Addressing the Needs of Children in a Time of Health Reform via Medicaid, CHIP, or Subsidized Markets

Health care systems designed to meet the needs of adults often fail to meet the needs of children. To compensate, the federal government has created systems specifically designed to meet the needs of children, such as the Maternal and Child Health Bureau, Medicaid, and the Children’s Health Insurance Program (CHIP).1-3 All these endeavors have been relatively successful. At the time of the passage of the Patient Protection and Affordable Care Act (hereafter called the Affordable Care Act) in 2010, children had achieved relatively high levels of insurance coverage and access to health care services compared with the nonelderly adult population.4,5 Most child insurance coverage included specific components, such as the Early and Periodic Screening, Diagnostic, and Treatment program within Medicaid, to ensure that the specific needs of children were met, especially those of children and youth with special health care needs.6 The Affordable Care Act was designed primarily to address3 largeproblems inourhealthcaresystem:access to,quality of, and cost of services for adult citizens.7While therewere numerous specific references tochildren throughout the2000 pages of legislation,most of the innovations focused onmanaging the multiple chronic diseases seen in those insured by Medicare.8 In particular, access to health care for adults was expanded dramatically through the creation of health insurance exchanges, marketplaces in which adults living in near povertycouldpurchase subsidized insuranceproducts tomeet their health careneeds.At the time,many inCongress thought that this innovation obviated the need for CHIP, which was, in fact, separate children’shealth insurance for a similar population. Congress authorized CHIP until 2019 but only funded theprogramuntil 2015.9 Last spring,Congress extended funding for CHIP until 201710 without addressing the fundamentalquestion:Would thosechildrenbebetter servedbythesame private sector that was being activated to serve the needs of their parents? What was lacking from the discussion was a head-tohead comparison of Medicaid, CHIP, and private insurance: how adequate was insurance coverage for children living in near poverty (100%-300%of the federal poverty level) under those different regimes? In this issue of JAMA Pediatrics, Kriederet al11 tried toaddress that issue fromtheparents’point of view using novel but rigorous methods to separate children insured through CHIP from those insured through Medicaid and those with private insurance in a large data set with detailed information regarding the parents’ perception of the adequacy of insurance coverage. The results from the parents’ perspective were somewhat unsurprising: families with insurance coverage had better access to health care services than did those without, and those with public insurance (MedicaidorCHIP)hadfewerout-of-pocketexpenses than did thosewith commercial insurance. All families, regardless of insurance type, had somedifficulty in gaining access to pediatric subspecialists.Whatwas surprisingwas that thosewith public insurancehadbetter access topreventive services than did those with private insurance and that families insured by Medicaid reported fewer problems in accessing subspecialists than did thosewith CHIP or commercial insurance. Some may argue with the methods, particularly those that separated the groups for analysis. Nonetheless, this work provides a singular view into the meaning of adequate coverage by bringing the parents’ voice into the discussion through the National Survey of Children’s Health. Aswithmost studies,weare leftwithmorequestions than answers.Why are families having such difficulty in accessing services for their children? Is it the out-of-pocket expenses? If so, the Affordable Care Act and the health insurance exchange plans are likely to make that worse since consumers seem tobe favoring the less expensive, high-deductible plans when offered a choice.12 Is it lack of availability of services? Perhaps it is time to fund the Pediatric Subspecialty Loan Repayment program to encouragemorepediatric residents to choose pediatric subspecialties rather than primary care.13 Is it the different standards towhich the various plans are held, in defining adequacy of coverage? The Early and Periodic Screening, Diagnostic, and Treatment program and theminimumbenefit standards for thehealth insuranceexchanges are quitedifferent; perhaps they shouldbe aligned.14 Is it the general lack of reimbursement for care coordination services? Perhaps Medicaid and CHIP should be looking at the care coordination codes now reimbursable under Medicare.15 This study is good science in that it generates the next set of questions that must be addressed if we are to move forward. In the end, however, policy makers must act on the data they have, tempered by their understanding of history, and knowing that systemsdesigned tomeet theneedsofonegroup do not always meet the needs of all groups. Medicaid, CHIP, and commercial insurance have done a great job of providing children with insurance coverage for the past 20 years. The health insuranceexchanges createdby theAffordableCareAct are stillworks in progress, evolving as they learnhow to serve the needs of those ineligible for Medicaid but unable to afRelated article page 43 Opinion