Generational differences in U.S. public spending, 1980-2000

Intergenerational enrollment and expenditure changes in Medicaid: trends from 1991 to 2005

BACKGROUND

From its inception, Medicaid was aimed at providing insurance coverage for low income children, elderly, and disabled. Since this time, children have become a smaller proportion of the US population and Medicaid has expanded to additional eligibility groups. We sought to evaluate relative growth in spending in the Medicaid program between children and adults from 1991-2005. We hypothesize that this shifting demographic will result in fewer resources being allocated to children in the Medicaid program.

METHODS

We utilized retrospective enrollment and expenditure data for children, adults and the elderly from 1991 to 2005 for both Medicaid and Children's Health Insurance Program Medicaid expansion programs. Data were obtained from the Centers for Medicare and Medicaid Services using their Medicaid Statistical Information System.

RESULTS

From 1991 to 2005, the number of enrollees increased by 83% to 58.7 million. This includes increases of 33% for children, 100% for adults and 50% for the elderly. Concurrently, total expenditures nationwide rose 150% to $273 billion. Expenditures for children increased from $23.4 to $65.7 billion, adults from $46.2 to $123.6 billion, and elderly from $39.2 to $71.3 billion. From 1999 to 2005, Medicaid spending on long-term care increased by 31% to $84.3 billion. Expenditures on the disabled grew by 61% to $119 billion. In total, the disabled account for 43% and long-term care 31%, of the total Medicaid budget.

CONCLUSION

Our study did not find an absolute decrease in the overall resources being directed toward children. However, increased spending on adults on a per-capita and absolute basis, particularly disabled adults, is responsible for much of the growth in spending over the past 15 years. Medicaid expenditures have grown faster than inflation and overall national health expenditures. A national strategy is needed to ensure adequate coverage for Medicaid recipients while dealing with the ongoing constraints of state and federal budgets.

Children in an aging society

OBJECTIVES

This article explores ways in which population aging in the United States between 2010 and 2030 might impact the well-being of children, with a distinction made between advantaged and disadvantaged children.

METHODS

A variety of economic and demographic statistics are used to describe the changing age structure of the population and changing public spending on older people and children. Data from the 1985 General Social Survey and Wave 2 of the National Survey of Families and Households are also used to examine connections between older people and children.

RESULTS

In recent decades, there has been a graying of the federal budget, and programs for children have received a declining proportion of domestic spending. These trends will be exaggerated between 2010 and 2030 unless structural changes occur. Grandparents may provide increasing resources for their grandchildren. Age segregation results in relatively few older people being directly involved with children not related to them by kinship.

CONCLUSIONS

The implications of population aging for children are relevant primarily for disadvantaged children. Disadvantaged children have grandparents with fewest resources and are most in need of public spending. As costs of supporting the older population increase, intentional social changes will be needed to prevent growing inequality among children.

Immigrant children's reliance on public health insurance in the wake of immigration reform

OBJECTIVES

We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs.

METHODS

We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey.

RESULTS

Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured).

CONCLUSIONS

In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.

Americans' views about the adequacy of health care for children and the elderly

Recent attempts to increase health coverage for specific populations incrementally have been more successful than efforts to dramatically reconfigure the health care system. We present findings from a survey to assess support for programs for children compared with those for the elderly, as well as the public's desire to prioritize whether the needs of one should be addressed over the needs of the other. Americans believe that the health care needs of both children and the elderly are not being met, and there is clear and widespread support for a government role in ensuring adequate health care.

Intergenerational Equity And Public Spending

Concerns over public spending for elders and children are not new. Some of our previous work, combined with the analysis by Susmita Pati and colleagues in this volume of Health Affairs, documents a substantial divergence of social welfare spending for children and elders between 1965 and 2000. Looking to the future, our concern is that social welfare spending for children and elders will be driven more by political concerns and macroeconomic trends than by the needs of the two populations. We argue that the country needs to adopt a new fairness doctrine in allocating social welfare resources, whereby the needs of both groups are met.