Paying Attention to Children in a Changing Health Care System (1996) / Chapter Skim
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1 Including Children and Pregnant Women in Health Care Reform
1 Including Children and Pregnant Women in Health Care Reform
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CHAPTER 1 Including Children and Pregnant Women in Health Care Reform Sarah S Brown, Editor National Forum on the Future of Children and Families National Research Council Institute of Medicine National Academy Press Washington, D.C.
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2 PAYING ATTENTION TO CHILDREN IN A CHANGING HEALTH CARE SYSTEM CONTENTS INTRODUCTION 3 UNDERLYING THEMES 5 HEALTH INSURANCE: ACCESS AND BENEFITS 8 Goal 1: Continuous access to health insurance, 8 Goal 2: Affordable insurance premiums, deductibles, and other copayments, 10 Goal 3: Coverage for services that emphasize primary and preventive care, 11 Goal 4: An objective process for refining and updating benefits, 16 RESOURCE DEVELOPMENT: SERVICES AND PEOPLE 16 Goal 5: Health services by qualified providers in a variety of settings, 16 Goal 6: Increases in the number and diversity of qualified providers, 18 ADMINISTRATION 21 Goal 7: Reduction in the administrative complexity of the health care system, 21 Goal 8: Cooperative, complementary administrative structures to monitor and improve the health care system, 23 Goal 9: Consideration of the role of government grant programs in reforming the health care system, 25 COST MANAGEMENT AND QUALITY ASSURANCE 26 Goal 10: Cost management measures to accommodate the special needs of children and pregnant women, 26 Goal 11: Vigorous, well-financed systems of quality assurance and research, 29 REFERENCES 30
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devoted to the health sector, leading to considerable anxiety about whether such growth will continue and whether it can be afforded; concern about the health and competence of the nation's work force at the turn of the century; substantial growth -- by as many as 7 million people -- -in the number of uninsured Americans between 1980 and 1990; higher levels of uncompensated hospital care because of increased numbers of patients without any form of third-party payment for health care; alarm among corporations and employed individuals about the continued escalation of private health insurance costs; fear among the currently insured that their coverage may be canceled if they become very ill or that preexisting conditions will limit their insurability; embarrassment over the poor international ranking of the United States on such basic measures of health as infant mortality and immunization rates among children; recognition that the aging of the population will lead to increased health care costs; the problems many states are encountering in meeting their share of growing Medicaid expenditures; and, finally, the steady erosion of the public health care system because of chronic underfinancing and the seriousness and intensity of problems brought to its doorstep, including AIDS, drug addiction, and violence. Noting the renewed interest in health care reform and concerned that insufficient attention was being given to children and pregnant women in the debate, the National Forum on the Future of Children and Their Families (jointly sponsored by the Institute of Medicine and the National Research Council)
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In particular, the health services needed by this group, which are frequently routine and predictable, are often not paid for in a risk-based health insurance model -- the model that dominates current discussions of health system reform. Thus, the Forum decided to develop a monograph discussing the important health policy issues presented by children and pregnant women that should be addressed by any major proposal for health care reform.
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Three proposals from private associations were studied along with four developed by members of Congress. Five of the seven are "multipayer" plans, that is, they retain a mix of private health insurance and one or more publicly financed programs.
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The participants discussed, for example, the current practice in the Medicaid program of placing flat dollar and duration limits on coverage of ambulatory services but not on coverage of longterm care services -- a practice that has led many state Medicaid programs to spend an ever larger share of their funds on the elderly, further reducing resources for children and pregnant women, who rely primarily on ambulatory services. Another underlying theme of the workshops was the recognition that although financial barriers are a major -- some say the major -- obstacle to health care services, other important barriers can be defined for children and pregnant women (Institute of Medicine, 1988a)
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A final note. The workshop participants were not asked to construct their own proposal for health care reform, but instead to discuss those issues important to maternal and child health that they believed should be included in any reform bill.
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Failure to satisfy one or more requirements can cause pregnant women and children to be ineligible for coverage altogether or ineligible for coverage for a period of time or for certain conditions. Principally for reasons of cost containment, health insurance plans may exclude certain groups with special relevance to maternal and child health; in some instances, legal concerns form the basis for exclusions (as when health insurance is not available to children in certain types of custodial arrangements)
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In addition, if administratively possible, it would be useful to allow the paper work completed when applying for public health insurance to be used also for application to other social services such as food stamps and WIC (Special Supplemental Food Program for Women, Infants, and Children)
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. The Medicaid program prohibits balance billing; it is an issue primarily in transactions involving private health insurance.
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encouraging participation in preventive services. Covered Benefits Deciding which services should be financed under a given health insurance scheme has proven to be one of the most contentious issues in health policy.
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This list, an amalgam of lists constructed by numerous groups in recent years (Select Panel for the Promotion of Child Health, 1980; American Academy of Pediatrics, 1991; U.S. Department of Health and Human Services, 1989; American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 1988; Health Policy Agenda for the American People, 1988)
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3. Special services and supplies for persons with extensive or complex health care needs -- Durable medical equipment; -- Extended mental health and substance abuse services; -- Home health care and nursing in specialized day care for medically fragile children; -- Nutritional services; -- Recuperative stays in long-term care facilities; -- Hospice care; -- Home visiting; -- Respite care; -- Coordination of care for chronically ill or high-risk individuals with special health care needs; and -- Occupational, physical, and speech therapy and rehabilitation.
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The importance of this issue is thrown into sharp relief when comparing the broad range of services that many Medicaid programs now support with the benefits packages typically offered through commercial insurers. For example, recognizing the special needs of low-income people, Medicaid often helps to pay for transportation to a health care facility, many home health care services, comprehensive dental care and eyeglasses for children, and extensive mental health services -- services commonly excluded or highly limited in private plans.
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It may also be possible to offer incentives for practitioners to provide, and for patients to receive, such care: for example, bonuses from insurers to providers, and perhaps even to patients, who complete the recommended immunization schedule; higher reimbursement rates for prenatal care begun in the first trimester of pregnancy; 100 percent payment for vaccine replacement and administrative costs; and so on. [The section applying goal 3 to legislative proposals has been deleted.]
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(See goal 11 for further discussion of practice guidelines, outcomes research, and related issues.) [The section applying goal 4 to legislative proposals has been deleted.]
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, migrant health centers (MHCs) , maternal and child health services in local health departments, school-based clinics, and similar organizations can blend the various services needed by high-risk individuals into units understandable to both consumers and providers.
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increased emphasis in graduate medical education for health professionals on primary and community-based care rather than on tertiary care. Direct Placement In an earlier era, a partial solution to the provider maldistribution problem was the direct placement of health professionals in underserved areas, typically through the National Health Service Corps (NHSC)
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To improve access to care for pregnant women, therefore, a proposal for health care reform should take up the malpractice challenge. A proposal could, for example: -- earmark funds to study the effects of various state remedies to the medical malpractice problem, including, for example: subsidizing the liability premiums of obstetric care providers; establishing publicly funded indemnity insurance for obstetric providers caring for low-income or medically high-risk women; and
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. Graduate Medical Education of Health Professionals Historically, the nation's policies supporting graduate education in the medical and health professions have been strong in inpatient and tertiary care training and weak in primary care, preventive medicine and community health -- all areas particularly important to maternal and child health (Institute of Medicine, 1989b)
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[The section applying goal 6 to legislative proposals has been deleted.] ADMINISTRATION Goal 7: The administrative complexity of the health care system is substantially reduced from the perspective of both providers and consumers.
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. Because it is more difficult for individuals to secure continuous health insurance coverage under multipayer models, reform proposals that retain a complicated mix of public and private financing should devise some means of moving between plans -- especially between public and private plans -- that is swift and easy.
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Whatever the construct chosen, important administrative functions that the proposal should address include the following (Select Panel for the Promotion of Child Health, 1980) : -- monitoring the overall health status of children and pregnant women in relationship to such standards as the "Year 2000" goals that is, immunization levels, trimester of enrollment into prenatal care, rates of cesarian section, and so on)
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[The section applying goal 8 to legislative proposals has been deleted.] Goal 9: The future role of existing government grant programs in maternal and child health is explicitly considered in reforming the health care system, with regard to both the personal health services supported by these grant programs and to their planning, evaluation, and training functions.
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Examples of such programs that are especially important to children and pregnant women include: -- Title V, the Maternal and Child Health Services Block Grant, -- the Preventive Health Services Block Grant, -- Childhood immunization grants to states, -- Health services that are part of special education programs, -- Pediatric emergency medical services, -- Title X family planning services, -- Pediatric AIDS health care demonstration program, -- Injury control grants, -- Grants for lead poisoning prevention and abatement, and -- Poison control activities. Many of these programs provide health services to those with no source of payment for health care, serving in some instances as providers of last resort.
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A major revision of health care financing would undoubtedly cause states and localities to rethink and possibly reconfigure their own expenditures in this area, but whatever the realignments, it is important that a proposal for reform not interfere with the ability of states and localities to create and support their own health services and systems. [The section applying goal 9 to legislative proposals has been deleted.]
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Two principal approaches to overall cost management and containment are in current proposals for health care reform: managed care and global budgeting. Managed care deserves special comment because of its growing popularity as a tool for managing costs for privately insured as well as Medicaid-insured children and pregnant women.
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This possibility suggests that plans based on global budgeting should devise some means at the outset for better meeting the needs of children and pregnant women, and correcting some of the problems noted elsewhere in this monograph. [The section applying goal 10 to legislative proposals has been deleted.]
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It might even be wise to peg overall healthrelated research expenditures to some minimum fixed percentage of health care expenditures. In particular, strong ties between the clinical research community and those who design the benefits package of a health care financing plan should be fostered.
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[The section applying goal 11 to legislative proposals has been deleted.] REFERENCES The Alan Guttmacher Institute 1989 Blessed Events and the Bottom Line: The Financing of Maternity Care in the United States.
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Washington, D.C.: National Gover nors' Association. 1991 Strategies for Improving State Child Health Programs.
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Select Panel for the Promotion of Child Health 1980 Better Health for Our Children: A National Strategy. Washington, D.C.: Select Panel for the Promotion of Child Health.
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