For N.C.'s health, insuring all children

CHAPEL HILL -- North Carolina's health care system is in trouble. According to the latest estimates, 1.4 million residents (over 17 percent of the state's population) lack health insurance. As the costs of health insurance premiums rise and businesses cut back on coverage, the number of uninsured North Carolinians will surely grow in coming years.

The state cannot count on the federal government to fix this problem. To be sure, the issue of what to do about the uninsured is a national dilemma that requires a national solution: across the country, 46 million Americans lack health insurance and all states are wrestling with the impact of rising health care costs.

Yet even as the ranks of the uninsured have grown in the last decade, the federal government has done nothing. Even worse, recently enacted cuts in federal Medicaid spending actually make it more difficult for states to afford their health care bills. And with a sizable federal budget deficit and continued partisan polarization in Congress, it appears that help from Washington is not on the way.

If North Carolina wants to make progress on health reform and expand access to affordable insurance for its citizens, the state has no choice but to take the lead itself. Doing nothing only assures that North Carolina will confront a much greater problem down the road.

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What can the state do about the uninsured? There is one obvious starting point for health care reform: covering all children.

There are currently 264,000 North Carolina children under the age of 18 without health insurance. Whatever their political differences, can't our legislators agree that every child should have comprehensive health insurance?

Extending health coverage to all children will not solve the uninsured problem and should not be the end point for health reform. We must also pursue policies that make affordable coverage available to low-income working adults and small businesses. But expanding children's health insurance is a promising place for reform to start.

Covering children is relatively cheap and represents an investment in the state's future. Research shows that uninsured children are less likely than insured children to have a regular source of medical care, less likely to receive preventive services and more likely to go without needed care. For example, children with asthma who are covered by public insurance have better health outcomes and require fewer hospitalizations than uninsured children with the same condition. "Leave no child behind" is a familiar refrain in public policy, yet in health care we have been doing exactly that.

Covering children is not only the right thing to do, it's also smart politics. The politician who champions this issue is likely to find a public ready to rally to his or her side. And those who oppose reform will have to explain to voters why guaranteeing our children access to medical care should not be a state priority.

Moreover, we can build on existing state programs (Medicaid and North Carolina Health Choice) that already provide public insurance to many children. Indeed, one of the state's challenges will be to enroll the estimated 147,000 children who are eligible but not now enrolled in these programs.

North Carolina can also build on the experiences of other states: Illinois recently enacted legislation aimed at covering all its uninsured children and Oregon is considering a similar measure.

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Of course, making a political promise to cover all children means nothing without a financial commitment to pay for that coverage. In part, state expansions of children's health insurance can be financed by available federal matching revenues. Yet North Carolina will still need to raise its own funds.

One possible solution, though not the only one, would be increasing the state cigarette tax. Even after the cigarette tax rises to 35 cents per pack this summer, North Carolina will have the eighth-lowest cigarette tax in the country, lagging far below the national average of 92 cents.

Raising tobacco taxes in North Carolina is never easy, but if such an increase is explicitly linked to expanding health care coverage for children, a majority of voters likely would support it. A higher cigarette tax would also produce health benefits by decreasing the rate of teen smoking.

Unless another funding source is found, North Carolina is going to have to choose: does the state want to maintain low prices for cigarettes or does it want to ensure that all its children have health insurance?

(Jonathan Oberlander is an associate professor of social medicine at UNC-Chapel Hill.)