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Researchers call for improved, unified national pediatric health policy
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As Congress debates an extension for funding the Children’s Health Insurance Program beyond September 2015, the current state of pediatric health coverage must be considered, according to several researchers.
Despite recent reforms, health insurance programs for children, including Medicaid, Children’s Health Insurance Program (CHIP) and the Affordable Care Act (ACA), appear to have created a disjointed system of coverage. Each program has its benefits, however, and they must be considered as CHIP’s uncertain future is determined.
“Medicaid’s Early and Periodic Screening, Diagnosis and Treatment benefit for children up to age 21 is broad and detailed, focuses on pediatric principles, and includes a right to treatment that is ‘medically necessary’ as determined case by case,” according to Aimee M. Grace, MD, MPH, of Children’s National Health System in Washington, DC, and colleagues, who wrote a study published in Health Affairs.
CHIP offers states more flexibility to define child health assistance by allowing them to create their own “benchmark” plan as a reference for CHIP-sponsored plans.
Medicaid and CHIP have had significant success, according to Sara Rosenbaum, JD, a professor of health, law and policy at George Washington University, and Genevieve M. Kenney, PhD, of the Urban Institute’s Health Policy Center.
Genevieve M. Kenney
The proportion of uninsured children decreased from 15% in 1989 to 6.6% in 2012, according to research conducted by Rosenbaum and Kenney that also was published in Health Affairs. Further, from 1984 to 2012, the proportion of poor and uninsured children decreased from 30.3% to 7.3%.
“Research has documented the positive impact of Medicaid and CHIP on children in terms of improved access to and use of care,” Rosenbaum and Kenney wrote. “A growing body of literature also points to long-term health and other benefits associated with expanded public health insurance for children.”
Although the ACA was structured to align with Medicaid and CHIP programs, a close reading of the act suggests Congress aimed to restructure the health insurance system to better serve children.
Despite this, with the exception of oral and vision care, the ACA does not provide a clear definition of essential pediatric services that should be included in insurance plans. In addition, each state maintains a major role in determining the range of services offered under health coverage plans.
“As a result, different states require coverage of different benefits, with no overarching national pediatric benefit standard,” Grace and colleagues wrote.
Defining essential pediatric services
To gain a sense of what states considered essential pediatric services, Grace and colleagues reviewed each state’s essential health benefits benchmark plan as identified by the Center for Consumer Information and Insurance Oversight. They found that no state’s benchmark plan summary included a benefit category specifically for pediatric services.
There were, however, numerous mentions of specific pediatric treatments or services. Excluding oral and vision care, some of the most frequently included treatments or services were orthodontia, congenital defects, autism spectrum disorder services and hearing aids.
In general, children were not excluded from population-wide benefit categories, but researchers found specific exclusions of children within certain treatment categories, most commonly associated with developmental and mental health conditions.
Thirteen states excluded services for children with learning disabilities. Ten states excluded speech therapy for developmental delays, stuttering or both.
The future of pediatric health policy
Going forward, these data should be considered alongside benefits and disadvantages of Medicaid, CHIP and the ACA to improve national pediatric health insurance coverage, the researchers suggested.
“Fixing the family glitch emerges as the most obvious first step toward a more unified child health policy,” Rosenbaum and colleagues wrote.
The “family glitch” refers to a lapse in pediatric coverage experienced by workers who are barred from obtaining premium subsidies for their children because their own coverage meets the affordability threshold.
If CHIP funding is not extended beyond the 2015 fiscal year, children affected by the family glitch may not have access to affordable insurance, the researchers pointed out.
CHIP’s cost sharing model is another benefit to be considered, as it “appears to be superior to levels imposed under employer plans, where high-deductible plans that include separate high deductibles for each family member are increasingly found,” according to Rosenbaum and Kenney.
Another benefit of current pediatric insurance programs, is the ACA’s design of benefit standards, which includes a distinct pediatric category and helps to establish broader protection for essential coverage and cost-sharing levels for children.
“The immediate need is to protect children enrolled in CHIP; the bigger need is to protect all children,” Rosenbaum and Kenney wrote.
The debate over CHIP funding has started an important conversation about the future of child health policy, one that Grace and colleagues said must continue until successful reforms that close gaps in pediatric health care are implemented.
“As [the Department of Health and Human Services] revisits the standard during the next year, it is critical that the essential health benefits regulations for pediatric services be improved,” Grace and colleagues wrote. “HHS could revise the standard to bar pediatric treatment limits and exclusions, particularly exclusions based on mental retardation, mental disability, or other developmental conditions; incorporate the concept of medical necessity into a defined pediatric benefit; address both covered services and actuarial value; and permit CHIP plans to be used as a benchmark for pediatric services.”
For more information:
Rosenbaum S. Health Affairs. 2014;33:2125-2135.
Grace AM. Health Affairs. 2014;33:2136-2143.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Richard Lander, MD
These articles do a good job of providing many of the facts relating to the ACA, specifically provisions affecting pediatrics, that are not being addressed in the pediatric world — such as the inclusion of children with developmental problems and what is referred to as the "family glitch," provisions that do not include the cost of family coverage rather just the "self-only" coverage.
The authors accurately state that 38% of children under the age of 19 years are covered by Medicaid or CHIP and that millions of families not eligible for Medicaid have been helped. They mention that CHIP is governed by the state. This should be one decision for all states as the child in New Mexico should have the same availability of health care as the child in Ohio. The articles also correctly mention that Medicaid and CHIP have demonstrated increased health care to those targeted populations.
The drop in participation in employer-sponsored plans is attributed in the articles to increasing premiums, decreasing employer contributions and somewhat stagnant wages. Certainly a healthy economy would be beneficial but curtailing the incredible profits that the insurance companies generate would prevent the ever-escalating insurance premiums.
I would offer the following suggestion to help adjust the spiraling costs of health care in the United States. First, there should be better controls over Medicaid eligibility. Many people have learned how to game the Medicaid system and the Medicaid rolls are bloated with people who should not be there. Second, there needs to be a tightening of cost containment but not by the insurance companies that profit by denial of care. Rather there should be an entity staffed with physicians that determines the need for medical care based on medical necessity. Third, there should be a malpractice reform. Unfortunately in today's medical liability environment some testing is performed for liability protection. A remedy to this would be malpractice reform which would include caps placed on settlements.
Perspective
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William T. Gerson, MD
Three articles should be on the reading list for all pediatricians. If, as a group, our interest is the well-being of all children in this land we cannot be good advocates without the necessary understanding of how health insurance for children has been carved out in the past, in the present and how we must prepare for the future. Two of the articles, both recent commentaries from Health Affairs, are reviewed here. The complimentary third, is the January 2012 position statement from the AAP Committee on Child Health Financing, “Scope of Health Care Benefits for Children From Birth Through Age 26” (Pediatrics. 2012;129(1):185–189).
Even if thinking about health insurance is your answer to either insomnia or entry into a padded cell, these three are clear, concise but powerful reminders of the tenuous nature and significant limitations of our government supported insurance-based system. For the many of us who ask “how can the system really work this way?” the two commentaries explain the historical context of federal involvement from 1945 to the present and explain the workings of Medicaid, CHIP and now how they overlap into and with the ACA system. As the Department of Health and Human Services plans to revise how it interprets the ACA in terms of pediatric care for the 2016 plan year the time is now for all of us to better understand what is at stake.
With the benefit of time under the ACA both Health Affairs commentaries are able to finally put some data toward such a future look and thus prepare the battleground for advocacy. What is quite obvious is that providing for the availability, affordability, and access to quality care for our nation’s children has been a lesson in the sausage making of politics at the federal and state levels. Testimony to the dedication of so many who have fought for reform but scattered with remnants of a system that more easily rewards single interest groups rather than the proposed beneficiaries, our children, the results have been uneven but improving.
The greatest challenge is of course the present. We must thank the two groups of authors who have weighed in on the current state of affairs. They have outlined where energy must be utilized to stabilize, correct, improve and hopefully emerge with a more understandable and functional system of insurance for expectant families and children through young adulthood. The AAP has provided the counterweight to the political give and take with a simple policy statement that sets forth recommendations for the design of a comprehensive benefit package for any insurance plan — public or private — to ensure adequate care. With its “Bright Futures” project the AAP has provided the foundation for the referenced policy statement. By advocating for all our children and their families the AAP presents the needs in the simplest form: a patient- and family-focused, comprehensive, developmentally based and pediatric reasoned charter.
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