While the US lags behind other developed nations in providing access to health care, important gains were achieved for US children over the past 3 decades. In 1994, the Vaccines for Children Program of the Centers for Disease Control and Prevention began to provide no-cost immunizations to children for families unable to afford them. In 1997, the State Children’s Health Insurance Program (CHIP) was established to ensure coverage, resulting in a large decrease in the percentage of children and adolescents without health insurance. As of January 2020, 49 US states had extended CHIP eligibility to children with family incomes up to at least 200% of the federal poverty level (FPL), and 19 allowed incomes at or above 300% of the FPL. These policies helped millions of children access recommended health care and reduced racial/ethnic disparities.1,2
While children gained access to health care from these programs, the COVID-19 pandemic is a significant threat. Healthy children have lower risk of morbidity and mortality than older people, but the pandemic is having severe indirect effects on children, especially for those who are Black, Indigenous, and people of color, who experience significant health disparities3 and are disproportionately affected by COVID-19.4 The health of children is being adversely affected through increased rates of poverty, food insecurity, and health conditions, particularly for children in families affected by systemic racism.5 Disruptions in schooling are also negatively affecting many of these children.6 Recommendations for physical distancing and sheltering at home are affecting preventive care for children, including a 21.5% decrease in childhood immunizations (excluding flu vaccinations).7
COVID-19–Related Changes in Parental Health and Health Insurance Can Affect Children
Policy makers must develop interventions designed to help entire families during the pandemic because parent health has a profound effect on the health and well-being of children.3 For example, maternal depression is associated with fewer well-child checks and recommended immunizations and worse child health status.8 The negative effect on children’s health of not receiving care during the pandemic will be compounded by how access to care is affected for parents and caregivers.
Health insurance is important for both parents and children to promote access to recommended care. Unfortunately, from 2017 to 2019, Medicaid and CHIP enrollment declined for children by 3%, mirroring a 2% decrease among adults. The unprecedented unemployment rates (eg, 14.4% in April 2020) associated with the COVID-19 pandemic will likely accelerate this trend. As parents lose jobs, they will lose employer-sponsored health insurance for themselves and their families. Adults with low incomes who lose employer-sponsored coverage in the 12 states that have chosen not to expand Medicaid under the Affordable Care Act will likely become uninsured. Assuming that children are eligible for CHIP or Medicaid will not be enough, because children may not be enrolled if parents are not enrolled in health insurance.
Creating Family-Centered Health Care During the Pandemic and Beyond
While Medicaid for children should be improved and coverage expanded,9 efforts to increase insurance coverage must go beyond children and include assistance for everyone in the family to ensure sustainability. Primary care practices and public health programs can help families apply for health insurance coverage. In addition to helping children maintain health insurance, family-centered approaches can also help children and their caregivers obtain needed health care. A recent National Academies report asserted that “pediatric care will be more effective if primary caregivers, parents, and others are healthy and have the support and resources to care for their children.”3 Therefore, creative solutions to promote timely delivery of recommended care are needed now.
Most individuals with COVID-19 are treated in community settings and clinics, which have been forced to adapt and transform rapidly during the pandemic, thereby creating opportunities for innovative solutions. As the future of health care during and after the COVID-19 pandemic is unknown, we envision new possibilities to create family-centered care. For example, primary care clinics and systems could implement family telemedicine visits where attention focuses on the health of the whole family. Some families may benefit from receiving health care from the same family physician and a team trained in family-centered care. Families could have in-person visits together to provide all members with recommended care at the same time.
If this type of care is not available, another option for families receiving care from multiple health care locations is to improve family care systems for clinicians to share health information across service providers of family members. Clinicians could have access to a “family health record” to communicate with all health care professionals involved in a family’s care or that shared telemedicine visits involve multiple clinicians and family members meeting together at the same time. A family health record facilitating connections and communication between multiple clinicians could help with diagnoses and treatment decision-making. Currently, many health systems use the same electronic health records vendor, which allows for sharing of health information from different sites and decreased issues related to interoperability.
To address health equity, this work must include identifying and addressing the worsening social and economic conditions many families are facing during the COVID-19 pandemic, which is increasing health and health care disparities.5 Risk prediction models and chronic disease registries can be developed within electronic health records, including screening for adverse childhood experiences and family-level social determinants of health.10 While some clinicians and health systems already offer some of these care options (eg, providing flu vaccines to several family members during 1 visit), collaborations between internal medicine and pediatric care clinicians are needed to implement similar strategies more widely.
These ideas for treating families as a unit are aspirational and will require feedback, input, and support from policy makers, health care providers, and families. They also will require different training paradigms for teams to learn how to care for both families and individuals, innovative reimbursement models for family visits, updated privacy rules, and efforts to connect electronic health records across family units.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Angier H et al. JAMA Health Forum.
Corresponding Author: Heather Angier, PhD, MPH, Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Drs Angier, Garvey, and DeVoe reported receiving grants from the Agency for Healthcare Research and Quality.
Funding/Support: This article was supported by the Agency for Healthcare Research and Quality, grant No. R01HS025962.
Role of the Funder/Sponsor: The funder had no role in the preparation, review, or approval of the manuscript and decision to submit the manuscript for publication.
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Angier H, Garvey B, DeVoe JE. Focus on Families to Improve Child Health During the COVID-19 Pandemic and Beyond. JAMA Health Forum. 2021;2(3):e210238. doi:10.1001/jamahealthforum.2021.0238