Editor’s note: For more on the topic of children’s health, stay tuned for the December issue of Health Affairs, set to be released next week.
Health Affairs’ recent policy brief on the family glitch highlights one of the key issues affecting how well children will be served in the new post Affordable Care Act (ACA) coverage landscape. Many observers thought that with the creation of health insurance marketplaces and subsidies for low-income families, there would no longer be a need for the Children’s Health Insurance Program (CHIP), which was created in 1997 to provide health coverage for uninsured low-income children.
Together with its larger sister program, Medicaid, CHIP has been quite successful in achieving this legislative goal. From 1997 to 2012, the national rate of uninsured children was cut in half from 14 to 7 percent. Yet, 7 million children still remain uninsured. The ACA, meanwhile, was aimed primarily at reducing numbers of uninsured adults. The question now is, what policies and systems are needed to sustain and further the progress that has been made to increase rates of children’s insurance?
Where CHIP and the Exchanges Differ
In addition to the family glitch, there are discrepancies in cost sharing and benefits between CHIP and exchanges that have been documented in several studies recently. These differences suggest that at least under current policy, children will lose coverage altogether or have diminished access to services needed for their growth and development if CHIP is no longer available. Qualified health plans may fall short in offering children what they need in both affordable coverage and care — from hearing aides to special therapies to dental care. Yet, without Congressional action federal funding for CHIP is due to run out in less than a year.
In addition to CHIP’s direct benefits for the millions of children enrolled in the program, it also has brought to both state and federal policy a sharpened focus on children’s health and coverage needs. This spotlight has resulted in enrollment and renewal simplifications as well as innovative outreach strategies that pre date the enactment of the ACA. CHIP also brought greater attention to the quality of children’s health care, at both the state level and in a new national program created as part of CHIP’s reauthorization in 2009. In large part state innovations come from the flexibility afforded states to design and administer CHIP.
CHIP has also had a strong impact on Medicaid programs. CHIP outreach has connected with and brought in many children who are eligible for Medicaid. Both CHIP and Medicaid now have a common national set of quality measures, and many state Medicaid programs adopted enrollment simplification strategies that were tested and proven by CHIP. There is great potential for health insurance marketplaces to learn from both CHIP and Medicaid and establish similar policies and initiatives ensuring that the unique needs of children, especially low-income children, are well served in qualified health plans.
Despite this enormous potential, we have not as a nation developed or implemented effective policies to ensure that children are as well served in exchanges as they have been in CHIP. To be sure, we are still in the ACA’s early years and the fractious political environment around reform has made any changes difficult. But our nation has already made significant investment and progress in ensuring that children in families with low-income have health coverage.
We must continue working toward policy solutions to sustain these gains. One important step would be to remedy the family glitch. Another is to define pediatric services within the set of essential health benefits to ensure they include the services children and adolescents need. Yet another area for progress would be for exchanges to require or incentivize qualified health plans to adopt the child core set quality measures.
Understandably, these options have their challenges. And any policy changes will need to be consistently incorporated into state and federal systems and practices. Even with strong stakeholder support, addressing the issues within the post ACA landscape to ensure affordable and appropriate coverage for children will take time.
Considering the work still to be done, a growing number of states and stakeholders are looking to Congress to extend funding for CHIP. Ultimately, this is a time for creative, innovative, and bi-partisan focus on how we continue meeting children’s needs.