The widely held sentiment that a culture’s evolution can be measured by how well it takes care of its weakest, most vulnerable members is being put to the test, according to children’s health advocates.

The idea of applying a defending-the-defenseless yardstick to civilization is not new. World leaders including Mahatma Ghandi, Winston Churchill, Harry Truman and at least two popes have uttered some variation on the idea.

In the health care spectrum, the most vulnerable are usually at the two ends of life — the very young and the old. The U.S. took a large step toward caring for elders by establishing Medicare a half century ago. At the other end, caring for U.S. children has been more of a patchwork effort over the past several decades.

“The safety net for children can’t begin to compare with what we’ve done for the elderly,” said Jay Berkelhamer, former president of the American Academy of Pediatrics and current chair of the academy’s Subcommittee on Access.

One of the goals of the Affordable Care Act is to knit together some of those patches to make coverage for kids more effective and affordable. Legal challenges to the ACA, now awaiting a ruling from the Supreme Court, leave children’s advocates with an uncomfortable mixture of worry and optimism.

Jane Perkins, legal director for the National Health Law Program, told California Healthline that despite the fractured nature of coverage, there is a strong commitment in the U.S. to care for children.

“I agree that Congress has covered children through a patchwork of enactments. However, their commitment to improving children’s access to care has been consistent and strong, having amended the Medicaid Act on numerous occasions to expand eligibility to increasing groups of low-income children and giving states numerous options to cover additional children and to clarify the scope of Medicaid-eligible children’s entitlement the early and periodic screening, diagnostic and treatment services,” Perkins said.

Children’s Coverage Included in ACA

In a recent webinar, “Children, the Court and the Constitution,” Perkins highlighted six provisions of the ACA that affect children and youth:

• Individuals can stay enrolled in their parents’ health plans until age 26;
• Beginning in 2014, Medicaid will cover children who have aged out of the foster care system but younger than 26;
• Health plans participating in state-based exchanges must cover essential health benefits, such as maternity and newborn care; pediatric services, including oral and vision care; mental health/substance abuse services; and rehabilitative and habilitative services;
• Workplaces must provide women who are breastfeeding with a private location to express breastmilk;
• Health homes will be established for those with chronic conditions; and
• Demonstration projects will address obesity.

“There are so many provisions in this law that help children and young adults,” Perkins said in her preview of oral arguments before the Supreme Court.

She added, “What happens to those provisions is going to be important as we move forward as a country.”

More Children Live in Poverty

Coverage patches at all levels are less effective when children live in poverty, and poverty among children is growing in the U.S. About 20% of the nation’s children are living below the federal poverty line, according public and private research.

“Now, with one in every five children in the United States living in poverty, that makes it difficult enough,” said Andrew Racine, chief of pediatrics at the Children’s Hospital at Montefiori Medical Center in New York.

“But it’s not only a question of poverty but the distance between the rich and poor that seems to have an impact on the health of children,” Racine told journalists last week at the annual Association of Health Care Journalists conference in Atlanta.

Racine cited research by UNICEF that suggests that “as income inequality increases, children’s well-being goes down.”

“None of this is news,” Racine said. “It’s all pretty well known but considering what we see happening with the distribution of wealth and the challenges to health care reform, it’s pretty sobering.”

Parts of ACA Descended From ‘MediKids’

Some of the ACA’s provisions aimed at children’s coverage are descendants of the House “MediKids” bill sponsored seven years ago by the American Academy of Pediatrics and introduced by California Democrat Rep. Pete Stark. The MediKids Health Insurance Act of 2005 would have amended the Social Security Act to guarantee comprehensive health care coverage for all children born after 2006. The bill died before gaining much traction.

MediKids was an attempt to augment coverage provided by the Children’s Health Insurance Program, probably the single largest national patch in children’s health coverage. Signed into law in 1997, CHIP helps states provide health coverage to about eight million children in families who have incomes too high to qualify for Medicaid, but not high enough to buy insurance on their own. Healthy Families is California’s CHIP program.

“With MediKids, we were trying to drive a stake in the ground saying every child ought to have access to affordable health care,” Berkelhamer said.

“We think the ACA does drive that stake, but there will still be a considerable number left without coverage. It leaves out children who are newly immigrated to our country, for instance,” Berkelhamer added.

The ACA moves closer to the American Academy of Pediatrics’ contention that quality health care is a right, regardless of income or any other status, according to Berkelhamer. The academy spelled out what the reform law means for kids in “ABCs of the ACA: What the Law Means for Children and Pediatricians.”

Extra Patches in California

In California, the patchwork of kids’ coverage has included statewide efforts such as First 5 California, as well as county-specific initiatives.

In 1998, California voters approved Proposition 10, which created and funded First 5 California, also known as the California Children and Families Commission. The initiative added a 50-cent tax to each pack of cigarettes sold in the state. The money is used to fund health services, education, child care and other services.

California Coverage & Health Initiatives, an association of community-based programs operating in 29 of the state’s 58 counties, helps kids and their families enroll in health insurance programs funded at federal, state and local levels.

“We have tried to go the next step in providing health coverage for children in California,” said Kristen Golden Testa, California health program director for The Children’s Partnership.

“We’re trying to actualize a culture change,” Golden Testa said. “Before, the process operated on a ‘Prove-to-me-that-you’re eligible’ premise. We’re trying to move that to a ‘Yes, everybody is eligible’ culture. Come on in and we’ll figure out the best way to do it.”

“I think we’re doing that with our county initiatives and that’s what ACA is trying to do, too. The idea is to come into these exchanges through any door and we’ll figure out how to get you covered,” Golden Testa said.

Children’s advocates say they’ll move forward no matter what the Supreme Court decides.

“While we don’t want the ACA to go away, we will forge on regardless,” said Michael Odeh, California health policy associate with Children Now.

“Kids’ health has to remain a priority at state and national levels. The ACA will help us evolve as a society, but either way we still have a ton of work to do — with or without the ACA,” Odeh said.

Here’s a look at what else is happening in health reform.

Administration Actions

• In her keynote address at The Atlantic‘s Health Care Forum last week, HHS Secretary Kathleen Sebelius reiterated that the Obama administration does not have a backup plan if the Supreme Court strikes down the federal health reform law (Zigmond, Modern Healthcare, 4/19). She also said HHS is ready to help states implement the law “when the court finds the law constitutional” (Norman, CQ HealthBeat, 4/19).

Challenges to Reform

• Legal experts fear that if the Supreme Court strikes down only part of the federal health reform law, it could result in the court appointing a third party to sort through the remainder of the law or at least another year of legal proceedings before the rules of the health care system are decided. During oral arguments last month, Justice Stephen Breyer touched on the idea of a third party when he asked Paul Clement — the lead attorney for the plaintiffs — if the court should “appoint a special master” or “go back to the district court?” (Feder, Politico, 4/23).

In the States

• More than half of states have expressed interest in a managed care program under the federal health reform law that would provide care for individuals eligible for both Medicare and Medicaid. Last week, Melanie Bella — head of the Medicare-Medicaid Coordination Office, which was created under the law — said that 28 states have asked to take part in the managed care demonstration, which is slated to begin in January and involve nearly two million dual eligibles (Reichard, CQ HealthBeat, 4/19).

Inside the Industry

• Hospital and physician groups say they do not support a newly proposed rule by CMS that would require them to report and repay Medicare overpayments within 60 days of identifying them. The proposed rule — required under a provision in the federal health reform law to improve CMS’ prompt recovery of Medicare overpayments — also would require payment records to be kept for at least 10 years. Some groups took exception to the tone of the proposed rule, calling it harsh and saying it seems to suggest that providers are out to defraud the government (Norman, CQ HealthBeat, 4/20).

On the Hill

• A growing number of Democrats have begun to criticize the Obama administration and the federal health reform law, reflecting anxiety surrounding the overhaul ahead of the November election. For example, Rep. Brad Miller (D-N.C.) said President Obama spent too much time and money on the law when he should have “dealt first with the financial system and the other related economic issues.” Sen. Jim Webb (D-Va.) recently said Obama has lost credibility on health care and predicted that it would be his “biggest downside” in the presidential election (Pecquet/Baker, “Healthwatch,” The Hill, 4/19).
• Last week, the Joint Economic Committee said HHS has grown by 11% under the Obama administration, which it attributed to the federal health reform law. However, the figure includes data from before the law took effect. HHS’ workforce grew by 6% between March 2010 — when the health reform law was enacted — and March 2011, adding about 4,600 jobs (Baker [1], “Healthwatch,” The Hill, 4/17). JEC also said the law will cause tax increases of $4 trillion over the next 25 years. The committee noted that the Congressional Budget Office has estimated that the reform law would cause taxes to increase by $800 billion over the next 10 years (Baker [2], “Healthwatch,” The Hill, 4/17).

Rolling Out Reform

• Thousands of jobs created to implement the federal health reform law could be at risk if the U.S. Supreme Court declares the overhaul unconstitutional. The bulk of the job losses would affect the 500 workers at the Center for Consumer Information and Insurance Oversight and the Center for Medicare and Medicaid Innovation, which were created specifically to implement the law. A recent Senate GOP analysis of federal jobs also found that HHS hired thousands of new workers to implement the law, with about 3,000 of those positions in the Office of the Secretary (Feder, Politico, 4/17).

Studying Its Effects

• Hundreds of U.S. community health centers are underperforming on key health care quality measures — such as vaccinating children and helping diabetic patients control blood sugar — according to a Kaiser Health News/USA Today analysis. The analysis — which was based on 2010 data — found that centers in the South generally performed worse than those in California, New England and the Midwest (Galewitz, Kaiser Health News/USA Today, 4/18).

Public Opinion on Reform

• Public opinion on the federal health reform law has remained static over the last month, but more people are aware of the law’s individual mandate, according to the Kaiser Family Foundation‘s new monthly tracking poll (Bristol, CQ HealthBeat, 4/24). The poll found that although support and opposition to the law have each remained at about 40% since the law’s enactment, 70% of respondents oppose the mandate (Sanger-Katz, National Journal, 4/24). The partisan gap in views of the law also is growing, with 70% of Democrats supporting the overhaul, compared with just 7% of Republicans (CQ HealthBeat, 4/24).

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