So, before jumping into some of the blow-by-blow of what this bill means for kids, it is worth stepping back to say that if health reform were to follow the path outlined in the HELP bill, it would be a major, transformative step forward. Millions of Americans would secure health coverage. And, our health care delivery system would begin to move toward the much-discussed (but little acted upon) goal of delivering more cost-effective, high quality health care that focuses on preventing disease rather than merely treating it.
1. Build affordable coverage pathways for all children.
The good news is that the bill proposes to expand Medicaid to 150 percent of the federal poverty level (FPL) for everyone (except it fails to mention legal immigrants, a shortcoming we’ll have more to say on in future posts); retain any Medicaid coverage – such as for children — already in place at levels above 150 percent of the FPL; and create a new a subsidy program to help families with income up to 500 percent of the FPL purchase coverage.
The bad news is that it fails to address the future of the CHIP program, a critical component of coverage for millions of low-income children. While not under the jurisdiction of the HELP committee, the members could (and did on other topics, such as Medicaid) outline what they thought should happen to it. With CHIP on the chopping block in states such as California, it is a dangerous time to leave its future unspecified.
2. Beyond insurance — Ensure children get the care that they need.
The HELP bill is strong and sweeping in its efforts to modernize and reform the health care delivery system, calling for creation of a national strategy to improve the quality of care; making major new investments in workforce training; promoting the use of preventive care; and creating a grant program for medical homes.
I’ve complained in the past that kids have been left out of efforts to transform the delivery system, but the HELP bill scrupulously includes children.
For example, in its prevention section, it specifically requires all health plans, to cover the preventive care and screenings identified in “Bright Futures.” (Developed by the American Academy of Pediatrics, Bright Futures is the “gold standard” for preventive care, including services needed to address the unique developmental needs of children.)
On the other hand, the HELP bill potentially does not go as far as is needed in covering other, non-preventive services, that children require. Under the bill, health plans are expected to cover pediatric services as a “general category”. But, it doesn’t put much meat on the bone, leaving it up to a Medical Advisory Council to provide more detail on what must be covered. So, for example, we know that a child with speech delays would be able to get a screening for a hearing problem under the HELP proposal, but can’t be certain that if the screening shows an issue, that the child would be able to get a hearing aid.
3. Create a unified “no wrong door” enrollment and renewal process.
The coverage system proposed by HELP – and by every other major committee considering the issue – is a patchwork of employer-based coverage, Medicaid, and presumably CHIP (although see above). Increasingly, we’re concerned that families will find it extremely hard to navigate this three-part system, leaving them at risk of ending up in a no-mans land without any coverage. The best way to prevent this is to create a unified, simplified application and renewal process in which families can get coverage regardless of whether they initially apply via a Gateway, a Medicaid agency, or a CHIP agency. In other words, there should be no wrong door into health coverage, a particularly important point if, as the HELP bill proposes, people face a mandate to secure coverage.
The HELP bill moves in the “no wrong door” direction, calling for Gateways to have responsibility to “assist” uninsured people in signing up for coverage. But, as we’ve learned from the experience of Medicaid and CHIP, an “assist” might not be enough when people must navigate multiple programs — if a family has applied for coverage, the family should actually be enrolled in coverage. As we discuss in detail in The Last Piece of the Puzzle, to make such a system possible, it may be necessary to create simpler rules for establishing eligibility in Medicaid, CHIP, and the Exchange across the country such as requiring electronic verification of income data when feasible and requiring 12-months of continuous coverage in Medicaid, CHIP and the proposed subsidy program. Promoting simplification and creating automated processes along with providing assistance are critical in order to ensure that we are not adding red tape that makes getting and keeping coverage more onerous.
4. Strengthen financing for public programs – the backbone of coverage for low-income children.
This is an easy one…. The HELP bill does not address these issues, even via “assumption,” presumably because they are well outside its jurisdiction.
We’d love to know what others are thinking. In the meantime, people may also find helpful the thoughtful comments of the American Academy of Pediatrics and the March of Dimes, both of which are acutely focused on the needs of children and pregnant women in health reform.