Children’s Health At Risk Without CHIP Funding, Even If They’re Insured

March 2, 2015

I came belatedly to an enlightening article on the potential end of funding for the Children’s Health Insurance Program. Learned more than I knew when I blogged about it last October.

Professor of Pediatrics Aaron Carroll, who wrote the piece, notes the concern about children who may have no health insurance whatever — about 2.2 million, according to one count. But he focuses mainly on concerns for those who will have coverage because their parents have an affordable family plan purchased on a health insurance exchange.

Or we surely hope so. As you’ve probably read, the Supreme Court has been asked to rule that the federal government can’t subsidize plans purchased on the exchange it established for people who live in states that didn’t create their own.

Many trustworthy experts think the Court won’t. But if it does, as many as five million children could wind up with no affordable health insurance, according to a friend-of-the-court brief filed by the American Academy of Pediatrics and seven other organizations engaged in healthcare services and advocacy for children.

Carroll doesn’t allude to this doomsday scenario. He instead makes several points in favor of renewing CHIP funding, even with the subsidies intact.

The first is that CHIP covers a larger portion of children’s healthcare costs — more than 90%, as compared to 70% in the mid-level silver benchmark plans the Affordable Care Act provides for.

A troublesome difference. Some parents, however, might opt for plans with rock-bottom monthly premiums, but even higher deductibles and other out-of-pockets. This could cause them to forgo needed care — for themselves and perhaps their children.

Cost aside, Carroll raises several concerns about the health care children could receive through plans available on the exchanges. They’re rooted in the fact that the plans, unlike CHIP, aren’t tailored to children’s healthcare needs.

The problem begins with the ACA itself. The law establishes essential benefits that all plans must cover, both those offered directly to individuals and those small employers can purchase. They include pediatric services, with vision and dental care specified.

For reasons known best to the U.S. Department of Health and Human Services, the rules are silent on all but the two named services. And they allow for a separate, optional dental care plan — at an additional, unsubsidized cost — rather than requiring coverage in the overall plan.

I don’t suppose I need to elaborate the potential consequences for low-income children.

More generally, the failure to specify essential pediatric services has allowed states to choose as the basis for their minimum requirements plans that exclude a variety of healthcare services for children.

Carroll cites, among others, services for children with learning disabilities and autism. He also notes gaps in services expressly required, e.g., care of congenital defects, hearing aids and implants for children whom hearing aids can’t help.

Another related variation applies to plans families may purchase. Some, Carroll says, have very narrow networks, i.e., hospitals and physicians whose services the insurance company will pay for.

They’re narrow for providers of pediatric care than care for adults — and especially narrow for providers of specialty care, he adds. The narrow-network plans tend to be cheaper. And we’ve some evidence that many purchasers don’t understand the trade-off.

So parents may learn, when it’s too late, that there’s no in-network children’s hospital or other source of affordable services from doctors trained to treat children with complex, chronic conditions.

What’s rather strange about CHIP is that the ACA extends it through Fiscal Year 2019 — and sets a higher federal match rate for states’ costs beginning in Fiscal Year 2016. Yet it gives the federal government authority to spend money on the program only through this fiscal year.

States may have some leftover funding, but it’s unlikely to last through the year. There’d still be a match for low-income children who’ve been served through Medicaid, rather than separate CHIP programs, but it could be lower. It would definitely be lower for the children states shifted into Medicaid, as the ACA required.

For the rest, there’s no assurance state exchanges would have insurance plans with benefits and cost-sharing comparable to CHIP. Carroll’s analysis suggests that many don’t now. They could, but wouldn’t have to if CHIP funding dries up.

Surely it would be irresponsible to let CHIP funding lapse and see what happens. If children’s health problems aren’t promptly and expertly diagnosed and/or don’t get appropriate treatment, no one can remedy the harms by restoring CHIP or refining the ACA later.

 

Advertisements

Let’s Make Health Care Reform Work For Low-Income Children

December 11, 2009

As I wrote awhile ago, the current health care reform bills could leave many low-income children worse off than they are now. The children at risk are some portion of those who are currently enrolled–and others others who should be enrolled–in the State Children’s Health Insurance Program.

Those whose families are poor enough will have a broad range of very low-cost benefits through Medicaid. Not-quite-so-poor children now enrolled in SCHIP will be shifted to the health insurance exchange–immediately under the bill the House passed and in 2013 under the bill the Senate is debating. And that’s where the problems lie.

Plans purchsed through the exchange will have considerably higher premiums and out-of-pocket costs. And neither the House nor the Senate bill requires them to cover all the health services children need.

Moreover, just because the Senate bill would temporarily extend SCHIP doesn’t mean that all eligible children would be covered. According to a Kaiser Family Foundation brief, most of the 8.9 million children without insurance now are eligible for a public health care program. The Congressional Budget Office estimates that SCHIP and Medicaid combined will cover only 5.6 million more children in 2013.

Nor does the current Senate bill mean that children in SCHIP will get adequate health care. The Children’s Defense Fund has called the current system “an unjust lottery of geography”–in part because some states operate SCHIP programs that offer less than the comprehensive screening, prevention, diagnosis and treatment services available under Medicaid.

Senator Bob Casey (D-PA) has introduced an amendment (#2790) that would address these problems. As his summary indicates, it would:

  • Continue federal funding for SCHIP through 2019.
  • Require the U.S. Department of Health and Human Services to report on differences between coverage under subsidized plans in the exchange and coverage under SCHIP, thus giving Congress a basis for deciding whether to preserve SCHIP beyond 2019.
  • Require states to offer the same range of services to children in SCHIP as they cover under Medicaid.
  • Provide federal matching funds for all covered services SCHIP children receive instead of giving states a predetermined grant for each year.
  • Prohibit states from reducing income eligibility standards for SCHIP and require them to cover all children up to 250% of the federal poverty line, beginning in 2014.
  • Ensure that SCHIP remains affordable by prohibiting states from increasing charges, except to reflect increases in the median income for low-income families.
  • Provide grants and a significant financial incentive for states to increase outreach and streamline their  enrollment process.

Voices for America’s Children has a customizable e-mail that those who have Senators can use to support this worthy amendment. We who live in Washington, D.C. can call or e-mail Senate Majority Leader Harry Reid, since he will reportedly will incorporate changes he likes into a final manager’s amendment.

The leadership is pushing to get something passed before Christmas. So time is of the essence here.


Low-Income Children Could Be Worse Off After Health Care Reform

November 7, 2009

Last Wednesday, hundreds of concerned citizens answered the Children’s Defense Fund’s call to join a “stroller brigade” to the U.S. Capitol. Other brigades strolled in at least 16 communities across the U.S.

These brigades were to demonstrate grassroots support for “comprehensive, affordable, accessible health care for all children, no matter where they live.” This is by no means an inevitable result of federal health care reform.

CDF warns that the health care reform bills Congress is debating give short shrift to the needs of millions of uninsured and under-insured poor and near-poor children. They could, in fact, leave many worse off than they are now.

CDF and the “champions for children” it’s organized want Congress to do three things.

1. Guarantee all children access to the full range of health benefits they need, i.e., the early and periodic screening, prevention, diagnosis and treatment (EPSPDT) services children can get under Medicaid. There are four related concerns here.

  • Only some children enrolled in the State Children’s Health Insurance Program (SCHIP) get comparable benefits because states can offer more limited coverage.
  • Under the bills now pending, children whose families purchase insurance through the newly-created exchange will not be covered for all EPSPDT services.
  • These children will eventually include those enrolled in SCHIP. The bill the House will vote on would sunset the program in 2013. The final Senate bill will probably extend it to 2019. But even before then, SCHIP children will be shifted to the exchange if a state runs out of funds for the program.
  • Premiums and out-of-pocket costs in exchange plans will be higher than what families pay under SCHIP. As a study for First Focus shows, the difference could be as great as 33%.

2. Eliminate the unjust lottery of geography. Here again, the problem is that SCHIP benefits and eligibility vary from state to state. In some states, SCHIP is structured as an expansion of Medicaid, thus ensuring EPSPDT benefits. Other states have separate, more limited programs. Twenty-two states permit enrollment of children up to 300% of the federal poverty line. The eligibility cap in the remainder is lower.

So what CHN wants in the final health care reform package is mandatory coverage under SCHIP for all children under 300% of the FPL, federal funding to ensure states can enroll all eligible children and, I infer, a nationwide benefits standard comparable to EPSPDT. It also wants SCHIP retained until the alternative can be shown to provide coverage at least as good.

3. Address bureaucratic barriers that keep children eligible for Medicaid or SCHIP from getting the care they’re entitled to. CHN says that complex application and enrollment processes and frequent renewal requirements now keep about two-thirds of eligible children out of these programs. It wants Congress to require a simple, streamlined process.

Those of us who didn’t stroll can support CHN’s agenda by signing on to its letter to Members of Congress.

As Washington Post columnist Harold Meyerson observes, “children–most particularly, children of non-affluent parents–have no clout whatever in the political process.” They depend on us and venerable champions for children like CHN.