Society Will Pay the Price of Cutbacks
On the roller coaster that is U.S. health care policy, things started looking up in 1997. That year, Congress approved the children’s health insurance programs (CHIP) to provide health insurance to the children of the working poor. Since then, 4.6 million uninsured children have been enrolled in the program. But now the downward plunge has begun. As a front-page story in The Times documented last week, many states, including California, are cutting back on the program or curtailing expansion. Some states have established new eligibility limits and erected barriers to enrollment. In California, Gov. Gray Davis has proposed a delay in expanding the program, known here as Healthy Families, to parents of children in the program until July 2003.
As states reduce benefits, the number of uninsured children will rise across the country. As a consequence, sick children will likely get sicker; children who do not receive preventive care and developmental assessments will develop preventable physical and mental problems that may impede their ability to learn.
But these are not the biggest problems with cutting back on Healthy Families: We now know that what happens in childhood--even in utero--has a major impact on physical and mental health conditions that develop at age 50 or 60. If we’re not doing everything we can to insure the health and development of infants and children, we will unquestionably pay the price later.
For many years, the prevailing view guiding American health policy and research has been a paradigm of “cumulative risk.” This view holds that the cumulative influence of poor diet, lack of exercise, stress, smoking and other vices increases the risk for common, debilitating conditions like heart disease. This is of course true, but we now know it is only part of the story. Over the past ten years, epidemiologic studies from around the world have demonstrated that experiences in early life and in utero can have lifelong impacts on the risk of developing heart disease, diabetes, hypertension, asthma, cancer and many other conditions.
We’ve learned, for example, that babies who were malnourished in the womb or who don’t gain enough weight in the first year of life have higher rates of heart disease when they are 60, even when other known risk factors are controlled for. Since an infant’s genetically determined operating system is programmed by its early conditions and experiences, this relative deprivation sets in motion certain physiologic processes. A baby getting too little nutrition, say, develops an altered metabolism to maximize the benefit from the cholesterol in its diet. Unfortunately for future health, these metabolic patterns are not necessarily easy to change. If one’s cholesterol metabolism has been “up-regulated” early in life due to relative malnutrition, it will continue to metabolize cholesterol in the same way even if the child’s diet changes dramatically. And in a world of abundant cheeseburgers and potato chips, that can spell heart disease.
Similar links between conditions in early life and health conditions in later life have been established for diabetes, hypertension and asthma, as well as for the onset of puberty and menopause. This growing body of research on the early-life precursors of adult medical conditions is complementary to an increasing body of research about the importance of the early years for brain development. The evidence clearly suggests that there are critical and sensitive periods in early life that influence lifelong physical and mental health. Which brings us back to CHIP.
When Congress approved the program in 1997, it represented the first major federal focus on children’s health since the Medicaid program (known as Medi-Cal in California) was launched more than 30 years earlier. It also reflected a whole new approach to children’s health policy, in that it created a mechanism at the state level to move large numbers of uninsured children into mainstream managed care, with its performance standards, accountability systems and quality improvement mechanisms. It raised the hope that every child in every state could be insured, and in doing that raised hopes that the primary public health thrust for children could shift from merely getting them insured to promoting optimum health and development.
Since Healthy Families came to California, child advocates have used it as a platform for launching ambitious early child development and school readiness programs. The state legislature is creating a new master plan for education. But such initiatives can provide full benefits to children only if those children already have access to the medical, mental health, dental and developmental services required for school success and lifelong learning.
A recession, an energy crisis, and Sept. 11 have all hit California hard. And in times of shrinking revenues it is generally accepted that the last thing funded is the first thing de-funded. But this principle is not acceptable for children’s health. Retreating from Healthy Families would undermine the state’s future, both by keeping children from reaching their potential and by insuring greater future health care costs.
Congress was quick to jump on Enron’s collapse, holding hearings that allowed every committee member to grab the microphone and decry the scandal. But cutbacks to children’s health are no less scandalous. Like that undernourished infant whose propensity for heart disease will likely go undetected for decades, the consequences of cutting back on children’s health care may not be immediately apparent. In the end, though, society will bear the costs.
