PERSPECTIVES

Children and the Patient Protection and Affordable Care Act: Opportunities and Challenges in an Evolving System David Keller, MD; Lisa J. Chamberlain, MD, MPH From the Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo (Dr Keller); and Department of Pediatrics, Lucile Packard Children’s Hospital at Stanford, Stanford University School of Medicine, Palo Alto, Calif (Dr Chamberlain) The authors declare that they have no conflict of interest. Address correspondence to David Keller, MD, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E 16th Ave, B065, Aurora, CO 80045 (e-mail: [email protected]). Received for publication October 14, 2013; accepted February 14, 2014.

ABSTRACT models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health professionals within and outside academe will need to focus their efforts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children.

The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a relatively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address issues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment

KEYWORDS: child health; health reform; health care systems; pediatrics

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WHAT’S NEW

Blue Cross health insurance plan began in Texas.1 The concept quickly spread throughout the country, accelerated by tax incentives afforded companies that provided health insurance as an employee benefit during World War II.2 After the war, the need for improved access to care for the newly insured led to passage of the Hill-Burton Act, fueling construction of thousands of hospitals across the country.3 The new diagnostic and therapeutic modalities were expensive. To fill the gaps in care to the poor, disabled, and elderly, public insurance programs (Medicare and Medicaid) were created in the 1960s, expanding insurance coverage to those outside the private health insurance system.4,5 In the 1970s, new delivery systems (community health centers and health maintenance organizations) were promoted, extending services to rural and urban underserved areas.6,7 The United States has developed a wide variety of health care delivery systems that move medical science into medical practice. Each system is, in a sense, an answer to a larger societal question: “What level of access to care should we provide for patients, at what level of quality, and at what cost?” The multiplicity of responses to that question have resulted in a patchwork system, delivering excellent care locally to specific subpopulations within states or regions,

The Patient Protection and Affordable Care Act (ACA) is intended to expand insurance coverage, enhance the range of services covered, and change the payment and incentive structure of medical practice in the United States. The coming changes may have unintended consequences for children and for child health providers. Active engagement is required by the pediatric community to assure that children’s health is not adversely affected by implementation of the ACA.

NO COUNTRY CAN be strong whose people are poor and sick. —President Theodore Roosevelt (1912) The explosion of knowledge in the life sciences over the last century has changed the morbidity, mortality, and life course of people in the developed world. As medicine improved the diagnosis and treatment of illness, health care delivery and payment systems evolved to support physicians’ efforts. In 1929, as physicians and hospitals began incorporating science and technology into practice, the first ACADEMIC PEDIATRICS Copyright ª 2014 by Academic Pediatric Association

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with little capacity to align care of the sick with health needs of the whole population. In 2010, Congress and the Obama administration passed the Patient Protection and Affordable Care Act (ACA) in an effort to align the interests of a wide range of stakeholders, focusing on the triple aim of better health, better health care, and lower cost.8 The ACA is focused on solving the problems of adults, but the changes in payment for and delivery of health care it fosters will likely impact the health care of children.9,10 Here we focus on children and US health care reform. We review the ways in which children and child health providers have been affected in past health reform, suggest ways the reforms embodied in the ACA could affect the care of children, and highlight opportunities for pediatricians to engage in ACA implementation to address the health needs of children.

EVOLVING EPIDEMIOLOGY OF PEDIATRIC ILLNESS Children and children’s health care are rarely at the center of health reform,11,12 and the existing environment is no exception. The current focus on cost-containment mandates policy shifts being tailored to adults, particularly those with dual-diagnoses and serious chronic illness because the total cost of pediatric care in the United States (roughly $300 billion per year) is dwarfed by adult costs ($2.4 trillion in 2010).13–15 Unfortunately, a sound policy approach for adults may undermine health access for children. The epidemiology of pediatric illness has shifted over the last 50 years, where the prevalence of serious acute illnesses and accidental injury has fallen while the prevalence of chronic disease has risen. In 1962, a total of 25% of pediatric admissions were for chronic conditions, compared with more than 50% in 2003 (excluding normal newborns and trauma).16 The 16% of children with special health care needs consume 41% of pediatric health spending.17 For the most medically fragile children, spending is further skewed: across 37 children’s hospitals 19% of admissions and 23% of inpatient charges were accounted for by 3% of patients with frequent recurrent hospitalizations.18 Because this subset of medically complicated children is relatively small, their care has become regionalized in pediatric specialty centers over the last 30 years, in some cases leading to increased survival and improved outcomes.19 A second epidemiological pattern includes increasing health disparities described by Dr Judy Palfrey: “In the ever-moving swirl of environmental and social change, there is now a new ‘millennial morbidity.’ The causes of poor physical and mental health are multi-focal. The ever-widening gap between rich and poor has produced large differentials in child health outcome by class and race. Moreover, underlying cultural, racial, and ethnic misunderstandings, biases, and miscommunication have resulted in an inequitable distribution of health care that is unconscionable.”20 The health disparities seen in the 2 most prevalent child conditions, asthma and obesity, are

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significant, and the morbidity is borne largely by the poor.21 The ACA’s focus on prevention, including the responsibility of physicians for the health of populations through accountable care organizations, may incentivize community engagement and a combined medical and public health approach to reduce health disparities.22

CHILD HEALTH REFORM IN THE 20TH CENTURY With strong advocacy, past efforts for change in health care delivery have focused on children. After President Roosevelt’s call for a healthier public in 1912, the Children’s Bureau was established, leading eventually to the establishment of the Maternal Child Health Bureau (MCHB) through Title V of the Social Security Act in 1935.23,24 Working with state governments over the decades, MCHB has supported system changes addressing the needs of the most vulnerable children in America. When Congress passed Medicare in 1965, providing universal health coverage for the elderly, it also created Medicaid to care for America’s poorest children through Title XIX of the Social Security Act. After the failure to pass omnibus health reform legislation in 1994, a bipartisan effort in Congress resulted in the State Children’s Health Insurance Program (SCHIP),25 covering 8 million children of the working poor whose families earned too much to qualify for Medicaid but whose jobs did not provide private health benefits. Evaluation of SCHIP showed that it improved quality access to care and led to better use of care.26 SCHIP became the focus of attention in the latter years of the Bush administration, when its reauthorization was vetoed twice. A continuing resolution by Congress sustained the program until it was reauthorized as the first act of the Obama administration in January 2009. The ACA authorizes SCHIP until 2019 and provides $40 million to support Medicaid and SCHIP outreach and enrollment.27 Funding for SCHIP under the ACA, however, ends in 2015. Children have benefited when federal policy has recognized the connection between public health and primary health care. After the measles epidemic of 1989 to 1991, the Centers for Disease Control reported afflicted children were unimmunized despite having access to medical care. Congress responded by establishing the Vaccines for Children (VFC) Program as section 1928 of the Social Security Act.28 VFC improved immunization delivery through a combination of access for the uninsured, improved payments to providers, and enhanced distribution systems. Overall, while children and their unique health care needs have not always been the focus of US efforts at health reform, history shows that focused advocacy can create policies that direct evolving systems to meet the needs of children.

ROLE OF CHILD HEALTH SERVICES RESEARCH IN PREVIOUS EFFORTS AT HEALTH REFORM In the past, health reform efforts have used child health research to address the unique needs of children. A series of studies funded through the Children’s Bureau in the

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1920s informed the establishment of the Maternal and Child Health Bureau in 1935.29 After the passage of Medicaid in 1965, studies reported high rates of disability among participants in Project Healthstart and among young men reporting to the Selective Service. Many of the conditions diagnosed were preventable if identified and treated earlier in life given appropriate screening. This led to the creation of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program in 1967.30 Studies of the impact of child disability on families led to important changes in defining disability, informing the changes to the Supplemental Security Income (SSI) program and establishing the “Katie Beckett” waiver program within Medicaid in the 1970s and 1980s.31,32 Most recently, SCHIP provided many lessons learned: it included a robust evaluation requirement and provided a vehicle for others, including private foundations, to fund research examining the benefits of coverage and the challenges of expanding markets across a variegated US social landscape. The wealth of information informed the development of the ACA’s access provisions.33,34 Focused advocacy during the renewal of (S)CHIPs in 2009 created the Children’s Health Insurance Program Reauthorization Act of 2009 Quality Measures Program, a set of initiatives to develop, test and validate both a core set of quality measures for child health and a new set of measures to evaluate outcomes in hard-to-assess areas such as behavioral health.35,36 These measures are essential if children are to be integrated into the ACA’s novel proposed payment mechanisms.

THE AFFORDABLE CARE ACT The current efforts at health reform through the ACA were triggered by a combination of economic pressure and political realignment.37 The growing number of elderly patients, increasing life expectancies, and increasing medical costs were driving up the cost of Medicare.38 Large businesses with self-insured health plans were increasingly shifting costs to employees through copays and deductibles. The health insurance market for small employers and individuals faced numerous challenges.39 Families frequently could not buy coverage as a result of costs or exclusions, leading to an increasing number of uninsured patients and more bankruptcy filings due to medical debt. Before the election, both parties seemed prepared to engage in a serious effort in health reform. The major economic downturn of 2008 led to the election of a Democratic Congress and president, who continued the discussion as they developed a strategy to deal with the challenges of that downturn.9 The newly seated Obama administration chose an incremental approach, stabilizing existing private and public insurance markets while encouraging the development of integrated systems of care to manage the growing number of elderly adults with multiple chronic conditions. The result was the Patient Protection and Affordable Care Act of 2010. Parts of the ACA were based on legislation implemented in Massachusetts in 2006.9 That legislation sought to control

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health care cost by first achieving near-universal access to health insurance and then creating cost-containing payment models. In a similar fashion, the ACA attempted to increase access to health insurance among the uninsured, notably the poor and the near poor trying to purchase insurance as individuals and small group markets. States were directed to expand Medicaid to adults living below 133% of the federal poverty line, with significant federal support.40 A subsequent Supreme Court ruling made expansion voluntary, leading many states to opt out and others to renegotiate Medicaid expansion terms with the administration.40 In addition, the law directed states to implement American Health Benefit Exchanges, where uninsured individuals could purchase coverage in a competitive environment beginning January 1, 2014.41 These exchanges would serve as regulated and transparent marketplaces where individuals and small businesses could purchase health insurance, administered either by the state or federal government. In 2014, all citizens would be required to have health insurance through public or private sectors, or pay a penalty on their income tax. Subsidies would be available on a sliding scale for those with low income who were not eligible for Medicaid. These interventions were expected to reduce the number of uninsured people in the United States from 52 million to about 26 million. An estimated 20 million of the remaining uninsured reside in the United States without documentation and would not be eligible to participate in the new exchanges.42 As more citizens could become insured, payment reform begins. The ACA has numerous provisions that shift the health care system from a fragmented collection of service providers, paid primarily on the basis of the volume of procedures and services provided, to become a more integrated health care system built around a robust primary care infrastructure. Numerous payment reform efforts within Medicare, Medicaid, and the private sector were designed to support primary care–based systems of care focused on the 3-part aim of improved health, improved health care, and reduced cost,43 often focusing on high-cost populations within publicly funded health plans. Two new entities, the Center for Medicare and Medicaid Innovation (CMMI)44 and the Patient Centered Outcomes Research Institute (PCORI),45 were established with distinct missions: to test new systems of care and to develop the evidence base necessary for evidence-based medicine. For the first time since establishing Medicare and Medicaid, the ACA gave the secretary of Health and Human Services the authority to take to scale any innovation developed that measurably improved quality, reduced cost, or both. For providers and health plans, motivation for participation in these reformed care systems was the promise of enhanced payment for improved performance through a model of shared savings. Providers and health plans were incentivized by the opportunity to share in the calculated savings, based on actuarial estimates of what care would have cost had they continued to rise as in the past.46,47 In this model, an Accountable Care Organization (ACO) would assume responsibility for the health of a population and benefits from keeping that population healthy.48

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The ACA recognized and funded change in the primary care service delivery system while doing less to support the workforce development required to staff it. There was enhanced support for community health centers and for the National Health Service Corps loan repayment program.49 Title VII and Title VIII of the Public Health Service Act, supporting the Bureau of Health Professions within the Health Resources and Services Administration (HRSA), were reauthorized and directed to support primary care training but received little additional funding. The Center for Medicare and Medicaid was directed to reallocate currently approved residency slots toward states with a greater need for primary care, but the number of Medicare residency slots remained capped. HRSA was directed to initiate a program of teaching health centers to move residency training out of hospitals into community sites, and new funding was allocated to that program.50 The law, however, did not directly address the current funding of graduate medical education through the Medicare payment system, keeping in place the current system of hospital-centered residency training.51

THE ACA AND CHILDREN The Five D model, proposed in 199752 and updated in 2009,53 is an important lens though which to view the ACA. Do the proposed systems account for the differences in development, dependency, demographics, differential epidemiology, and dollars between adult and child health? Overall, the major impact of the ACA on the health children may derive from its impact on household income, through income supplementation (qualifying parents for Medicaid or exchange subsidies) or through the avoidance of medical bankruptcy. In addition, the legislation addressed a number of child health issues. INCREASING ACCESS TO CARE A central feature of the ACA for children is the promise to “eliminate the threat of a lack of health insurance as a possibility for nearly all children.”54 Furthermore the expansion of Medicaid for parents will help children as the evidence indicates; as parents gain coverage, their children benefit through increasing participation in Medicaid.55 However, gaps remain for undocumented children. Providing coverage for this particularly vulnerable population has been shown to reduce unmet health and dental needs, improve health status, and reduce child school absenteeism, so much remains to be done.56 Children with serious chronic illness fared well under the insurance reforms mandated by the ACA. The prohibition of denying coverage for children under 19 years of age with preexisting conditions, coupled with the lifting of lifetime coverage limits and the caps on out-of-pocket expenses, will increase access to care and reduce the financial burden on families who care for seriously ill children.57 The ACA requires the Department of Health and Human Services to define a set of essential health benefits including dental, vision, and habilitation benefits. One of the most popular aspects of the ACA is the extension of

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coverage for young adults to remain on their parent’s insurance policy until the age of 26. This has already decreased the number of uninsured young adults by 3 million, with the greatest gains among unmarried adults, nonstudents, and men.58 Although Medicaid for children in the foster care system was also extended to age 26, families on Medicaid and young adults with uninsured parents are not eligible for this benefit. SCHIP and Medicaid were strengthened by the ACA, although funding for SCHIP is not assured in the future.59 SCHIP was reauthorized through 2019 but only funded through 2015, putting the program at risk in the current fiscal climate.60 Some think that with the coming of the state health benefit exchanges, SCHIP will no longer be needed. Others note, however, that many families who are eligible for subsidized insurance within SCHIP as it currently exists would be ineligible for subsidized insurance on the exchange, the so-called family glitch, because of differences in the formulas for the calculation of the subsidies. In addition, SCHIP programs have a more comprehensive and child-focused benefit package than most insurance products proposed for the exchanges. Finally, the ACA enhanced Medicaid reimbursement to Medicare payment rates for a subset of specific evaluation and management codes used by primary care pediatricians beginning in 2013 and continuing through 2014.61 TRANSFORMING PEDIATRIC HEALTH CARE DELIVERY SYSTEMS Some of the most disruptive and exciting components of the ACA promote new payment models that support a new paradigm for care: where formerly a physician was responsible for a group of individual patients, now a care team will be responsible for the health of a defined population. Within Medicare, these practices are supported through bundled payments and ACO,48,62 but these models of care are specifically designed for Medicare recipients.63 Within Medicaid, states are offered the opportunity to create health homes,64 and the Center for Medicaid and CHIP Services has authorization (but no funding) to create a state Medicaid-based ACO for children. In addition, state regulators are working to create state definitions of ACOs. This approach holds promise for caring for medically complicated children by requiring the formation of interdisciplinary teams, which are difficult to support in a feefor-service payment system. It also provides an opportunity to build bridges between medicine and public health by focusing on the health of populations. Funding to support the transformation process, however, is based on a shared savings derived from improved management of patients with chronic diseases, which are much more prevalent in adult populations. One early experiment in alternative payment for pediatric care with a shared savings component was unable to demonstrate savings at the plan level.65 The ACA also expanded the Maternal, Infant, and Early Childhood Home Visiting Program.66 Many community pediatricians work closely with the agencies involved in home visiting programs.67 The expansion of the model provides an opportunity for pediatricians to work with

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community agencies to address some of the social factors that are critical to child health.68 STRENGTHENING THE PEDIATRIC WORKFORCE The workforce provisions of the ACA present a few opportunities for pediatricians. Pediatricians who commit to work in community health centers will benefit from increased funding under the ACA.69 Pediatric residency programs could be developed to fit into the teaching health center model authorized through the ACA, although most programs proposed thus far have been in family medicine. Pediatric residency programs will be largely unaffected by redistribution of programs under Medicare because much pediatric training has a separate funding stream through freestanding children’s hospitals through HRSA. The ACAwill affect the entire pediatric workforce by strengthening training of pediatrics subspecialists through loan repayment. The ACA authorizes, but does not fund, loan repayment for up to $35,000 per year for 3 years for individuals training in pediatric subspecialties willing to provide care in medically underserved areas.61 Overall, workforce enhancement, particularly for pediatrics, will need to be a part of future legislation.

OPPORTUNITIES FOR ACADEMIC PEDIATRICIANS IN THE EVOLVING SYSTEMS The ACA engages federal and state governments in a transformative process that has been gathering momentum throughout the country. Within that process, there are opportunities for academic pediatricians to participate through 1) clinical care, 2) research, 3) education, and 4) advocacy. OPPORTUNITY 1: CLINICAL CARE Pediatricians frequently provide care for vulnerable populations, those who experience disruptions in their health coverage (churn), and those who are undocumented and therefore are excluded from the system.70 Pediatricians within and outside of academe can bring change to pediatric practice through implementation of the medical home model and improved coordination of care for children with serious chronic illness for children. The ACA provides numerous opportunities to bring evidence-based care coordination efforts to scale, in parallel with efforts to transform practice in the adult realm.71 In the first round of innovation awards distributed by the newly created CMMI, only 10 of the 105 projects funded included children in their target populations,72 so much remains to be done. CMMI is funding states to develop innovation plans to change payment and delivery at the state level. Pediatricians can play a leadership role in assuring the unique needs of children are addressed as those plans are implemented. OPPORTUNITY 2: RESEARCH The words study, research, and evaluate appear more than 500 times in the ACA as legislators realized they were moving into areas where much remained to be learned. Many opportunities for research involve children and should engage child health services researchers over

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the coming decades.73 The ACA will increase coverage for large numbers of Americans, providing many natural experiments that can and should be leveraged by health service researchers.74 For example, unequal access to any treatment often widens health disparities. As a subset of young adults acquire health insurance under their parents’ insurance plans, we may see health disparities for 19- to 26-year-olds widen. By studying the impact of health reform on disparities, we can identify an evolving problem quickly and provide the data to help policy makers develop novel solutions to the challenge of care transition. Other opportunities may emerge from the work of the Pediatric Quality Measures Program, which continues contemporaneously with ACA implementation. The measures being developed provide the tools needed to implement ACOs for children, including emergency department utilization, pediatric hospitalization and rehospitalization, and pediatric care coordination.75 The science of dissemination and implementation presents another way for pediatric researchers to offer data that supports the sound implementation of new systems of care.76,77 Finally, PCORI will “examine the relative health outcomes, clinical effectiveness, and appropriateness of different medical treatments.”78 To date, PCORI has awarded $88.6 million dollars across 51 varying projects examining patientcentered comparative clinical effectiveness, many of which have a focus on children and child health. OPPORTUNITY 3: EDUCATION By extending the focus of care from individual patients to improving outcomes for populations, the ACA fundamentally affects the education requirements for pediatric residents. Pediatricians of the future will be responsible for a population of children, and this shift moves the discipline beyond the traditional domains of medicine. The evolving field requires training in population health, understanding health disparities, and mastering skills in community engagement and advocacy. Pediatrics is well suited to meet this challenge. Already new requirements echo this reality: in July 2013, programs will increase from 1 to 2 required rotations in community pediatrics. The burgeoning field of community pediatrics and advocacy has seen expansion over the last 14 years, starting with the Dyson Initiative, evolving through the leadership of the Community Pediatrics Training Initiative of the American Academy of Pediatrics, and the formation of educational collaboratives dedicated to rapid expansion of community pediatrics training.79 Pediatrics, unlike internal medicine, is experiencing a subspecialty shortage. The ACA affects postgraduate pediatric training by incentivizing training of pediatric subspecialists, pediatric surgical specialists, and providers of mental and behavioral health services for children and adolescents areas by authorizing $50 million per year in loan repayment programs,61 and although it is included in the president’s budget, it still has many congressional hurdles to clear. Finally, the influx of nurse practitioners and physician assistants into the pediatric primary care workforce elevates the need for interprofessional education, to which HRSA has responded

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Table 1. Opportunities and Challenges for Academic Pediatrics in the ACA Characteristic

Field

Opportunities

Description

Clinical care Research Education Advocacy

Challenges

Essential health benefits SCHIP Including children in innovation opportunities

Clinicians can improve the coordination of care through expanding the medical home model. Researchers can evaluate the large natural experiments under way, providing significant health service research opportunities. Medical educators can expand the focus of training from the individual patient to pediatric populations. Child advocates can work with elected state officials to ensure children’s unique needs are considered in implementation of the ACA. Establishing consistent and comprehensive essential health benefits for children across all states. Maintaining the Children’s Health Insurance Program as the exchanges/marketplaces begin to function. Assuring that children are included in the development of innovative delivery systems and payment models, and that new models of care account for the Five D model.*

ACA ¼ Patient Protection and Affordable Care Act; SCHIP, State Health Insurance Program for Children. *The Five D model refers to the following: Do the proposed systems account for the differences in development, dependency, demographics, differential epidemiology, and dollars between adult and child health?

by establishing a National Coordinating Center for Interprofessional Education and Collaborative Practice, in collaboration with the Macy Foundation.80 OPPORTUNITY 4: ADVOCACY The ACA introduces many new regulations for states to implement and thus opens the opportunity for pediatricians to engage in advocacy. For example, states are currently working to develop the aforementioned health insurance exchanges, the details of which will profoundly influence access to care for children, especially those with special health care needs. Pediatricians need to convey to policy makers, who are focused largely on developing systems of care for adult populations, that established regionalized systems of care for children are critical to providing highquality care. Evolving integrated health systems should incorporate existing pediatric networks so as not to unravel existing regional networks for neonatal intensive care and other specialized pediatric services. The emergence of advocacy training in pediatric programs and novel statewide collaboratives79 coincide with this need for an enhanced advocacy voice.

CHALLENGES FOR PEDIATRICIANS, CHILDREN, AND FAMILIES The ACA focuses on the highest risk and highest cost components of health care delivery. Child health is

generally not in that category, presenting a challenge for children, families, and child advocates; child health may be inadvertently harmed by efforts to improve care for the elderly (Table 1). Indeed, such unintended consequences have already occurred. An early example was the implementation of an ACA requirement that preventive services be delivered without a copay, encouraging adult patient compliance with recommended screenings and preventive care. These services were new to Medicare recipients, who were suddenly able to access mammography and colonoscopy services without copays. Pediatricians, on the other hand, have been billing for and collecting copays on well-child visits for decades. In many practices, well-child care constitutes 40% of visits. The law did not specify that insurers increase their payments to compensate for that loss of revenue, although it is doubtful that lawmakers intended to reduce funding to support child preventive services. One significant challenge will be to work with the states that did not expand Medicaid coverage to adults, exploring the potential of starting with parents. This issue will become a high priority as the Disproportionate Share Hospital payments are reduced. The impact of changes in payment on safety net hospitals is real,81 and any loss in safety net facilities is likely to affect the many children living in poverty.82 Other challenges to child health and pediatric providers during the implementation of the ACA also exist.

Table 2. Online ACA Implementation Resources Name

URL

Kaiser Health News

www.kaiserhealthnews.org

Commonwealth Fund

www.commonwealthfund.org

Health Reform GPS National Association of State Health Policy Center for Children and Families

www.healthreformgps.org www.nashp.org ccf.georgetown.edu

ACA ¼ Patient Protection and Affordable Care Act.

Description Daily updates available drawn from news around the country Weekly updates, analysis and webinars on a variety of health reform topics Topic-based updates on key issues in health policy State policy issues, many of which relate to children and families Analysis focused on the impact of the evolving health system on child health care

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ESTABLISHING ESSENTIAL HEALTH BENEFITS FOR CHILDREN In order to rate the quality and scope of a health insurance plan, the ACA called for the development of a package of essential health benefits, including services to children based on the Bright Futures guidelines. This could have become a national standard. In implementing the law, however, the Department of Health and Human Services has given enormous discretion to the states, such that inclusion of vision, hearing, dental, and habilitative services in the basic health plans offered on the exchanges, as well as the standard for medical coverage, is set at the state level. It will be difficult to assure a uniform standard of care for children, particularly those with special health care needs, without a national standard. MAINTAINING THE CHILDREN’S HEALTH INSURANCE PROGRAM AS THE EXCHANGES BEGIN TO FUNCTION The ACA authorizes the SCHIP program through 2019 but only provides funding through 2015. SCHIP guarantees that children receive many services not included in the essential health benefits packages of the exchanges, providing higher-quality coverage than is likely to be available in many states. This will require amending the family glitch and providing seamless transitions to new coverage.59 It will be challenging to fund these services in the current political environment. ASSURING THAT CHILDREN ARE INCLUDED IN THE DEVELOPMENT OF INNOVATIVE DELIVERY SYSTEMS AND PAYMENT MODELS CMMI is required to fund projects that demonstrate substantial cost savings to Medicare or Medicaid within a short time frame (6 months to 3 years). Often, such savings in innovations in child health service delivery take longer to achieve and are realized in other sectors of government, such as education or juvenile justice. Achieving child health care innovation will require advocacy at multiple levels to convince CMMI to take a broad view of its mandate to improve the care of all.

CONCLUSION The implementation of the ACA is chaotic. To understand the process as it continues to evolve, we recommend the resources outlined in Table 2. The ACA is a landmark piece of social legislation with the potential to change the way health care is delivered in the United States. It was designed to address problems of cost and quality, most of which relate to the practice of medicine in adults. It has survived numerous political challenges, and as of this writing, it is being implemented with enthusiasm within the federal government and with varying degrees of enthusiasm by state governments. It is imperative that academic pediatricians be part of the many conversations taking place within federal and state governments as the law is implemented. The ACAwill, in the end, be judged how it treats “those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick, the needy, and the

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handicapped,” as Hubert Humphrey said in 1977. To meet that standard, academic pediatricians need to engage in the conversation that the ACA has begun.

ACKNOWLEDGMENTS Dr Keller was a Robert Wood Johnson Foundation Health Policy Fellow (2009–2012).

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Children and the Patient Protection and Affordable Care Act: opportunities and challenges in an evolving system.

The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and ...
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