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By Amanda Jezek, March of Dimes

Health reform is giving pregnant women throughout the U.S. a far more valuable package than anything they could ever unwrap at a baby shower -- access to maternity coverage.

Coverage for maternity care is crucial because, without it, women face much more difficulty in obtaining needed health services.  Women who have insurance coverage for maternity care are more likely to receive screening and diagnostic tests that can help to identify problems; services to manage developing and existing problems; and education, counseling, and referral to reduce risky behaviors like substance abuse and poor nutrition.

Prenatal care can help reduce infant mortality and improve birth outcomes; postpartum care can help women appropriately space pregnancies, which can reduce the risk of preterm birth.

According to U.S. Census data prepared for the March of Dimes, a whopping one in five women of childbearing age is uninsured. Now consider that 50 percent of pregnancies are unplanned. Those who tried to get coverage on the open market were in for a rude awakening: insurers considered pregnancy to be a pre-existing condition and would therefore often deny coverage.  Needless to say, many women found themselves facing this dilemma.

Consider a March of Dimes family in Virginia who signed up for private insurance because their COBRA coverage from a previous job was about to end. They took the precautionary step of adding a maternity rider, which had a six-month waiting period before covering pregnancies. They didn't think there would be any issue as they used fertility treatments to conceive their first child. Despite being told by doctors that they had only a five percent chance of getting pregnant naturally, four months into the six-month waiting period, they discovered they were expecting. At that point, no other insurance company would pick-up coverage determining that the pregnancy was "a pre-existing condition." It cost the family $20,000 out-of-pocket.

Thanks to health reform, the practice of pre-existing condition exclusions will be prohibited in 2014 (earlier for children).  But the pre-existing condition exclusion was only one of many hurdles that pregnant women faced to obtaining coverage -- and that health reform will fix. 

In 2006, a Georgetown University study commissioned by the March of Dimes found that 19 states had adopted laws to require coverage of maternity care. However, these laws varied in scope, and only five of the states (MA, MT, NJ, OR and WA) required all insurers in the individual market to cover maternity care. In states without such requirements, maternity coverage is typically available only through an expensive rider to the underlying policy -- and then with a waiting period or outright denial if the woman is already pregnant.

Health reform will require insurers to cover an essential benefits package that includes maternity care.  Insurers will no longer be able to exclude this critical benefit from policies.

While these private insurance reforms are a tremendous step forward, over 40 percent of pregnant women rely on Medicaid for their coverage.  Health reform makes improvements for these pregnant women too.  Beginning in 2011, all state Medicaid programs will be required to cover tobacco cessation counseling and pharmaceuticals for pregnant women. Given that pregnant women in Medicaid are 2.5 times more likely than other pregnant women to smoke and that smoking dramatically increases the risk for numerous poor birth outcomes (such as preterm birth and low birth weight), this policy will provide much needed assistance to millions of pregnant women.  The U.S. Preventive Services Task Force has found that tobacco cessation interventions are very successful in helping pregnant women quit, and these services have even been found to save money.

Health reform also gives states the option to start covering more low-income women before they get pregnant using Medicaid family planning expansions.  States previously needed a waiver to extend this coverage, but now they may use a simple state plan amendment.  In addition to appropriately spacing pregnancies, women whose pregnancies are planned are more likely to begin prenatal care early, increasing the likelihood of a healthy birth.  And Medicaid family planning expansions have been found to save money at both the state and federal levels.

The daunting task of implementation awaits, but women throughout the country can at least be assured that when they become pregnant, they will have coverage for maternity care to help provide their children with the healthy start they deserve.

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families. The photo of the mother and baby was provided by the March of Dimes Foundation and may not be reprinted without that organization's permission.

Last week my son turned in his final paper and defended his senior thesis, his last acts as a college senior. In a few short weeks, he'll join the 3 million young adults graduating from college this year. Fortunately, this year's crop of grads (and their parents) will have one less thing to worry about as they transition to work or further education: health insurance. Thanks to health reform and advocacy efforts by the White House and HHS, many major insurers have announced they will voluntarily allow adult children to stay on their parents' health plan earlier than is required by the new health reform law.

Continuing access to their family's health plan for young adults - the age group with the highest uninsured rates - is one of the significant early wins in health reform for children and families. As of September 23, 2010, all new or renewing plans will be required to cover young adults up to the age of 26 as dependents regardless of their student status (unless they are eligible for employer-sponsored health insurance). About two-thirds of the states had previously taken similar action but the individual state laws did not apply to large group and self-insured plans governed by federal regulations. These states often excluded young adults who were married or did not live at home.

Until March 30, 2010, those continuing dependent benefits provided through state laws had also been subject to federal tax causing additional administrative work on the part of employers and incurring tax liability on the part of families who were able to continue coverage for their young adult children. Health reform has taken care of this problem as well by making these benefits tax-exempt. The tax exemption also applies to qualified medical expenditures under flexible spending accounts for adult children.

Luckily, my son has a job that will provide health insurance. But I am relieved he has something to fall back on should he experience a gap in employment or decide to tackle graduate school. And I'm thrilled to see tangible and early results from the new health reform law in improving access to health coverage for children and families.

About 55 percent of Americans say they are confused about the new health reform law and more than half say they don't yet have enough information to understand how it will affect them personally according to Kaiser's latest tracking poll.  As was clearly evident during the health reform debate, people take their health coverage very personally.  In order to ensure that the promise of health reform becomes a reality for all, we must help people develop an accurate understanding of the bill and how it will touch their lives.

The following resources are a good place to start:

• The New York Times posted a simple, easy-to use graphic that is a great launching off point for those trying to figure out how health reform will impact them.  
• The Obama Administration maintains a site that shares the latest news on health reform and tracks how it is being implemented in each state.  The site is also the place to go for weekly webchats on health reform.  This Friday at 2:30 EDT, HHS Secretary Kathleen Sebelius and other health reform experts will focus on how stronger insurance company oversight will protect consumers.   You can submit questions by clicking here and watch it live here. 
• PICO, a national network of faith-based community organizations, created an informative poster to help community leaders and others reach out to help people understand and benefit from the new health reform law.
• Consumer Reports hosts a website dedicated to helping consumers navigate the changing health care system.  Award-winning reporter Nancy Metcalf accepts questions from consumers and posts the answers online. 

For those of you who are more concerned about the question of "what's in it for others", there have been a number of touching personal stories that demonstrate how the new law is already transforming lives. 

The McClatchy News wrote about a 12-year old boy from Fort Worth Texas with a seizure disorder whose family was unable to obtain insurance coverage for him from a private insurer.  His father agreed to a 50% cut in pay so that his son would qualify for CHIP coverage.  The enactment of health reform means the boy will either be able to move to private coverage under the elimination of pre-existing condition discrimination or a high-risk pool.  This will free up his father to earn a fair salary and start saving to buy a house (not only good news for the family but for the Ft. Worth housing market and U.S. economy).  

The Delaware News Journal ran an extensive story on the benefits of the new law and how it could help a single mother and her son who was diagnosed with diabetes just a few months before she lost her job.  

The Fiscal Times provided a very interesting snapshot of how the new law would impact coverage for individuals and families in a variety of circumstances.  

Finally, I was really impressed with the example set by a county councilwoman in Washington state who used her weekly column to help her constituents develop a better understanding of the new law.   Instead of passing the buck to federal and state lawmakers, her column demonstrates that she understands that we all have a part to play in making the promise of health reform a reality.  

All of us at CCF would be interested in hearing about what's going on in your communities to help people better understand and benefit from the new health reform law.  Please send us your comments.

Once President Obama signed into law the health care reform bill, we all started to dig a little deeper into what the provisions mean for those in the "real world."  One issue that has risen to the top is untangling the new rules governing when insurance companies have to cover sick children. So, let's break down what the bill does.

Soon children with employer-based insurance no longer can be subject to pre-existing conditions. For example, a child with asthma who is on a parent's employer plan cannot be denied coverage for services during any length of time related to his/her condition. This provision will be applicable in a new health plan year beginning after September 23rd. (Note: this specific change will not apply to children currently in individual market plans.)

The question many are asking is "what about a child that is not currently insured?" While the current legislative language is not clear on this issue, the White House has provided assurances that HHS will issue regulations to address it. HHS spokesman Nick Papas stated:

"... the secretary of HHS is preparing to issue regulations next month making it clear that the term 'pre-existing exclusion' applies to both a child's access to a plan and his or her benefits once he or she is in the plan for all plans newly sold in this country six months from today."

With this clarification, a new health plan would not be able to deny coverage for a child under either an employer or individual plan because of a pre-existing condition. For families with limited or no options to secure coverage right now when their child is sick, this change cannot come soon enough.

While this is all good news for families, how the insurance industry responds to these new protections for children will also be critical. Specifically, since the provision to limit insurers from charging different premiums based on health status doesn't go into effect until 2014, we need to monitor whether insurers will attempt to place the burden on families and raise premiums once these changes go into effect.

By Gary Brunk

President & CEO, Kansas Action for Children

"I just couldn't believe the state would cut personnel on a program that's for kids," commented Harold Stultz to a reporter from the CBS affiliate in Wichita, Kansas. 

According to a local television news report, Harold's 12-year-old son Keenan had injured his knee during a wrestling match.  Harold believed that Keenan was covered under HealthWave, the state's Medicaid and CHIP program, but was surprised to learn that the application had never been processed because of a backlog. 

In fact, Keenan is one of many children in Kansas waiting for health care coverage because the state has not been able to process their applications.

The need for health coverage has been growing as the number of uninsured children in Kansas climbed from 51,000 to 72,000 in just three years.  The pool of potential applicants was further expanded on January 1 of this year, when income eligibility for HealthWave increased from 200 to 250 percent of the federal poverty level.

Cuts in funding that reduce the state's ability to process applications, on top of the increase in demand, add up to a large backlog of unprocessed applications, now at around 20,000.  The state is taking steps to simplify the application and renewal process that should result in long-term improvements, but the ongoing recession and a projected state deficit of around $400 million for the next fiscal year mean that reducing the backlog in the short-term will be extremely difficult.

The situation in Kansas underscores the pressing need for further fiscal relief for the states, and in particular for the FMAP extension proposed by Senators Rockefeller and Reid.

For self-employed Harold Stultz, the backlog means his family has $6,000 in medical bills they need to cover.  But Harold knows he is not the only one affected.  "It...upsets me even more that there are more people in my situation," he says.  

How will Congress respond to the predicament of Harold's family - and the predicament that so many other families find themselves in during these tough economic times?

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Most of us were glued to the TV set last night waiting to see what President Obama was going to say about the future of the health care reform bill given its now uncertain fate in Congress. As I settled in to watch with my husband and one of my girls (the other one sadly could not be pried away from reading New Moon), I found myself getting antsy.

Why do we find ourselves in this situation? Why isn't he announcing that he signed the bill today?

Passing comprehensive health care reform legislation is extraordinarily difficult. Passing any comprehensive bill is difficult these days. But I have very little patience at this point for the political pundits and everybody else assessing the political calculations of whether passing the bill is the right political choice. Personally I think it is. And I thought the President did a nice job in his speech last night in making clear that he wants to see a bill. But the public wants to see results -- results that will improve the lives of families.

Having worked on public policy issues affecting low-income families for the last twenty years in Washington it's easy to become cynical. It's almost embarrassing to let your compassion for people show through in public without citing research and data and carefully crafted messages. Here goes, I'm going to let the policy wonk take a backseat and talk about people because that's what this is really all about -- people who need results from our leaders.

Children need health care reform to ensure that they have access to affordable comprehensive coverage. Yes kids have done relatively well with our current assortment of public programs, but not everywhere. Some states are leaders, but other states will never catch up. And the current state fiscal crisis reminds us that until we have a universal, federal guarantee of comprehensive coverage for children we will be selling our kids short.

Parents need access to affordable coverage options that don't disappear when they lose a job or become sick. Coverage of low-income parents through Medicaid is inadequate at best and almost non-existent in some states. Children do better when their parents have health coverage. Expanding Medicaid coverage to all parents below a specified income level regardless of where they live, as both bills do, would be an enormous victory for the most vulnerable families in our nation.

So-called "childless adults" need access to affordable coverage options. OK the first two are kind of no-brainers for childrens' advocates. So why do I keep finding myself thinking about two "childless adults" that I met in 1991 when I was writing a report on homeless veterans? Childless adults are not politically popular. But I can't get the stories of these two men out of my head.

Both of these men were Vietnam veterans and had seen combat duty in Vietnam. One was white and one was black. One was a Member of Congress who was the primary sponsor of a bill to help homeless veterans (I'll call him Al) and one was a homeless veteran (I'll call him Bill) who was an eloquent spokesperson. At the time that I did the report, I met Bill who was living in his truck. He had, ironically, been working in the Senate as a maintenance worker who moved furniture around. But one night a woman got shot outside his apartment. A shotgun ripped off half of her face. Bill went out to help her (he had served as a combat medic in Vietnam), and she died in his arms. This tragedy triggered PTSD and his blood pressure soared. He lost his job and his health insurance and got little help from the VA. He ended up living in his truck. He was a "childless adult" with no insurance.

Now let's turn to the former Congressman. Surely he doesn't need any help from the pending bills?? Well it turns out that because this public servant was an extraordinarily dedicated guy, he turned down all of the perks of his job (the pension and the health insurance). Then, at an early age, he developed Parkinson's disease. And because he had the audacity to live longer than expected, Al has hit the lifetime cap on his insurance policy. Now people have to have fundraisers to pay his medical costs. Pending bills would remove lifetime caps.

So let's all redouble our efforts to pass health reform. For the kids, their parents and for Al and Bill.

The image of sweet little Sarah McIntyre immediately came to mind as I read the Pediatrics Journal's study that showed that children with special health care needs were 57% less likely to be uninsured in 2005 than those in 2001.  The Pediatrics report is great news but it should be taken with a dose of caution.  CHIP and Medicaid have helped improved access to affordable health coverage for children with special health care needs but those gains can be as precarious as their health so without continued vigilance, this trend could rapidly deteriorate. 

The precarious nature of health coverage for children with special health care needs is what brought Sarah to mind.  Sarah is a 3rd Grade girl from Yakima, Washington who was born with a hole in her heart and cysts on her lungs.  Her life depended on consistent, quality health care that she received through Apple Health for Kids, Washington State's Medicaid and CHIP program.  She lost her health coverage when her parents received modest raises that put their income slightly above the eligibility cap.  The McIntyre family went through a difficult period in which Sarah was uninsured.  Fortunately, Washington state expanded coverage to families earning up to 300% of FPL with the help of increased federal funding included in CHIPRA and Sarah was able to enroll in Apple Health for Kids once again.

There are many more Sarah McIntyre's out there.   According to another report in last month's Pediatrics, approximately 1 of every 7 children in the United States has special health care needs. Children with special health care needs are those who are at increased risk for a "chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally". They are at greater risk for unmet health care needs and, on average, expenditures for their care are about 3 times higher than for other children. Their families oftentimes must rely on Medicaid or CHIP programs to find coverage.  (Medicaid coverage is a better fit because it is more comprehensive than CHIP and provides an important lifeline to children whose health care needs are often greater than the norm and whose families' limited incomes make it difficult for them to afford uncovered health expenses.) There are also many children with special health needs who remain uninsured because insurance providers will not accept them with a pre-existing condition or because their families can't afford the high private health insurance premiums to get the coverage their children need.

Sarah's story and the Pediatrics reports remind us of what's at stake in the health reform debate for families of children with special health care needs. 

 

 

 

 

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.

Last week, I attended a briefing at the Kaiser Family Foundation that sought to highlight the impact of the current economic crisis on the ongoing struggle to find affordable health coverage.  There was hardly a dry eye in the room after the Foundation screened this video, profiling people in three communities hard hit by the recession: St. Petersburg, Florida, Beloit, Wisconsin, and Long Island, New York.

I cried an extra tear because these heart-wrenching stories are being overlooked in the absurd din over completely fabricated claims about things like 'death panels' of government bureaucrats allegedly coming to Granny's house to decide if she is going to live or die. (Fact check: The House bill includes a provision to provide Medicare reimbursement for advance care planning so that patients have the option of consulting with their physicians about their wishes for end-of-life care.)
 

Meg Comeau, Project Director for the Catalyst Center, Boston University School of Public Health




As policymakers consider health reform, they will need to consider the needs of families raising children with special health care needs.  These families are not only hit hard in the pocketbook, they face overwhelming bureaucratic obstacles to coverage.  We asked Meg Comeau to address this issue from a policy perspective and from her personal experience raising a daughter with special health care needs.

"Promises are like babies:  easy to make, hard to deliver."  - Author Unknown

In my wallet, I have a small piece of white plastic with my name on it under the logo of a well-known health insurance company.  To me, this insurance card represents a promise, so to speak, that if I need access to the high-tech world of modern-day health care services I can get it.  In their wallets, my husband and daughter each have a similar card with their names on it.  For a small co-pay and with reasonable deductibles, we can see a doctor or get a prescription filled whenever it's necessary.  The promise that we can get what we need is for the most part fulfilled and we know we are very fortunate in this.

But for one of us, that small white card is not enough.  Equally important to us all is the little blue card that also sits in my daughter, Sarah's wallet.  This card displays the logo of the Massachusetts Medicaid program.  Sarah was born with a complex genetic disorder that has seriously impacted her physical, developmental and behavioral health.  She requires many primary and specialty care doctor visits every month, an average of 6 prescription medications per day, habilitative physical, speech, and occupational therapies, medical equipment and supplies such as oxygen and more.  Without the supplemental coverage she receives through Massachusetts Medicaid, the small co-pays and reasonable deductibles our primary insurance requires would have overwhelmed our middle-income family long ago.