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Grading Health Care Reform - House Bill

Health Reform and Children — November 2009

Report Card: Child Health Provisions in Congressional Health Reform Bills

House Bill 

QUESTIONS
GRADE
COMMENTS
1. Does the proposal require that all children have coverage?
A-
Mandates coverage for all children and achieves an estimated coverage of 96% of the population.
2. Does the proposal provide comprehensive coverage for children?
B-
Benefits and services required for everyone to have in order to meet the mandate will be determined by a council chaired by the Surgeon General. Although pediatric and well baby services are mentioned in the bill as part of a list of potentially covered items, a separate council should be established to define benefits and services for children.
3. Does the proposal provide affordable coverage for children?
C-
Includes subsidies to help with purchasing coverage, but for certain low-income families the subsidies are not sufficient to ensure healthcare is affordable. Out-of-pocket healthcare costs should not exceed more than 8% of income.
4. Will all children currently enrolled in or eligible for the Children’s Health Insurance Program (CHIP) and Medicaid have the same or better coverage?
C-
Eliminates CHIP after 2013 and replaces it with subsidies to help children enroll in private plans on the Exchange. As a result of this change, children currently enrolled in CHIP will be worse off. They will face higher premiums and other out-of-pocket costs, and potentially may fall through the cracks when parents opt not to enroll their children in any plan due to costs.
5. Does the proposal expand and strengthen the pediatric workforce?
B-
Includes loan repayment and scholarship programs to incentivize more primary care physicians to join the pediatric workforce and work in health shortage areas. However, the effort is insufficient to meet what will be a rapidly growing need.
6. Does the proposal sufficiently reimburse providers for the care of children?
B
Increases Medicaid reimbursement rates for primary care services to 100% parity with Medicare rates in the first few years and then 90% in 2015 and going forward. Lower payment rates can result in less doctors accepting Medicaid patients. Even at parity, Medicare rates remain lower than the average rates paid by private plans.

 
Report Card: Behind the Grades, What CHF Considered in Grading Health Care Reform
 

 

QUESTIONS
JUSTIFICATION
1. Does the proposal require that all children have coverage?
To evaluate this question, CHF examined the provision in the bill mandating health insurance coverage and the estimated percentage of the population that would be covered by the bill. This bill includes a solid mandate that all children are required to have coverage but is estimated to actually cover 94% of the population.  CHF GRADE: A-
2. Does the proposal provide comprehensive coverage for children?
CHF examined the essential benefits and services that are mandated by the bill to be offered by private plans that take part in the Exchange (the new health insurance marketplace). The bill lists categories of services to be covered: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use services, rehabilitative and habilitative services, preventive and wellness services and pediatric services, including oral and vision care. Though the bill states that the scope of the essential health benefits be equivalent to the scope of benefits provided under a typical employer plan, it does not mandate early and periodic screening, diagnosis and treatment (EPSDT), the standard of care for children for which CHF advocates. Although certain categories of pediatric services are required, the bill leaves many benefit and service details for definition by the Secretary. In defining benefits, the Secretary is required to take into account health needs of certain populations, including children. CHF believes that a specific advisory council with pediatric healthcare professionals should be established to define the benefits and services for children.  CHF GRADE: B
3. Does the proposal provide affordable coverage for children?
CHF examined the premium subsidy levels for children in families making up to 400% of the Federal Poverty Level (FPL). The bill requires families to pay premiums on a sliding scale from 2.0% of income to 9.8% of income for families making 100% to 400% of FPL. For working families, CHF believes that the affordability of plans decreases significantly once more than 8% of income is required to obtain insurance.  CHF GRADE: C
4. Will all children currently enrolled in or eligible for the Children’s health Insurance program (CHIP) and Medicaid have the same or better coverage?
CHF examined how the legislation treats children who currently get coverage through CHIP and Medicaid, and whether they are held harmless and receive the same standard of insurance. The bill continues CHIP benefits, cost-sharing and authorization under current law until 2019.  CHF GRADE: A
5. Does the proposal expand and strengthen the pediatric workforce?
CHF examined efforts to increase primary care providers, incentives for healthcare professionals to practice in shortage and underserved areas, loan reimbursement and repayment programs, and other provider incentive programs. The bill takes positive steps to strengthen the existing National Health Service Corps, creates new grant programs for health professionals that work in underserved areas and grant programs to encourage students to go into primary care and public health practice settings. However, the effort is still insufficient to meet what will be a rapidly growing need for pediatric primary care.  CHF GRADE: B-
6. Does the proposal sufficiently reimburse providers for the care of children?
CHF examined how the bill proposes to increase Medicaid payment rates, as this is a large determinant for whether physicians will take on Medicaid patients. Although the bill provides a 10% payment bonus for practitioners in medically underserved areas for five years, it does not improve Medicaid payments for the long term.  CHF GRADE: C