Every Breath They Take

This column is about health-care policy, but please don't turn the page. Yes, it includes statistics and quotes from experts. It even touches on the maddening complexities of the State Children's Health Insurance Program (SCHIP), the subject of much debate and two presidential vetoes last year. But the real topic here is something so basic anyone can understand it: breathing.

According to the American Lung Association, 6.8 million children in the United States under 18 have asthma. The chronic lung condition is the third leading cause of hospitalization among children under 15 and, in 2005, resulted in approximately 679,000 ER visits for that age group. Asthma keeps kids out of school—12.8 million lost days in 2003—and off the playground, eroding their quality of life and causing them to fall behind in the classroom. Deaths are rare, but they happen; asthma killed 141 kids under 15 in 2004. I have a touch of it myself and I can tell you there's nothing quite so scary as taking a breath and not getting enough oxygen.

The good news is that asthma, though sometimes life threatening, is a manageable condition. There are effective medications to treat it, and with regular doctor visits kids can avoid attacks and minimize the impact of the disease. The bad news is that hundreds of thousands of kids with asthma can't manage their condition properly because they lack health insurance. The math is as simple as it is cruel. When you increase the number of kids without health insurance—it jumped from 7.5 million in 2005 to 8.3 million in 2006, and Bush's SCHIP vetoes will likely reinforce that trend—you automatically increase the number of kids who have asthma and no coverage. The more kids in that category, the more kids you put at risk of serious health complications.

A new study by researchers at the University of Rochester, published in the January issue of Ambulatory Pediatrics, puts the number of children with asthma and no health insurance at 759,000. The study concludes that this lack of coverage leads to "poor access to consistent primary care," the linchpin of asthma control. Laura Shone, one of the coauthors, can speak at length about the intricate economic and public-policy issues behind that number, but she's also eloquent on the big picture. "Allowing prolonged gaps in insurance for children with special needs is unconscionable," says Shone. "It lets them get worse, it costs them more, it costs the rest of us more, it affects their trajectory in life."

As the former head of emergency services at Children's Hospital Boston, Paul Wise knows what modern medicine can do. He also understands the harsh law of averages. "Most of the time we are really good at saving kids with asthma," says Wise, director of Stanford's Center for Policy, Outcomes and Prevention. "If a kid comes in who's not insured and is near death, they are going to get care in most settings. But we can't always save them. You are going to have kids who break through modern medicine's capability, and they're going to die. That's what happens." For Wise, then, the purpose of health insurance couldn't be more obvious: "To ensure that the number of kids presenting catastrophically ill to an emergency room is very small."

A continuing drop in employer-sponsored health insurance, combined with the underfunding of SCHIP (the Bush vetoes torpedoed plans by many states to expand the program), means more kids with asthma (which is more common among poor children, by the way) will likely lose coverage this year. That prospect angers Sara Rosenbaum, chair of the department of health policy at George Washington University's School of Public Health. "No other industrialized democracy does anything less than cover every single child," says Rosenbaum. Hold your breath and think about that.