State, federal issues affect delivery of pediatric health care

Two competing bills in Congress would approach vision care for uninsured children in different ways.

Issue: December 1, 2005

ByDaniele Cruz

Pediatric ophthalmologists must cooperate with state and national eye societies and associations of pediatricians to work for funding for pediatric health care for the uninsured, according to a specialist in pediatric ophthalmics.

“Vision screening, like all issues dealing with medicine, is a states’ right issue,” said Michael X. Repka, MD. “It’s not one legislated by our federal government.”

Despite this, the national government affects health care delivery for pediatric patients in many ways, he said. Dr. Repka spoke about the government’s role in children’s eye health care during the Pediatric Subspecialty Day at the American Academy of Ophthalmology meeting.

Two bills that would support eye care for uninsured children in different ways were introduced in the previous session of Congress, the 108th, Dr. Repka said. Neither was passed, and now both have been reintroduced in the 109th Congress.

One, which was supported by organized ophthalmology, would establish a grant program to facilitate preschool vision screenings and appropriate follow-up and treatment. The other, which was supported by optometry, would also establish a grant program, but these grants would fund comprehensive eye exams and necessary follow-up and treatment.

“Generally, you can look at those bills as ‘feel-good’ proposals,” Dr. Repka said. “There was no money available to fund them in the congress last year. There were too many other things to spend money on. Ample public relations efforts were generated around both bills. It was an election year, so they never were voted out of committee.”

In the current session, the 109th Congress, the bill supported by the AAO, the American Academy of Pediatrics and other medical groups was reintroduced by Rep. Vito Fossella, R-N.Y., and a number of co-sponsors from across the country, Dr. Repka noted.

“This bill acknowledges the value of state-mandated and other screening programs, acknowledges that many problems are best treated in childhood, and provides funds for a follow-up program,” Dr. Repka said. “The funds, just $75 million for 2006, complement other state and federal funds, so it’s a secondary coverage.”

If funded, the bill would provide coverage for eye exams and treatments for children identified as needing care by existing screening programs, he said. The bill would limit to 20% the amount of the funding that could be spent on education of practitioners and patients about vision impairment, and it would require data collection to assess the impact of the care provided.

The other bill, which has been supported by optometric groups, was reintroduced in this Congress by Rep. Bill Pascrell, D-N.J., and co-sponsors. The bill would fund grant programs to provide comprehensive exams, Dr. Repka noted.

“The big difference is that it pays for initial exams and funds follow-up care, and an unlimited portion can be spent on education,” he said.

“Neither bill is likely to pass because of the lack of resources available, but they can be used, and are being used, as a vehicle to increase public awareness of children’s vision problems,” Dr. Repka said.

Other issues

Other government issues that affect the delivery of eye health care for children include medical assistance programs such as Medicaid and the State Children’s Health Insurance Programs, as well as policy objectives from the Department of Health and Human Services, Dr. Repka said.

In the United States, there are 73 million children under the age of 18 years, he said. Of these, about 6.5% have no health insurance in a given year.

In addition to the totally uninsured, “Often forgotten are the 7.5% of patients whose insurance is discontinuous,” Dr. Repka said. “The good news, if you will, is that the proportion of children who are uncovered is only about half that rate of patients between the ages of 18 and 65, largely because of the federal programs in place.

Gaps for some uninsured and underinsured children are filled by the Medicaid program, he said. About 60% of Medicaid beneficiaries are covered through managed care programs.

“The coverage policy remains largely a state decision,” Dr. Repka said. “There’s little determination of coverage coming from the federal government. However, budgets have become stretched, as we all know, and these coverages are becoming targets for bureaucracies trying to improve their cost-to-expenditure ratios.”

At any one time, Medicaid covers 23 million children in the United States, Dr. Repka said. In 2003, $266 billion was spent by Medicaid, including both federal and state expenditures, of which about one-sixth was spent on children, he said.

“Children’s eye care is relatively less expensive, perhaps the bargain in this program,” he said.

“State and federal budget deficits have put funding for Medicaid at risk on the state level,” Dr. Repka said. “Those deficits have led to the program, a voluntary program that’s been put in place in the states, called Medicare waivers, and states can propose programs that improve their flexibility. That is something that providers in every state have to look at on an individual basis.”

Setting health objectives

The Department of Health and Human Services, which has the duty of setting health objectives for medicine, has set three vision goals for children, Dr. Repka said. These are reducing vision impairment from 25 to 20 per 1,000, increasing the proportion of children who receive preschool screening and increasing the use of protective eyewear.

“These goals really require not just the American Association for Pediatric Ophthalmology and Strabismus, and not just this group here, but the collaboration of our state eye societies and American Academy of Pediatrics state chapters,” Dr. Repka told the audience.

For Your Information:

Michael X. Repka, MD, can be reached at 233 Wilmer Ophthalmological Institute, 600 N. Wolfe St., John Hopkins Hospital, Baltimore, MD 21287-9028; 410-955-8314; fax: 410-955-0809; e-mail: mrepka@jhmi.edu.

Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.