Ensure healthy lives and promote well-being for all ages

Currently, the world is facing a global health crisis unlike any other — COVID-19 is spreading human suffering, destabilizing the global economy and upending the lives of billions of people around the globe. Health emergencies such as COVID-19 pose a global risk and have shown the critical need for preparedness.

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3.1 Maternal Mortality


3.8 Essential Services


Disparate Rates of Insurance Coverage

Rates of American residents who are uninsured have increased from 2017 to 2019, and are expected to increase further due to the Coronavirus Pandemic causing increased unemployment. As of 2020, 28 million individuals are uninsured, with only 1% (or 407,000) of this group being over the age of 65. Hispanic people and Native Hawaiians and Other Pacific Islanders experienced the largest increases in uninsured rates as of 2019. Hispanic people accounted for over half (57%) of the increase in nonelderly uninsured individuals over the last three years, representing approximately 612,000, with more than a third of these numbers being children.

Most people who are uninsured are nonelderly adults and in working families. Variables affecting why these people remain uninsured are related to cost and financial stability. Most of the nonelderly in the US obtain health insurance through an employer, but this is not a universal benefit to all employees and employee-sponsored premiums may still remain too high. In 2019, 72.5% of nonelderly uninsured workers did not receive healthcare benefits from their place of employment. Additionally, from 2010 to 2020 health care premiums for family coverage increased by 55% and the worker’s share increased by 40%, outpacing wage growth. Further, Medicaid, the government’s health care system for low-income residents and persons with disabilities, is limited in some states, restricting access for vulnerable groups who do not have access to employee-sponsored insurance. According to the 2019 National Health Interview Survey, 73.3% of uninsured nonelderly adults said that coverage was not affordable due to high costs.

Additionally, health care coverage changes as a person’s situation changes, particularly regarding employment status and income. In 2019, 25% of uninsured nonelderly adults said they were ineligible for coverage (for example having pre-existing conditions) while 21% said they did not want or need it. Further, renewal and difficult sign up processes are other variables limiting insurance access, and is cited by 18.4% as the primary reason for being uninsured. Between 2016 and 2018, more individuals found it difficult to find coverage they needed or find coverage that is affordable.

Uninsured residents who are unable to pay medical costs result in uncompensated care costs that are covered by the government. Between 2015 and 2017, the government compensated an average of $42.5 billion per year, which is lower than rates before the implementation of the Affordable Care Act, in which annual costs totalled $62.8 billion. While health care systems themselves incur substantial cost while caring for the uninsured, the majority of is compensated by the federal government, states, and localities. Through using public funds, indigent care and public assistance programs, and other government payments, federal, state, and local government agencies split compensating health care provider costs through various funding programs. Because the pandemic is expected to increase the number of uninsured, the amount the government will spend compensating health care facilities is expected to increase. The government covers about 80% of uncompensated care costs for the uninsured, while the remaining 20% is available to be covered by private sources, provider charity, or transferred to other payers in the health care system. This percentage of uncompensated care costs amounts to about $8.8 billion as of 2021.

The primary federal programs to compensate for uninsured care costs are the Veterans Health Administration, Medicaid, Uncompensated Care Cost Pool Payments, the Indian Health Service, State/Local tax appropriations for Indigent Programs, Disproportionate Share Hospital Payments, and other state and local programs. As of 2017, these forms of payments are given on a scheduled basis and are based on uncompensated care levels rather than Medicare and Supplemental Security Income days. However, reductions in Medicaid Disproportionate Share Hospital payments are expected to decrease, with a cut of $8 billion a year beginning in fiscal year 2024 and continuing through 2027.

State Action

There are several ways in which the federal government, state, and local agencies are combatting gaps in insurance coverage. Primary at the federal level is the implementation of the Affordable Care Act (ACA), passed in the Obama Administration in 2010. This is a reform law that increases health insurance coverage for the uninsured and implements reforms to the health care system, such as ensuring that patients who have preexisting conditions or limited finances can secure affordable health plans. As mentioned above, the ACA did successfully lower the costs the government paid towards uncompensated care costs, and did decrease the number of uninsured. However, ACA has faced multiple legal challenges that threaten patients who are insured through the law. Additionally, as health care premiums increase, coverage becomes more restricted to those who can afford it. 

Aside from the ACA, there are 6 major federal health insurance programs to close the insurance coverage gap. First, Medicare, which provides health insurance to all individuals eligible for social security who are aged 65 and over, are eligible because of a disability, and those suffering from end-stage renal disease, covers about 40 million beneficiaries. Medicare is 100% federally financed and operated and health care services are almost entirely delivered through the private sector. Medicaid, which serves about 42 million people, provides insurance for those who are low-income and meet eligibility criteria, specifically being children, pregnant women, low-income parents, disabled adults, Federal Supplemental Security Income recipients, and those suffering from other medical needs. Medicaid coverage varies by state in regards to maximum income for eligibility and is administered jointly between the federal government and the states. Third, the State Children’s Health Insurance Program is another joint federal-state program to provide health insurance to poor and near-poor children through the age of 18 without another source of insurance. Fourth, the Veterans Health Administration provides health care to U.S. veterans based on the available government each fiscal year. Similarly, DOD Tricare provided health programs for the Department of Defense, specifically active-duty military personnel and their dependents. Finally, the Indian Health Service provides health services to members of federally recognized American Indian and Alaska Native tribes, totalling about 1.4 million.

In DC, residents have access to Medicaid through the DC Medicaid program, which has six offices throughout the District. Additionally, DC also has the DC Healthy Families Program, which provides free health insurance to DC residents who meet certain income and have US citizenship/eligible immigration status. DC Healthy Families offers doctor visit coverage, vision and dental care, prescription drugs, hospital stays, and transportation for appointments. Additionally, The DC Health Care Alliance provides health coverage for individuals who do not qualify for Medicaid through local funds. For Children, DC also has the Immigrant Children’s Program and the Child and Adolescent Supplemental Security Income Program to provide healthcare to children under the age of 21.

Maryland also has their state Medicaid program, also called Medical Assistance, as well as a Medicare Buy-In Program, which protects low-income Medicare beneficiaries from the cost of Medicare coverage. Maryland also has Qualified Medicare Beneficiary Programs, which provides individuals with modest assets (up to $7,280) and incomes that do not go over 100 percent of the federal poverty level payments for Medicare Part B premiums and cost-sharing amounts. The Specified Low-Income Medicare Beneficiary program pays only Part B premium for those with incomes between 100 and 120 percent of the poverty level. The Maryland Health Insurance Program provides public insurance to individuals who have not been able to qualify for insurance based on a pre existing condition. Similar to DC, Maryland also has a Maryland Children’s Health Insurance Program to provide assistance for uninsured children. Virginia’s health insurance program revolves primarily around Medicaid and FAMIS, which is Medicaid for children. Virginia also has an online application for assistance, known as CommonHelp to help residents find health coverage based on their eligibility.

Despite these programs, many still remain uninsured due to high costs. Many adults who fall into the coverage gap have incomes above state eligibility for Medicaid but below the poverty level, and are therefore significantly limited in what health care options are available depending on where they live. Despite an expansion on who is eligible for  Medicaid coverage, 12 states have not adopted this, making coverage variable across states. Additionally, increasing premiums for employer-based health insurance and general increasing medical costs make affordability of health insurance more difficult.  Confusing enrollment processes in government health care assistance programs also play a role in continued insurance gaps, as these processes may not be accessible for all individuals who may lack access to the internet or the ability to do these processes in person. Expanding Medicaid eligibility is the primary way that advocates and governments are acting to decrease the uninsured gap.

No Shots, No School: DC Pediatric Immunization Noncompliance and the Future of Pandemic Resilience

In the wake of the COVID-19 pandemic, vaccination requirements are becoming an increasing requirement at educational institutions. According to an April 2022 Centers for Disease Control and Prevention (CDC) study, the District of Columbia has the lowest compliance rate out of all U.S. States for key pediatric immunizations. These immunizations include the measles, mumps, and rubella vaccine (MMR), diphtheria, tetanus, and acellular pertussis vaccine (DTaP), and, as of 2022, the COVID-19 vaccine. With a national average of 93.6-93.8% children in compliance with vaccination standards, DC’s pediatric immunization rate is more than 10 points lower, at 78-79%. When separated by Ward, DC’s Ward 3 had the highest rate of noncompliance when looking at the data for all school types, at 32.1%, compared to a total average of 27.2% of noncompliance for all DC schools. Private schools had higher rates of noncompliance than DC Public Schools (DCPS), with a total average of 39% compared to DCPS’ 25%. Parochial schools held the highest average, with 50.5% of students not having the standard pediatric immunizations.

 To combat this, DC has implemented the No Shots, No School policy for the 2022-2023 school year, which will require a student to have proof of immunizations or a verified extension to receiving the vaccine from a health professional, or else they will be disenrolled. This will include the COVID-19 vaccination, unless a student has an exemption to receiving the vaccine, which must be verified by a religious leader, medical professional, or other authority who can vouch for the reasons behind not receiving the vaccine. To receive public feedback on this initiative, DC government held held a public roundtable on June 29th on No Shots, No School, bringing representatives from the Department of Health, the Office of the Deputy Mayor for Education, the State Superintendent of Education, District of Columbia Public Schools, the Public Charter School Board, the State Board of Education, and the Child and Family Services Agency to outline key goals for the new initiative and to encourage parents to update their children’s vaccination status. 

No Shots, No School is the foundation of DC’s 2022 Youth Vaccination Plan, which aims to prevent serious disease outbreaks by increasing student immunizations. The plan’s primary goal is that by the end of August 2022, the DC government will have supported routine immunizations for up to 90% of children, and COVID-19 vaccinations 60% of students aged 5-11, 80% of students aged 12-15, and 90% of students aged 16-17. The plan applies to all schools in the District, including private, parochial, and independent institutions. Students will be required to receive immunizations within 20 days of attendance and must provide written proof of an immunization record. For students without health insurance or a primary care provider, the DC Department of Health’s HealthLink program will provide assistance for receiving coverage for medical care. Medical exemptions must be signed by a physician and religious exemptions must be approved by the DC Department of Health. Families are, however, able to opt-out of the HPV vaccine, which is not part of the traditional primary vaccination series, by submitting the Annual Human Papillomavirus (HPV) Vaccination Opt-Out Certificate to the school. 

DC’s requirement for students to have vaccinations before attending is the latest attempt to expand pandemic preparedness and increase resilience in case of a new outbreak. While all 50 states require basic pediatric immunizations to attend school, requiring the COVID-19 vaccine has received skepticism among a tenuous political environment. Aside from DC, Louisiana, California, and New York will require the COVID-19 vaccine in schools, though the mandates will not take effect until the 2022-2023 school year. Illinois has a requirement for university students to have the COVID-19 vaccine, but has not applied the requirement to K-12 institutions. 

Vaccine mandates have frequently faced challenges, despite first entering into law in the 19th Century. In 2019, New York rejected the option for religious opt out of vaccines, which was challenged by several religious groups, who appealed to the Supreme Court for intervention. In May 2022, the Supreme Court rejected this appeal, allowing New York to remain one of six states who do not allow religious opt-out for pediatric immunizations. In response to the COVID-19 vaccine, several states have enacted bans against schools mandating vaccines in opposition to other states requiring them. At present, 20 states prohibit the requirement of a COVID-19 vaccine in schools for students, while 13 prohibit mandates for teachers and staff. The lack of consensus on requiring the COVID-19 vaccine may stagnate attempts to vaccinate the younger population within the United States, which the Federal Drug Administration (FDA) only recently greenlit in June 2022. 

In states that do allow mandates, enforcing them will be a challenge. In the case of DC, failure to comply with the mandate results in a student’s disenrollment from the school, which results in said child losing access to the education provided by the institution. The ability to enforce the mandates without causing harm to the children who are out of compliance with it is a key challenge that must be addressed by local governments as more states and regions are adopting similar provisions as No Shots, No School. Additionally, there is further challenge for non-public institutions, who may seek exemptions from state education laws. While DC’s law applies to all schools regardless of status, enforcement may be more difficult as parents may call for exemptions in higher numbers (as seen by the increased non compliance rates in DC’s private and parochial institutions), resulting in another roadblock to expanding vaccination coverage to community members.  

Despite this tumultuous environment within the United States, it has long been established that schools are a key way to measure the health and well being of a community, particularly as it relates to matters of adolescent health. The CDC utilizes local school vaccination assessments known as SchoolVaxView, to assess a community’s resilience to specific illnesses, as well as key vaccines that are missing from the mass majority of students, which inform future programs that prioritize under-served areas. Additionally, the World Health Organization identifies schools as a key way to implement vaccination programs for students without access to health care and offers several guidelines to school vaccination policies. Using schools as a way to both assess coverage against diseases and offer necessary immunizations is a key way of making progress on the indicators within SDG 3, which promote good health and wellbeing, while creating an important link to SDG 4, quality education. As the world moves through the wake of the pandemic with the intention of being more prepared for future outbreaks, schools will continue to be utilized as a means to assess, implement, and educate on health standards necessary for strong community resilience. 

While it is unlikely that a widespread requirement for the COVID-19 will be rapidly implemented, history indicates that this is not necessarily surprising. Indeed, in the instance of the polio vaccine, several decades passed before a polio vaccine requirement became commonplace, with only 20 states implementing the requirement by 1963. With the current political environment, it may be likely that vaccine requirements for COVID-19 will require a similar timeframe to become commonplace nationwide. This suggests that while the role of schools in ensuring childrens’ health is important, the ability to evolve to address current health crises normally takes a long time, and, in the case of the United States, requires state consent over that of the Federal government, limiting the ability for nationwide action. Moving forward, schools, in coordination with their local governments, must find a way to both rapidly respond to new health crises, while understanding the impacts of enforcing health mandates, particularly as it relates to the students involved. Ensuring the progress of one development goal should never come at the cost of another, and thus it is more vital than ever to find a balance between enforcement and associated penalties to ensure that a child’s quality education and good health and well being are both on a positive trajectory.