The Patient Protection and Affordable Care Act and the Future of Child Health Policy

Abstract

With the United States Supreme Court’s landmark ruling in NFIB v Sebelius1NFIB v Sebelius, WL 2427810 4 (2012).Google Scholar behind us, it is possible to attend to the full-scale implementation of the Affordable Care Act. The Act represents an unprecedented opportunity in child health policy, at least if those of us who in one way or another have immersed ourselves in child health make implementation a focus of our work. It would be naïve not to acknowledge the implementation challenges that lie ahead, conceptually, operationally, and politically, but working in a challenging environment hardly represents a new problem where improving child health is concerned.From a conceptual and operational perspective, the Affordable Care Act is a complicated law whose structure follows the (even more complicated) multipayer financing/regulated industry approach to health care that is the hallmark of the American health care system. Indeed, multipayer is an understatement in today’s health care marketplace, with millions of individual employer-sponsored plans, and 50 separate Medicaid and CHIP programs (57 when one includes the District of Columbia, Puerto Rico, the Virgin Islands, and the U.S. Trust Territories) that in turn are themselves devolving into multiple managed-care systems. Any attempt to systematically create and then introduce the best evidence into this type of financial and operational scheme presents enormous challenges. This is especially true in the case of child health, perhaps because children are limited health care users and attract low attention from the capital investor world. Making the health care system work better for children is a labor of love not a hot financial investment.The decision to uphold the constitutionality of the Act’s centerpiece—the requirement that all Americans who can afford to do so maintain health insurance coverage for themselves and their families—enables implementation to move forward. Many of the benefits will accrue principally to low- and moderate-income workers and their families who today lack access to affordable coverage. But for all of us, the Act’s benefits are immeasurable: access to coverage regardless of pre-existing condition; a bar against discrimination in pricing or coverage based on health status; an end to annual and lifetime coverage limits; comprehensive coverage for preventive care without cost-sharing; the right to cover young adults younger than the age of 26 through their families’ plans; and a standard of coverage in the individual and small group markets (known as essential health benefits) that assures comprehensive benefits, assures mental health parity, and provides coverage for pediatric vision and oral care. The Act also makes crucial investments in public health, access to health care in medically underserved communities, and strengthens the community benefit investment obligations of the nation’s nonprofit hospitals.At the same time, from both a policy and political perspective, an already complex law has been further complicated by the Court’s unprecedented decision that the Act’s Medicaid expansion—the vital core on which the entire Act is structured—amounts to an unconstitutional coercion. Having taken American social welfare law into new and worrisome territory, the Court then softened its own blow, saving the Medicaid expansion but, in doing so, making it unenforceable as a basic condition of state Medicaid participation. Opposition can be expected to be fierce, as a further (and ongoing) act of political defiance aimed at mortally wounding the Act and reminiscent of the southern states’ reaction to the Court’s ruling in Brown v Board of Education. Over time, this resistance can be expected to recede given the expansion’s fundamental importance to population health and the enormous infusion of federal funding that accompanies the Medicaid expansions. Although children are less directly affected, a significant proportion of the adults who will be assisted are themselves parents and caretakers, and thus, the cause of state Medicaid expansion must be embraced by the child health advocacy community. After all, what are the prospects for child health, when family health is not also front and center?Despite judicial and political setbacks, the Act will achieve full implementation status, if only because its benefits are so desperately needed. With full implementation will come the transformational health system changes that the Act both reflects and sets in motion. Along the way, several matters deserve special focus from the child health community.Achieving a Continuous and Stable Connection With the Health Care SystemWithout question, the Act’s central achievement is its potential to eliminate the threat of a lack of health insurance as a possibility for nearly all children. We have never known a world in which children are guaranteed the right to continued insurance coverage from the moment they are born until they grow into adults. With this unprecedented, near-universal right comes an array of priorities aimed at making this right work in a multipayer, market-driven world.There is nothing more important to families than having a solid, reliable, continuous relationship with a pediatric health care provider. Continuity of care is a key ingredient in health care quality, particularly for children who face elevated health and social risks. But income dynamics being what they are, it is inevitable that families will be forced to move among payers, sometimes multiple times in a given year. In this world of multiple health care financing markets increasingly dominated by large delivery companies, there will be no greater challenge than achieving cross-market stability, so that regardless of who is the insurer at any given moment—Medicaid, CHIP, a state health insurance exchange, or an employer-sponsored plan—families can remain with their pediatric provider in a continuing relationship. Getting to this point depends on multiple factors: stable enrollment periods; payer-to-payer transition systems; multimarket participation by health plans; and multimarket participation by pediatric providers. Addressing these factors will require multiple strategies: multipayer coordination around coverage, payment, and care management; the explicit incentivization of multimarket participation by plans and providers; improved health information technology; and other strategies to prevent coverage from lapsing and providers from refusing to enter, or exiting, certain markets. Simply put, the child health stake in making multipayer mechanics work is enormous because continuity of coverage and care are on the line.Keeping Coverage Generous and Patient Cost-Sharing AffordableToday’s families, particularly those with younger children, face economic problems that near crisis levels. When even median family income is no longer sufficient to afford decent housing (a reality in many metropolitan areas today), the last thing a family can afford to face is high premiums and cost-sharing. Achieving value and efficiency in health care is a matter of profound importance to child health policy. To be sure, in the aggregate children may cost relatively little, but because of the economic burdens facing families today, the child health policy stake in bending the cost curve could not be greater. Insuring families but leaving them exposed to $50 co-pays and $10,000 family deductibles will do little to help them.Training a New Generation of Child Health ProfessionalsThe Act emphasizes system transformation through greater financial and clinical integration, the alignment of payment incentives with evidence-based care, and a focus on patient-centered care that fosters maximum patient involvement in treatment and health decisions. Achieving this result means training a generation of pediatric health professionals who work in teams, who focus on efficiency and work integration, and who are at ease with the fact that their patients’ health may depend less on the tests they run and more on how they interact with their patients’ families, as well as the communities and social and educational systems in which children live and grow.Child Health Services ResearchThis is the moment for health services research, a time when, as a result of the Act, the nation is poised to make critical investments in research aimed at understanding the best approaches to health and health care. The immediate payoff may be relatively modest in the case of pediatric care; but the long-term benefits of child health services research are invaluable. The Act recognizes the importance of integrating child health outcomes into overall thinking about health care quality and system transformation, and focuses squarely on child health as part of its National Quality Strategy. Making the most of this opportunity means training a new generation of child health researchers who are steeped in child health policy and practice, adept in the most complex methods of health services research, and who possess the skills needed to be able to communicate the results of their research for policymaking and program management audiences.Despite the complexities and the long implementation journey that lies ahead, the Affordable Care Act is a gift to child health. Let’s get down to the business of making the most of it. With the United States Supreme Court’s landmark ruling in NFIB v Sebelius1NFIB v Sebelius, WL 2427810 4 (2012).Google Scholar behind us, it is possible to attend to the full-scale implementation of the Affordable Care Act. The Act represents an unprecedented opportunity in child health policy, at least if those of us who in one way or another have immersed ourselves in child health make implementation a focus of our work. It would be naïve not to acknowledge the implementation challenges that lie ahead, conceptually, operationally, and politically, but working in a challenging environment hardly represents a new problem where improving child health is concerned. From a conceptual and operational perspective, the Affordable Care Act is a complicated law whose structure follows the (even more complicated) multipayer financing/regulated industry approach to health care that is the hallmark of the American health care system. Indeed, multipayer is an understatement in today’s health care marketplace, with millions of individual employer-sponsored plans, and 50 separate Medicaid and CHIP programs (57 when one includes the District of Columbia, Puerto Rico, the Virgin Islands, and the U.S. Trust Territories) that in turn are themselves devolving into multiple managed-care systems. Any attempt to systematically create and then introduce the best evidence into this type of financial and operational scheme presents enormous challenges. This is especially true in the case of child health, perhaps because children are limited health care users and attract low attention from the capital investor world. Making the health care system work better for children is a labor of love not a hot financial investment. The decision to uphold the constitutionality of the Act’s centerpiece—the requirement that all Americans who can afford to do so maintain health insurance coverage for themselves and their families—enables implementation to move forward. Many of the benefits will accrue principally to low- and moderate-income workers and their families who today lack access to affordable coverage. But for all of us, the Act’s benefits are immeasurable: access to coverage regardless of pre-existing condition; a bar against discrimination in pricing or coverage based on health status; an end to annual and lifetime coverage limits; comprehensive coverage for preventive care without cost-sharing; the right to cover young adults younger than the age of 26 through their families’ plans; and a standard of coverage in the individual and small group markets (known as essential health benefits) that assures comprehensive benefits, assures mental health parity, and provides coverage for pediatric vision and oral care. The Act also makes crucial investments in public health, access to health care in medically underserved communities, and strengthens the community benefit investment obligations of the nation’s nonprofit hospitals. At the same time, from both a policy and political perspective, an already complex law has been further complicated by the Court’s unprecedented decision that the Act’s Medicaid expansion—the vital core on which the entire Act is structured—amounts to an unconstitutional coercion. Having taken American social welfare law into new and worrisome territory, the Court then softened its own blow, saving the Medicaid expansion but, in doing so, making it unenforceable as a basic condition of state Medicaid participation. Opposition can be expected to be fierce, as a further (and ongoing) act of political defiance aimed at mortally wounding the Act and reminiscent of the southern states’ reaction to the Court’s ruling in Brown v Board of Education. Over time, this resistance can be expected to recede given the expansion’s fundamental importance to population health and the enormous infusion of federal funding that accompanies the Medicaid expansions. Although children are less directly affected, a significant proportion of the adults who will be assisted are themselves parents and caretakers, and thus, the cause of state Medicaid expansion must be embraced by the child health advocacy community. After all, what are the prospects for child health, when family health is not also front and center? Despite judicial and political setbacks, the Act will achieve full implementation status, if only because its benefits are so desperately needed. With full implementation will come the transformational health system changes that the Act both reflects and sets in motion. Along the way, several matters deserve special focus from the child health community. Achieving a Continuous and Stable Connection With the Health Care SystemWithout question, the Act’s central achievement is its potential to eliminate the threat of a lack of health insurance as a possibility for nearly all children. We have never known a world in which children are guaranteed the right to continued insurance coverage from the moment they are born until they grow into adults. With this unprecedented, near-universal right comes an array of priorities aimed at making this right work in a multipayer, market-driven world.There is nothing more important to families than having a solid, reliable, continuous relationship with a pediatric health care provider. Continuity of care is a key ingredient in health care quality, particularly for children who face elevated health and social risks. But income dynamics being what they are, it is inevitable that families will be forced to move among payers, sometimes multiple times in a given year. In this world of multiple health care financing markets increasingly dominated by large delivery companies, there will be no greater challenge than achieving cross-market stability, so that regardless of who is the insurer at any given moment—Medicaid, CHIP, a state health insurance exchange, or an employer-sponsored plan—families can remain with their pediatric provider in a continuing relationship. Getting to this point depends on multiple factors: stable enrollment periods; payer-to-payer transition systems; multimarket participation by health plans; and multimarket participation by pediatric providers. Addressing these factors will require multiple strategies: multipayer coordination around coverage, payment, and care management; the explicit incentivization of multimarket participation by plans and providers; improved health information technology; and other strategies to prevent coverage from lapsing and providers from refusing to enter, or exiting, certain markets. Simply put, the child health stake in making multipayer mechanics work is enormous because continuity of coverage and care are on the line. Without question, the Act’s central achievement is its potential to eliminate the threat of a lack of health insurance as a possibility for nearly all children. We have never known a world in which children are guaranteed the right to continued insurance coverage from the moment they are born until they grow into adults. With this unprecedented, near-universal right comes an array of priorities aimed at making this right work in a multipayer, market-driven world. There is nothing more important to families than having a solid, reliable, continuous relationship with a pediatric health care provider. Continuity of care is a key ingredient in health care quality, particularly for children who face elevated health and social risks. But income dynamics being what they are, it is inevitable that families will be forced to move among payers, sometimes multiple times in a given year. In this world of multiple health care financing markets increasingly dominated by large delivery companies, there will be no greater challenge than achieving cross-market stability, so that regardless of who is the insurer at any given moment—Medicaid, CHIP, a state health insurance exchange, or an employer-sponsored plan—families can remain with their pediatric provider in a continuing relationship. Getting to this point depends on multiple factors: stable enrollment periods; payer-to-payer transition systems; multimarket participation by health plans; and multimarket participation by pediatric providers. Addressing these factors will require multiple strategies: multipayer coordination around coverage, payment, and care management; the explicit incentivization of multimarket participation by plans and providers; improved health information technology; and other strategies to prevent coverage from lapsing and providers from refusing to enter, or exiting, certain markets. Simply put, the child health stake in making multipayer mechanics work is enormous because continuity of coverage and care are on the line. Keeping Coverage Generous and Patient Cost-Sharing AffordableToday’s families, particularly those with younger children, face economic problems that near crisis levels. When even median family income is no longer sufficient to afford decent housing (a reality in many metropolitan areas today), the last thing a family can afford to face is high premiums and cost-sharing. Achieving value and efficiency in health care is a matter of profound importance to child health policy. To be sure, in the aggregate children may cost relatively little, but because of the economic burdens facing families today, the child health policy stake in bending the cost curve could not be greater. Insuring families but leaving them exposed to $50 co-pays and $10,000 family deductibles will do little to help them. Today’s families, particularly those with younger children, face economic problems that near crisis levels. When even median family income is no longer sufficient to afford decent housing (a reality in many metropolitan areas today), the last thing a family can afford to face is high premiums and cost-sharing. Achieving value and efficiency in health care is a matter of profound importance to child health policy. To be sure, in the aggregate children may cost relatively little, but because of the economic burdens facing families today, the child health policy stake in bending the cost curve could not be greater. Insuring families but leaving them exposed to $50 co-pays and $10,000 family deductibles will do little to help them. Training a New Generation of Child Health ProfessionalsThe Act emphasizes system transformation through greater financial and clinical integration, the alignment of payment incentives with evidence-based care, and a focus on patient-centered care that fosters maximum patient involvement in treatment and health decisions. Achieving this result means training a generation of pediatric health professionals who work in teams, who focus on efficiency and work integration, and who are at ease with the fact that their patients’ health may depend less on the tests they run and more on how they interact with their patients’ families, as well as the communities and social and educational systems in which children live and grow. The Act emphasizes system transformation through greater financial and clinical integration, the alignment of payment incentives with evidence-based care, and a focus on patient-centered care that fosters maximum patient involvement in treatment and health decisions. Achieving this result means training a generation of pediatric health professionals who work in teams, who focus on efficiency and work integration, and who are at ease with the fact that their patients’ health may depend less on the tests they run and more on how they interact with their patients’ families, as well as the communities and social and educational systems in which children live and grow. Child Health Services ResearchThis is the moment for health services research, a time when, as a result of the Act, the nation is poised to make critical investments in research aimed at understanding the best approaches to health and health care. The immediate payoff may be relatively modest in the case of pediatric care; but the long-term benefits of child health services research are invaluable. The Act recognizes the importance of integrating child health outcomes into overall thinking about health care quality and system transformation, and focuses squarely on child health as part of its National Quality Strategy. Making the most of this opportunity means training a new generation of child health researchers who are steeped in child health policy and practice, adept in the most complex methods of health services research, and who possess the skills needed to be able to communicate the results of their research for policymaking and program management audiences.Despite the complexities and the long implementation journey that lies ahead, the Affordable Care Act is a gift to child health. Let’s get down to the business of making the most of it. This is the moment for health services research, a time when, as a result of the Act, the nation is poised to make critical investments in research aimed at understanding the best approaches to health and health care. The immediate payoff may be relatively modest in the case of pediatric care; but the long-term benefits of child health services research are invaluable. The Act recognizes the importance of integrating child health outcomes into overall thinking about health care quality and system transformation, and focuses squarely on child health as part of its National Quality Strategy. Making the most of this opportunity means training a new generation of child health researchers who are steeped in child health policy and practice, adept in the most complex methods of health services research, and who possess the skills needed to be able to communicate the results of their research for policymaking and program management audiences. Despite the complexities and the long implementation journey that lies ahead, the Affordable Care Act is a gift to child health. Let’s get down to the business of making the most of it. ErratumAcademic PediatricsVol. 13Issue 1PreviewIn the commentary by Rosenbaum S (“The Patient Protection and Affordable Care Act and the Future of Child Health Policy” Vol. 12 No. 5, September/October 2012), a note should have appeared before the commentary stating the following: “This commentary is based on Sara Rosenbaum's speech at Academy Health's 2012 Child Health Interest Group meeting held in Orlando, Florida on June 23, 2012.” Full-Text PDF