Medicaid covers nearly half of America’s children, but its impact goes far beyond doctor’s visits and hospital stays. James Perrin, MD, Professor Emeritus of Pediatrics, MassGeneral Hospital and Harvard Medical School, and Founder of the MGH Center for Child and Adolescent Health Policy, explains why Medicaid is one of the nation’s most important investments in children, what’s at stake in current policy debates and how a health care system designed to support health — not just treat illness — could improve outcomes for generations to come.
Featuring:
James Perrin, MD, Professor Emeritus of Pediatrics, MassGeneral Hospital and Harvard Medical School
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer (00:00):
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast, produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer (00:12):
Each week, we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you’re here, let’s go.
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Well Beyond Medicine.
Carol Vassar, podcast host/producer (00:36):
My guest today is Dr. James Perrin. He is a pediatrician and really a national leader in child health policy, and has been for many decades. His work has helped shape how we think about Medicaid and children’s health in our country. And he’s joining us today to walk us through what’s working with Medicaid, what’s at risk, and what it would take to build a system that truly supports children and families. Dr. Perrin, welcome back to the podcast. You’ve been a previous guest, and we thank you for that.
James Perrin, MD, Professor Emeritus, Harvard Medical School (01:02):
Thanks very much, Carol. Good to be with you again.
Carol Vassar, podcast host/producer (01:05):
Now, you’ve described Medicaid as more than just insurance coverage. It’s more, from your perspective, a long-term investment in children’s health. That’s really important framing. Why is that important right now?
James Perrin, MD, Professor Emeritus, Harvard Medical School (01:18):
Well, I think it’s very important to realize what we know about Medicaid’s effect over the long term. We know that children who were insured by Medicaid are more likely to graduate from school, to go to college, to have good jobs, to have higher incomes, to have later pregnancies.
(01:40):
All of those are things that have been very well shown to happen for people who have Medicaid. We’ve also learned that even having Medicaid when you were a child improves outcomes for your children, too. So it goes up to more than just one generation. The results of Medicaid are really quite striking, incredibly important.
Carol Vassar, podcast host/producer (02:02):
Talk a little bit more about that. Medicaid’s been around since the mid-1960s. Several generations have probably used the program in many, many of our families across this nation. What have you seen across generations?
James Perrin, MD, Professor Emeritus, Harvard Medical School (02:15):
Well, I think what we have seen across generations is, for example, much less low birth weight in babies who were born to mothers who had Medicaid when they were children, which is quite marvelous. That’s just an incredible savings both in money. It’s also tremendously important and valuable in improving outcomes for children. These are children who are much more likely to grow up without chronic health conditions or chronic developmental problems. So that’s a tremendous benefit.
Carol Vassar, podcast host/producer (02:47):
That right there, that one statistic, is certainly a fantastic improvement over the way it was before Medicaid. I want to step back a little bit. Talk about Medicaid and CHIP, the Children’s Health Insurance Program. Take those together and really look at the last 15 years since the Affordable Care Act came together. What are some of the most important shifts over those last 15 years that have really shaped where we are today in children’s health?
James Perrin, MD, Professor Emeritus, Harvard Medical School (03:16):
It’s so important to realize, actually, CHIP goes back to the ’90s, i.e., before the Affordable Care Act came into play in around 2010 or so. And at the time CHIP was passed, about 20% of US children had no healthcare, no health insurance. And with the rise in CHIP coverage and the rise in Medicaid coverage, partly reflecting also the changes with the Affordable Care Act, we lowered that to below 5%. That’s a remarkable improvement in insurance rates of America’s children.
Carol Vassar, podcast host/producer (03:56):
Now, CHIP is a block grant, which is really meant to be that stopgap between who’s eligible for Medicaid but doesn’t quite meet the threshold to get commercial insurance. Is that correct?
James Perrin, MD, Professor Emeritus, Harvard Medical School (04:11):
That’s absolutely correct. Yeah. It was clear back in the ’90s, there were a lot of children who weren’t getting coverage, even though they had families who were working, employed, but these were families that didn’t have incomes or didn’t have jobs that got them employer-sponsored insurance.
Carol Vassar, podcast host/producer (04:29):
When I’ve heard you speak, you talk about the difference between financing and payment in terms of children’s health. Walk us through what you mean and what that difference is, and what does that look like for a child, let’s say, with a complex condition, in particular.
James Perrin, MD, Professor Emeritus, Harvard Medical School (04:47):
I think there are a couple of things to say here. One is financing, too simply, is just the total amount of money going into the system, whereas payment is how you take that money and redistribute it, what you paid for as a result of that. Medicaid, starting in 1965, has been chronically underfunded. So it was really baked into the Medicaid law back in 1965, 61 years ago. And it has really meant that persistently we pay for the care of people who receive their insurance through Medicaid at much lower rates than we do, for example, for us old people like me on Medicare, where the payments are better. So that’s been a chronic problem in the financing of the healthcare system. Everyone in the system is actually getting too little money to keep the doors open. And, in fact, we are seeing children’s hospitals closing in part because of that reason.
(05:48):
So financing is an important part. With expected children with a medical complexity, there’s a whole bunch of related issues about what services are covered, and what services aren’t covered, and how well they’re paid for. Now, for children, one thing that’s really, really important is there’s another piece of law called the Early and Periodic Screening, Diagnosis and Treatment statute. Not an easy thing to remember, by the way. I know that. I wish we had a better name for that than EPSDT. But that was passed in 1967, two years after Medicaid, because what they found out at that time was that half the young people applying to join the military had chronic health conditions that should have been treated in childhood, and they didn’t get treatment for it. And also in the late 1960s, Head Start, which was a new program then, there were studies of children in Head Start that showed lots of them had health conditions that no one had treated.
(06:49):
So this was really an effort to make sure that young people got the health services they need. And the EPSDT statute actually requires states to provide any coverable service that could treat or ameliorate any identified child health condition. It’s an amazingly good benefit and really important to have.
Carol Vassar, podcast host/producer (07:12):
Why don’t we hear much about EPSDT other than the acronym or the poor naming configuration?
James Perrin, MD, Professor Emeritus, Harvard Medical School (07:18):
Well, first of all, a lot of us are working on trying to get people to know more about it. It’s very important. There’s been good work both in the last administration and in this administration, too, from the people at CMS, the Medicaid agency in Washington, to keep the information out, to keep getting people to know what’s in EPSDT and how states could do an even better job there.
(07:42):
Some of the work that came out in September of 2024 indicated best practices by states, states doing really good work, and gave advice for other states as to how to do it. And another report that came out in December of 2025 just reminded everyone about what this is and reported to Congress on the progress in EPSDT. I think it’s so important that we get parents to know about this program, that we get state Medicaid programs to know about this program, and that we get doctors, nurses, and others to know about this program.
Carol Vassar, podcast host/producer (08:15):
Give us the 20,000-foot overview of what this is.
James Perrin, MD, Professor Emeritus, Harvard Medical School (08:20):
It includes screening, diagnosis, and treatment. All three are there. So it supports regulatory screening for all sorts of health and developmental conditions, number one, that’s paid for. Number two, it then says if something comes up in screening or even if, for some other reason, you think about it, it provides support for doing the right diagnoses.
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And very importantly, it also covers the treatments for any identified condition. Even if a treatment isn’t available to people over age 21 in that state, Medicaid agency, we don’t pay for this in Medicaid, no occupational therapy in Medicaid in the state of X for people over 21, you have to do it for people under 21. That is what’s so wonderful about the EPSDT statute.
Carol Vassar, podcast host/producer (09:14):
Even with those kinds of protections in place, which we need to shout from the hilltops, if you will, with regard to what are some of the biggest gaps today between what children are entitled to and what they’re actually receiving, particularly in the Medicaid program?
James Perrin, MD, Professor Emeritus, Harvard Medical School (09:32):
I think there are several issues here. I’ll probably point to two of them. One is the issue, again, of financing and payment. The result of low payment is an awful lot of doctors, an awful lot of nurses, and an awful lot of hospitals, too, either don’t take Medicaid or make it really hard for Medicaid patients to get in. So there’s a real problem about accessing the kinds of services that young people on Medicaid clearly need.
(10:06):
Sometimes, for example, if you live in Kansas City, you may have a doctor over in Kansas when your Medicaid program is in Missouri, and Missouri Medicaid will say, “Well, we don’t cover that doctor. You have to go to someone 100 miles away in Lawrence, Kansas,” or somewhere else, rather than going just across the river to Kansas City, Missouri. Those sorts of things happen a lot, the problems of getting access to the services a child needs.
(10:38):
And if we could deal with the financing problem, the access would be substantially better. The other thing I’d say is some services that kids need, especially kids with quite severe conditions, things like home and community-based services or home nursing, are often in very, very low supply, partly, again, because of the financing there. But, boy, that’s a problem I hear from families all the time.
Carol Vassar, podcast host/producer (11:06):
When we look at the financing and payment, as you talked about it, it’s almost inherent in the system that financing and payment are not to scale. You said that even in 1965, when it was initiated, Medicaid did not pay 100% of the services. There’s also inconsistencies, as you mentioned, between states. You go from Missouri over to Kansas, things are going to be a little bit different. Does that also create gaps? Does that also make it harder for kids to get the services they need?
James Perrin, MD, Professor Emeritus, Harvard Medical School (11:46):
Oh, sure. As I said, there are good studies that show that many doctors make it much easier for commercially insured patients to get an appointment than for Medicaid-insured patients. And there are many doctors who don’t even accept Medicaid at all. And similarly, if you look around the country in most of our big cities, it’s not as if there is equal access to hospital services for children, or adults as well, on Medicaid.
(12:24):
So you’ll often have in cities the big children’s hospital, which has a relatively low Medicaid burden or Medicaid number of people they’ve seen, whereas the local county hospital or city hospital will take care of most of the people on Medicaid. I don’t mean to say that they’re not doing a good job, please don’t get me wrong, but I am saying that this financing and payment arrangement does lead for some segregation in services received and by whom and where. And if you live in certain communities, you may have no services available to you.
Carol Vassar, podcast host/producer (13:01):
When you think about it, is there a stigma where somebody picks up the phone and says, “Hey, I have Medicaid,” that doctors are going to say, “Oh, no, can’t take you”?
James Perrin, MD, Professor Emeritus, Harvard Medical School (13:10):
Yes, definitely. There was a very nice study done, I believe, in Chicago about 10 or 15 years ago, which actually looked at what happened when people identified as having Medicaid as their insurance versus a commercial insurance. This was, I think, a trained caller to do this. And it was very clear, tremendously painfully clear, that if you were on Medicaid, you either didn’t get an appointment or it might be six or eight months later. Whereas if you were commercially insured, you got an appointment relatively soon.
Carol Vassar, podcast host/producer (13:51):
I think it’s important to point out at this point that 50% or more of the children in this country, and correct me if I’m wrong, are using Medicaid as their insurance. Is that correct?
James Perrin, MD, Professor Emeritus, Harvard Medical School (14:01):
It’s almost 50% Medicaid or CHIP, correct. One in every two children is on Medicaid. It’s not one in five or one in 10, it’s one in two.
Carol Vassar, podcast host/producer (14:13):
Right. So, kid next door, kid over here, chances are one of them is on Medicaid. I want to talk about potential changes to Medicaid. There’s been a lot of discussion in the news, on social media about that. What’s at stake for children at this moment, and what would families actually feel if those changes move forward?
James Perrin, MD, Professor Emeritus, Harvard Medical School (14:37):
That’s a wonderful set of questions. First of all, let me start out by saying one of the really remarkable things about Medicaid is that it’s an entitlement program. That’s not a block grant; it is an entitlement. That means basically that if a person is eligible and she applies to the state to be enrolled, the state is not allowed to say, “We’re out of spots, we can’t enroll you.” They’re required to do that. And it has essentially no copays, no waiting periods, and it has a fairly generous benefit package through EPSDT. Lots of really, really good things about Medicaid. I want to really stress that. And it’s interesting. What’s going to happen now? Well, first of all, it is important to realize that in the H.R. 1 discussions in Congress, children were thought to be a pretty deserving group of people. They were thought to be ones we want to protect and keep safe in the context of changes.
(15:37):
Unfortunately, the changes in H.R. 1 are going to have major impact on children and children’s health in two or three ways. States are going to have to find money that they don’t get anymore from the federal government, and therefore, they may lower how much they pay already, which is already too low. So the payments may go down even further. Very importantly, pediatric hospitals, the ones that provide a lot of the specialized services, heart disease, kidney disease, lung disease, et cetera, are actually at substantial risk of losing substantial income as a result of the H.R. 1 changes because all these funny things that people don’t understand like state-directed payments or state provider taxes or disproportionate share hospitals, they’re terrible names, by the way, but they’re all different ways that Medicaid has subsidized, provide additional funding for hospitals, and they are all going to change with H.R. 1 and be less available.
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And we are going to see pediatric hospitals losing services, closing doors, stopping their emergency rooms, maybe getting rid of their pulmonary group, et cetera, because they won’t have the funds available. This is going to have a major bad impact on children.
Carol Vassar, podcast host/producer (17:02):
Talk about that impact. It does sound dire.
James Perrin, MD, Professor Emeritus, Harvard Medical School (17:05):
It is dire, there’s no question about it. There are many, many hospitals in this country, pediatric hospitals. Some of them are sort of freestanding, the children’s hospital of X. Some of them are part of larger hospitals, a children’s program within a big community hospital, especially in less well-resourced communities. Those hospitals are going to be facing very hard times. They’re not well-financed to begin with, but with the changes in H.R. 1, which will cut down on their ability to get additional funds from the state, some of them will close their doors, totally. We’re going to see closures, but some of them are going to have to cut out services that are important for everyone. We all need children’s hospitals. They’re terribly important, right?
Carol Vassar, podcast host/producer (17:59):
As we talk about the system, and I want to talk specifically about the children’s pediatric healthcare system, but this, I think, also applies in the adult world, there is still a system, we’re looking at a system that pays for volume, that is diagnosis and treatment rather than prevention, long-term outcomes.
(18:17):
What would it take for Medicaid, in particular, but for the system in general, to support a paying-for-health model for children, especially when the return on investment is not going to be two years, it’s not going to be the next election cycle, it’s long-term?
James Perrin, MD, Professor Emeritus, Harvard Medical School (18:33):
I think that’s a really important question and one that does require us to rethink how we actually pay for services. This is on the payment side, less than the financing side. Right now, we do pay predominantly for diagnosis and treatment, and whereas that is important, for children especially, we’re thinking about prevention, health promotion, we’re looking at outcomes that may be 3, 5, 7, 10, 20 years down the line. So we’re not going to show major savings and costs.
(19:08):
Of course, kids are pretty inexpensive anyway, so there’s not much to save where they are. But even so, we’re not going to find mid-savings and costs, but could we change the incentives and payment from paying for just diagnoses and treating to really thinking about how to improve the whole health of a child, to think about really measures that are indicative of how well this child is doing in several areas? We should be able to do that. And some states are already experimenting with that. Not enough, but some are, and I think that’s really very exciting.
Carol Vassar, podcast host/producer (19:42):
What states are doing that?
James Perrin, MD, Professor Emeritus, Harvard Medical School (19:44):
Well, for example, here in Massachusetts, we really are trying to change the financing arrangement from paying for services provided to paying for people and to increase the payment if you’re providing services like mental and behavioral health services in your practice, or if you also got a community health worker who helps link families to community resources that may help treat their child’s asthma, for example. So those are all things we’re doing here to change the payment arrangement and the incentives. Is that enough? Probably not, but it’s a real step in the right direction.
Carol Vassar, podcast host/producer (20:23):
What do you think the ultimate system would look like when it comes to creating payment, financing, prevention, treatment for children moving forward, if you had that magic wand?
James Perrin, MD, Professor Emeritus, Harvard Medical School (20:38):
Well, I think two or three things are important. One is we need a system that makes sure that every child living in the United States has healthcare coverage. So one is looking toward a universal program and assuring coverage. And it might be something like making sure that every child leaving the nursery has a health insurance card, whether it’s public or commercial, but no one leaves without. And along with that is making the assumption that every child should continue on that insurance for most of her or his childhood, so up to age 21 or 26, without having to be redetermined or reviewed every six months or a year, which is very wasteful of public monies to go through that process, but to really say, “All right, you’re covered. You get the services.” So that’s one thing is the universal aspect of it.
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I think the second is really making sure that we do enforce an EPSDT-like package, that we really do make sure that children get the kind of services they really do need. I think three is to really stop the variations across the states. When I was still seeing patients, if I had a patient from New Hampshire, that person would have a different Medicaid program from people in Massachusetts. Well, that isn’t good for anyone, not good for the children, not good for me, not good for the travel back and forth, et cetera. So we’d like to change that. We need to get rid of that and make it national standards for all things like eligibility, payment, quality measurement, accountability, those sorts of things are all important in that. So that’s, really, a third piece that is really important here, I think. And a fourth piece is really increasing the financing to a reasonable level to really make it work. It’s not extremely expensive to do that, frankly, because children are relatively inexpensive, so we could do it.
Carol Vassar, podcast host/producer (22:45):
Talk about the downstream effects if we don’t put this kind of paying-for-health model into effect at some point. It’s going to take a long time.
James Perrin, MD, Professor Emeritus, Harvard Medical School (22:55):
Well, it will take some time, no question. I think we’re already seeing the downside effects today, Carol. I think the fact that we’ve had such really poor financing and lots of struggles for families to get access to care means that we’re seeing higher degrees of mental health conditions among children today than we should be and more than we have in the past, but we’re also seeing other diseases that should be preventable, things like sexually transmitted diseases. We’re seeing higher rates of asthma than we should be seeing. These are all now and today because we didn’t do the investment before.
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And what we do know also about America’s young workforce, people in their 20s and 30s and 40s, is they, too, have remarkably high levels of chronic health conditions, far more than people in England, Canada, France, Germany of the same age. Those conditions include a lot of mental health conditions and substance use problems, many of which we could have changed if we were taking care of these young people when they were 10, 11, and 12 effectively, but many of them also have asthma, many of them have obesity and obesity-related conditions, and many of them have increased rates of pulmonary disease. We’re also seeing increasing rates of cancers in this population. All of these are things that if we were providing better healthcare for young people, now we would have less of.
Carol Vassar, podcast host/producer (24:31):
You’re a Professor Emeritus, you’re retired, but you’re still working in the policy realm. You’re still spreading the news about Medicaid and how to change the system toward paying for health. I want to leave here today on a note of hope. What do you see that’s positive, moving us forward toward that paying-for-health model?
James Perrin, MD, Professor Emeritus, Harvard Medical School (24:53):
Well, I think there’s a lot of sense that we’re not doing what we should be doing in the healthcare system. There’s a lot of dissatisfaction with the healthcare system, and it’s probably growing. Not all of it, of course, is directed around the issues for children, but there’s a lot of concern that the healthcare system is not improving health. It’s improving treatment, but not health.
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And that’s, I hope, going to translate into some strategies around changing how we do pay for care. And I think that will happen. There’s slow progress, but really developing. The second is I think there’s increasing recognition of how important America’s children are, that we really need to be providing them what they need. And I think most working-age adults believe that way. Most parents of kids believe that way too.
Carol Vassar, podcast host/producer (25:43):
Oh, yeah.
James Perrin, MD, Professor Emeritus, Harvard Medical School (25:44):
So I think trying to build on that understanding. Help people understand what we could be doing better. Helping people realize that their third-grader is in school with children who may not be healthy, but she’d be better off if they were healthy and if they were all doing things together. So it’s really a part for all of us what we need to be doing. I think that’s important.
(26:08):
The second glimmer of hope, I would say, is, frankly, as I said before, even in the H.R.1 debates, children were considered a deserving population. Well, I think we have to go back to Congress and say, “We agree, they are a deserving population, but frankly, some of the things that happened that we weren’t thinking about in H.R.1 are going to make the healthcare for children substantially worse.” So maybe this is a time to say, “All right, folks, let’s step up and do it right. It’s not that expensive.”
Carol Vassar, podcast host/producer (26:45):
Dr. James Perrin is professor emeritus of pediatrics at Harvard Medical School and founder of the Mass General Hospital Center for Child and Adolescent Health Policy.
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Well Beyond Medicine!
Carol Vassar, podcast host/producer
Thanks to Dr. Perrin for sharing his time and expertise, and for the reminder that investing in children’s health is really about creating the conditions for kiddos, families, and communities to thrive.
While the challenges facing Medicaid are significant, so too are the opportunities to build a pay-for-health model of care that makes good on the promise of healthier children today and healthier generations to come.
The Nemours Well Beyond Medicine podcast is all about great conversations, discussions, and stories centered on children’s health, all of which live together on our website: nemourswellbeyond.org. Visit there to subscribe and like the podcast, subscribe to our monthly e-newsletter, and leave us a review or an idea for a future episode. That’s nemourswellbeyond.org. You may also subscribe on YouTube along with your favorite podcast app.
Our production team for this episode includes Susan Masucci, Lauren Teta, Cheryl Munn, and Alex Wall. Video production by Josh Hansbrough. Audio production by me. Join us next time as we take a look at how everything old is new again when it comes to our teens and nicotine. I’m Carol Vassar. Until then, remember that together, we can change children’s health for good, well beyond medicine.
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Let’s go…Well Beyond Medicine!
