The Stories of Jacob and Isabel: Will Their Needs Be Met by Health Reform? – Say Ahhh! A Children’s Health Policy Blog

As health reform discussions continue, one key question that will be addressed is what benefits will children be eligible for and how much will they cost?  Because they are growing and developing, children have a distinct set of health care needs that evolve over time and differ from those of adults.  Moreover, while as a group children are relatively healthy, one in seven has special health care needs.  Given that under reform, there is a lot of discussion about covering kids in private plans, it is particularly important to consider how well these plans might meet children’s health care needs.

Today the Kaiser Commission on Medicaid and the Uninsured released a paper CCF co-authored with our colleague at the Georgetown Health Policy Institute, Karen Pollitz, entitled “Children and Health Care Reform: Ensuring Health Coverage Meets Their Needs“. Jacob and Isabel are the protagonists of this report – we look at their health care needs in a typical year, and see how they would be fare in the Federal Employees Health Benefits (FEHBP) Blue Cross/Blue Shield Option – the private plan that Members of Congress receive – and a relatively generous one at that.

Jacob is a 7 year old boy who loves playing baseball and is generallly healthy, but has asthma and allergies. Isabel is a 13 year old girl who has cerebal palsy and needs extensive services to ensure that she is able to function optimally and attend school – where she has been doing extremely well. One of the key findings of the report is that a family with a relatively healthy child may still face significant out-of-pocket costs under the FEHBP Blue Cross plan. While most of the services Jacob uses would be covered, we estimate that Jacob’s family would spend about $2,020 in out-of-pocket costs under the BCBSSO plan to meet his annual health care needs in the past year.

A child with special health care needs , like Isabel, can face significant gaps in coverage and large out-of-pocket costs under the BCBSSO plan.  Isabel’s family faces annual out-of-pocket costs in excess of $9000. Some of her services are not covered, and sometimes her family has to go out of network to find the specialist she needs.

In contrast, Medicaid fully covers children’s acute and long-term care needs with no or very limited cost-sharing requirements.  Under Medicaid’s EPSDT benefit, all of the needed care for both Jacob and Isabel would be covered.  The EPSDT benefit covers all medically necessary care for children, which means it fully covers preventive and primary care, including dental, hearing, and vision care, as well as all acute care needs and long term care needs for kids that need it.

These findings illustrate that the content of coverage provided under reform will have significant implications for children’s access to care and their families’ financial security.  As policymakers consider standards for coverage provided to children under reform, it will be important for them to consider not only what benefits will be covered, but also the limits that will apply to covered benefits and required cost-sharing amounts, including deductible, copayment, and coinsurance charges.

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