Dans un communiqué de presse, l’Observatoire états-unien de la qualité et de la recherche en santé (Agency for 
Healthcare Research and Quality) rend publics les résultats d’une étude qu’elle a commandité. Elle est parue dans le JAMA du 22 octobre et Pharmacritique vous propose quelques extraits.
Voici de quoi faire réfléchir tout pays qui s’engage sur la voie de la dérégulation des structures étatiques de soin et d’assurance-maladie : 9 millions d’enfants n’ont aucune couverture maladie aux Etats-Unis ! Si l’on compte ceux qui ont des assurances ne couvrant pas toute l’année, on arrive à 18 millions d’enfants qui n’ont pas accès aux soins, avec toutes les conséquences imaginables en termes de santé !!
Principaux résultats et enseignements à tirer en France
L’étude parue dans le Journal of the American Medical Association (JAMA) s’est penchée particulièrement sur les enfants dont au moins l’un des parents est assuré et appartient aux classes socio-économiques à revenus bas ou moyens. Même dans ces familles, 2,3 millions d’enfants n’ont pas d’assurance-maladie, donc aucun moyen d’accès aux mesures de prévention et aux soins, même primaires. Nous ne serons pas étonnés d’apprendre, par exemple, que les Américains faisant partie des minorités ethniques sont les plus mal lotis. Beaucoup de ces enfants pourraient avoir droit à une couverture publique élémentaire, mais les familles ne sont pas informées de leurs droits.
On voit en lisant la discussion des résultats et les conclusions de l’étude que la solution ne peut venir que d’une révision majeure du modèle d’assurance-maladie – la jungle illisible des assurances privées, chacune avec ses grilles et ses conditions – qui prévaut actuellement aux Etats-Unis.
C’est dire à quel point le gouvernement français est condamnable, qui nous mène droit dans le mur en détruisant pas à pas la Sécurité sociale et les structures publiques de soins, alors même que ces pseudo-solutions néolibérales du tout privé ont prouvé leur totale inefficacité même en termes de maîtrise des coûts (médicaux et administratifs) et de limitation de la bureaucratie, comme nous l’avons déjà dit dans plusieurs notes de la catégorie « Privatisation de la santé ».
Sans parler des dégâts sur la santé des enfants et adolescents et des coûts lorsque des maladies sont soignées à des stades avancés… Et sans parler des conséquences socio-économiques ultérieures d’un tel départ dans la vie, puisque, n’en déplaise aux tenants du rêve américain, la plupart du temps, les déterminations sociales jouent pleinement leur rôle de frein dans l’ascension sociale. La pauvreté produit surtout de la pauvreté. Nous en avons abordé certaines dimensions dans les notes consacrées aux « Inégalités sociales en santé » ou dans celles parlant de notre « Protection sociale en danger ».
Extraits du texte intégral du JAMA et références complètes
« More than 9 million children in the United States have no health insurance coverage.1,2 When including those with a coverage gap at some point during the year, that number doubles.3–6 It is estimated that almost three-quarters of them qualify for public insurance coverage.7–9 Stable health insurance coverage allows for consistent access to health care services, which contributes to better health outcomes.10–14 Discontinuities in children’s health insurance coverage, even for only a few months, are associated with significant unmet health care needs.15,16 (…)
Predictors of Uninsurance Among Children and Adolescents With Insured Parents
Among the 28 908 children and adolescents in the cross-sectional analysis with an insured parent, the distribution of certain demographic and socioeconomic characteristics was different when comparing insured with uninsured (Table 2). (…)
Cross-sectionally, children experiencing this discordant pattern of family coverage were more likely Hispanic (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.23–2.03) than white non-Hispanic; low (OR, 2.02; 95% CI, 1.42–2.88) and middle income (OR, 1.48; 95% CI, 1.09–2.03) than high income; from single-parent homes (OR, 1.99; 95% CI, 1.59–2.49) than living with 2 parents who were married to each other; and living with parents who had less than a high school education (OR, 1.44; 95% CI, 1.10–1.89) than living with at least 1 parent who had completed high school; and living in the South (OR, 1.70; 95% CI, 1.23–2.34) or in the West (OR, 1.52; 95% CI, 1.10–2.10) than in the Northeast. Children whose parents had public coverage were less likely to be uninsured (OR, 0.64; 95% CI, 0.43–0.96) than those whose parents reported private health insurance. (…)
These patterns persisted in the full-year models. In particular, children from low- and middle-income families were more vulnerable than the poorest and the richest subgroups. For example, compared with those from high-income families, those from low-income families were more likely to lack health insurance coverage for more than 6 months (OR, 1.73; 95% CI, 1.18–2.55). Those from middle-income families were also more likely than those from high-income families to have long coverage gaps (OR, 1.56; 95% CI, 1.11–2.19). Middle-income children and adolescents were the most likely to have gone all year without coverage (OR, 1.48; 95% CI, 1.00
2.19). Although not evident at a point in time or all year, those from poor families (OR, 1.69; 95% CI, 1.11–2.59) and from near poor families (OR 2.15; 95% CI, 1.33 to 3.49) were more likely to experience a coverage gap than those living in high-income families.
Parental type of coverage was also associated with different rates of children’s coverage. Compared with children and adolescents whose parents had any private insurance, those whose parents had only public insurance were less likely to be uninsured at a point in time (OR, 0.64; 95% CI, 0.43–0.96), to have any length coverage gap (OR, 0.54; 95% CI, 0.37–0.78), and to have a coverage gap of more than 6 months of the year (OR, 0.59; 95% CI, 0.35–0.98). In the post hoc analyses focusing on children and adolescents whose parents reported only private coverage for the full 12 months of a given year, the predictors of children’s uninsurance were similar (Table 4). (…)
Longer-term Policy Implications
Evidence suggests that when family members are covered separately under different plans or when certain individuals have coverage and others do not, children’s health declines.21,29,46 Furthermore, if the assumption that insurance coverage is a “household good” is abandoned and the system shifts toward defining it as an “individual good,” we add layers of complexity for vulnerable families who must simultaneously learn different systems for enrollment and utilization of multiple insurance plans.47 Discordant patterns of family health insurance may become the norm rather than the exception; the current trend is certainly moving in that direction. 48 While a good short-term fix, it is unclear whether expansions in child-only public insurance programs that largely exclude parents will serve as the best longer-term solution. Among all children with an insured parent in this study, those whose parents had only public coverage were less likely to be uninsured confirming previous evidence that covering both parent and child in the same public program may lead to more stable children’s coverage.16,19,20,23–25 This approach may also be the most economical.49
If families are better off covered under 1 plan but US society rejects a public health insurance program for all members of the family, the question of whether the employer-based model is sustainable may need to be revisited. In this study, the private system did not do a good job of providing coverage for entire families. Among children and adolescents whose parents had only private coverage (Table 4), not only the low- and middle-income children and adolescents but all 4 groups below 400% of the FPL were more likely to be uninsured for more than 6 months when compared with children in the highest-income families. Some of these uninsured children qualify for public coverage but are not consistently enrolled for reasons that are only partially understood. 6,25,45,48
These families may benefit from being able to purchase public coverage on a sliding scale that would allow for fluidity of coverage with frequent fluctuations in family income and circumstances. Another possible policy intervention would be the expansion of partial assistance programs that help make private coverage more affordable for families who prefer coverage for everyone under 1 plan. 25,48 This approach, however, relies heavily on the current private insurance market. The bolder alternative requires replacing the current insurance paradigm with a new model. (…)
Unless health insurance coverage models are designed to keep entire families covered, some children will continue to get left behind. It is time to think beyond health insurance models to achieve a sustainable health care system and the best possible health outcomes for all families. »
Pharmacritique 