By Wendy Lazarus
Everyone who cares about children in California and around the country ought to be rooting for the Affordable Care Act (ACA) to succeed. If done right, it will mean kids who have never received regular check-ups, eye glasses, dental care, or screenings can get them and other needed health care — on time and when needed.
But whether this historic law results in a meaningful step forward for kids depends on crucial and complicated decisions states and the federal government make between now and Oct. 1, 2013, when the doors open for enrollment in coverage. Large numbers of children will be covered through the publicly-funded Medicaid and CHIP (Children’s Health Insurance Program) programs, administered by states. By contrast, the vast majority of adults will be covered through their employers and exchanges, not Medicaid. As a result, certain decisions have a disproportionate impact on children.
So what are the ingredients for success that matter most for kids?
First, getting the initial sign-up right for kids is essential and involves different priorities than those for most adults. When children enter the enrollment system required by the ACA, millions of kids — more than half of all children in California — will be transferred to Medicaid (Medi-Cal in California). This is because children in families with an annual income up to $58,875 for a family of four get their care through Medi-Cal or CHIP in this new health care landscape. To make sure kids are not lost in this transfer, the Medi-Cal service centers need to be up and running with trained staff from day one. If the centers are not ready, the exchange itself needs to step up to immediately enroll children as the federal law envisions. For the many parents who will apply online for their kids, states should make use of the federal model streamlined application, a breakthrough online tool that is being tested with consumers now, so states can take advantage of this in time for Oct. 1.
Second is making sure health care providers are available for kids. Consumers, providers, and employers alike are concerned about whether there will be enough doctors, dentists, and other medical personnel to handle millions more Americans gaining coverage in short order. In California, for example, it’s a well-documented fact that Medi-Cal’s reimbursement rates are a fraction of standard medical fees and that disproportionate numbers of children on Medi-Cal simply can’t get to a specialist — or even to providers that all children need to see, like dentists. With49.9 percent of California’s children on Medi-Cal not having seen a dentist even once during 2011, imagine the situation when an additional 1.2 million children in California alone get dental coverage once the ACA is implemented. But here, too, states like California are exploring reasonable ways to expand the dental and medical teams by training new providers and extending the scope of current providers to work in underserved areas under the supervision of doctors and dentists. Breakthroughs in technology like telehealth make these advances not only necessary but also realistic.
Third, covering parents matters. Another decision with a major impact on kids is the choice states make about whether to expand their Medicaid program to additional low-income adults. These adults, often parents, currently fall between the cracks of coverage because they can’t afford private insurance but are not currently eligible for Medicaid. Research shows that when parents are eligible for coverage, they are more likely to enroll their children and more children are likely to receive needed care. In California, pressure on Governor Brown is mounting to finish the health reform job by expanding Medi-Cal for adults.
Fourth and fifth are two “sleeper kids’ issues,” important areas where kids’ needs are at risk of being forgotten as policymakers instinctively focus on adults. Fourth has to do with the Small Business Health Options Program (SHOP) state exchanges will offer, designed to create a platform for delivery of small employer-sponsored health care. Because the majority of all children are currently covered through their parent’s employer, the SHOP program needs to connect employees to health coverage for themselves and also their dependent children. SHOP programs should provide a way for every parent to access coverage options for their children, including Medicaid.
Fifth is the ACA’s highly-touted requirement for plans to provide “Essential Health Benefits (EHBs).” Essential Health Benefits ensure that plans purchased through the exchange offer a wide array of services, such as preventive and wellness services and mental health services. However, one of the 10 EHBs — pediatric benefits — remains largely undefined by federal rulemakers, and states still have very important decisions to make about many of these benefits. In California, for example, questions remain about how pediatric dental care will be offered and paid for, and there are concerns about maintaining current levels of critically important mental health, hearing, and other important benefits for children.
Last, and arguably most important of all, is whether coverage under the ACA will be affordable to families with children. Today, 52 percent of uninsured Americans say the main reason they don’t have insurance is because they can’t afford it. Unless the ACA changes this situation, it cannot succeed. Astoundingly — since it is in direct conflict with the central goal of the ACA — the Internal Revenue Service recently issued a ruling on how subsidy levels will be determined. Their ruling poses a huge affordability problem for families with children. It says that subsidies for families will be based solely on whether the individual employee’s coverage is affordable; if it is, the whole family is ineligible for subsidies, even where the employer’s family coverage is unaffordable. As a result, nearly half of a million children across the country are expected to remain uninsured because parents would not be able to afford coverage for the whole family. The impact must be analyzed in 2014, and remedies must be found.
The ACA’s potential to help kids is enormous. There is a recipe for how to get this right. Our collective job over the months ahead is to make good decisions on behalf of the millions of children in this country who are not at these decision-making tables but whose well-being — and even lives — depend on making the right choices.