstream and brain, can lead to irreversible neurological injury and loss of IQ points. It cannot be removed from the living spaces of children fast enough. A national smoke-free workplace policy would be an additional step in the right direction. Block grants from the federal government to cities and states can ease the burden on removing toxins from where children live, play, and learn. Public transit systems need to be reinvigorated: at least as much should be spent on rail, bus, and subway infrastructure as on subsidizing the highways. Such investment would clean the air, provide high-tech and mid-skill jobs, ease traffic burdens, and give youth alternatives to driving (their most likely cause of death). At a national level, a serious commitment to cleaning the environment, investing in clean-burning technology, and ending our addiction to oil will make America more competitive, lower health costs related to environmental insults, and make us more economically secure. This should be an Apollo-style mission to make America a “green nation” by 2020.
Children must feel safe in their homes, schools, play areas, and streets. State, county, and city-level child and family service programs have suffered from budget cuts, only leading to more children being victims. Juvenile justice programs have experienced a halving of their funding since FY2002 and the President’s budget proposed a 43% reduction from the prior year. Another program, the Juvenile Accountability Block Grant, supports graduated sanctions, expanded substance abuse programming, and promotes mental health screening and treatment. The President wanted to eliminate this program, but Congress has rejected that for the past four years. It should do so again. The U.S. Department of Justice has a local delinquency program, but the President proposed a cut of over 60% ($64 million). Congress should refuse these cuts and fully fund programs that help children and youth stay on the right track. Dozens of violence-prevention programs have been evaluated and endorsed by an independent group, but need funding to be implemented at local levels.
Several federal programs also support community-based prevention and treatment programs that address child abuse and neglect. States and local governments need support to prevent and respond to abuse or neglect. Federal support for adoption and foster programs and initiatives to transition youth to independent living after foster care also need support. Many different programs reach a final common pathway of supporting adoption and foster care, and Congress should act to assure that all children find safe and loving environments in which to live. Programs that help grandparents (or other relatives) care for abused and neglected children should be supported and expanded.
Lastly, urban, suburban, and rural children have suffered great harm from the proliferation and easy access to guns and bullets. The awesome finality of the violence that guns pose, combined with easy access to them, particularly in the hands of emotionally labile children and teens, is a fearsome combination. Congress (and states) should stand up to the NRA and pass sensible gun control legislation that lessens the likelihood that children will be in the crosshairs of a gun. Purchase limits, waiting periods, background checks, gun locks, and tracking systems do not interfere with an individual’s ability to hunt or protect a home (even as the evidence shows harm is more likely to be self-inflicted). Appropriate regulations need to be passed and enforced.
While not traditionally considered a children’s issue, national fiscal stability cannot be ignored. Undisciplined spending without commensurate revenue limits the government’s ability to provide a safety net to its citizenry and make investments in the future. Since the free market is not structured to recognize and invest in positive externalities (like education, long-term basic science research, defense, and preventative medicine), the government must be able to do so. Growing deficits and debts consume more of the country’s savings and tax-collections, meaning that both private and public funds are used to service debt, not invest in education, health, and research. The U.S. shift from a creditor to a debtor nation also bodes poorly for children. Fiscal discipline today is necessary so that obligations to senior citizens and children can be met in the coming decades. Otherwise, a death spiral of cuts in productivity-enhancing programs only begets further loss of economic output from less healthy and less educated Americans, reducing the tax base and furthering a precarious economic situation. The point is not to be pessimistic about the future, but to be realistic and realize that compounding interest is as much an enemy when applied to negative numbers as it is a friend when applied to positive figures.
Tax policies are important to allow the government to have the funding needed to support federal, state, and local policies that benefit children and that provide a substantial return on investment to society. The estate tax cuts are due to expire in 2010 and Congress should allow the cuts to expire. (Permanently repealing the estate tax would cost roughly $1 trillion over the first ten years of extension, 2012-2021.) The return of over $100 billion per year in revenue to the government will allow Congress to fund children’s programs and close deficit gaps. Congress should undertake a serious investigation of all tax policy in the United States and seek to make it fairer to middle-class Americans and more enhancing to overall welfare. Corporate subsidies should end, and the corporate tax passed along to consumers anyway (and only generates $130-200 billion in federal revenue) should probably be repealed in an effort to keep corporations based in the U.S. and more competitive in a worldwide marketplace. Regressive aspects of FICA and the Social Security tax should be evaluated. Consumption taxes, flat taxes, luxury taxes, millionaire taxes should all be on the table to balance the budget and increase fairness, but not on the backs of children.
Pearl S. Buck wrote, “If our American way of life fails the child, it fails us all.” The United States has not been doing all that it can for children, particularly not in recent years. Without the ability to vote, children have been excluded from their place at the table of national decision making. The above ideas represent a starting point. The creation of a national child advocate as a Cabinet-level position would further the interests of children and the implementation of policies to help them and the nation. Broad fiscal policies and specific measures in education and health care, among others, should be reimagined in ways that enhance security, promote productivity, and invest in the next American century. The future, after all, is about the children. Remind your elected officials of that every chance you get.
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