From The Field J U L Y 1 8 , 2 0 1 1 Health Care Reform: Promises and Pitfalls for Maternal and Child Health KATHRYN L. SANTORO, M.A. Director of Maternal and Child Health Policy and Development, National Institute for Health Care Management Foundation I n 2009 health care spending in the United States reached receive Medicaid or some sort of financial assistance to pur- an all-time high of nearly $2.5 trillion, representing an chase private insurance available through health insurance almost two-fold increase in spending on a per capita basis exchanges (KFF 2010). Benefits offered across subsidized since 1997 (NIHCM Foundation 2011). Policymakers con- plans will be more uniform due to the establishment of an tinue to debate proposals at the federal and state levels to reign essential health benefits package and regulations requiring in health care spending, and there is ongoing uncertainty insurance to be at one of four actuarial values. Yet, there regarding the full ramifications of the Patient Protection and still will be differences in the patient cost-sharing structure Affordable Care Act (ACA) on spending and the affordability across the plans offered by exchanges. These variations may of health care itself. This article explores several challenges make it difficult for consumers to compare plans and ahead for securing access to affordable health insurance and choose one that best meets their needs and finances. In health care for women and children, shares examples of addition, women and children who experience changes in health plan efforts, and offers ideas for how grantmakers income or family situations may transition between can contribute to promoting access and controlling health Medicaid and subsidized coverage, resulting in potential care costs. gaps in coverage, changes in provider networks, or varying cost-sharing requirements. Due to the way eligibility is CHALLENGES AND OPPORTUNITIES FOR being expanded, many children will remain on Medicaid or MATERNAL AND CHILD HEALTH the Children’s Health Insurance Program (CHIP) while their parents become eligible for subsidized coverage, caus- While the ACA will potentially expand access to health care to ing confusion about plan benefits for all family members. currently uninsured women and children and attempt to reign Clearly, efforts to provide information and educate in health care costs, the changes ahead may negatively affect consumers will be needed so that they can derive the most maternal and child health. benefits possible from the coverage options available. ® Access & Quality under Medicaid Managed Care. Many ® Preventing Chronic Conditions. There is growing states utilize Medicaid managed care as a means of control- consensus that the increasing burden of chronic diseases, ling health care spending. In fact, about half of the nation’s particularly those related to burgeoning obesity rates, is an 50 million Medicaid recipients – predominantly children important contributor to exploding costs. Women and chil- and families – are enrolled in managed care plans, and stud- dren are at increased risk for developing a wide range of ies strongly suggest that these arrangements yield cost chronic conditions, and women incur higher medical savings (The Lewin Group 2009). State budget shortfalls expenses than men on several conditions, including obesity and surging Medicaid enrollments accompanying the reces- and depression (Dor et al. 2010; Birnbaum et al. 2003). sion, as well the looming Medicaid expansion in 2014, put Overweight children are estimated to incur $3 billion in tremendous cost pressure on the program and make addi- medical expenditures annually, and medical spending for tional Medicaid managed care expansions even more likely obese adults was estimated to be $147 billion in 2008 (KFF 2010). Given the growing reliance on managed care (Finkelstein et al. 2009). The ACA seeks to reduce future for low-income, potentially vulnerable populations of chronic disease and its associated costs by requiring all new women and children, it is important that these plans con- health insurance policies to cover preventive services with- tinue to ensure access to quality health care and preserve out cost-sharing for all services deemed highly effective by provider participation in their networks. the U.S. Preventive Services Task Force, including depres- ® Understanding Health Insurance Options. Beginning in sion and obesity screenings. To maximize the benefits of 2014, most women who are uninsured will be eligible to expanded coverage for preventive screenings, it will be important for health plans and other stakeholders to receive, and pay for health care. The tool is available at: promote use of the screenings, ensure ease of access to http://askbluereform.com/. providers with appropriate training to conduct screenings, • Several health insurers have created retail stores to and facilitate coverage for treatment of conditions offer consumers direct access to insurance specialists identified through screenings. who offer one-on-one assistance with health insurance shopping. Highmark Inc. currently operates eight stores HEALTH PLAN LEADERSHIP AND across Pennsylvania, and these stores have had more than COMMITMENT 63,000 visitors since the first one opened in March 2009. Health plans are committed to ensuring that women and Highmark expects the stores will continue to be impor- children maintain access to affordable and high-quality health tant resources for consumers as they become more care in the years ahead and are addressing concerns regarding involved in purchasing their own health insurance due the impact of the ACA on maternal and child health. to the ACA. More information is available at: http://highmarkdirect.com/default2.aspx. ® Access & Quality under Medicaid Managed Care. Health plans are already preparing for expansions in ® Preventing Chronic Conditions. Health plans continue to Medicaid managed care under which they will be account- seek ways to provide affordable, high-quality care and have able for providing beneficiaries with access to quality care made significant investments in preventive care for women and adequate provider networks under a fixed capitation and children. fee from the state. • Recognizing the value of stemming the rise in obesity • WellPoint’s State Sponsored Business (SSB) serves 1.8 among children, many health plans, including Blue Cross million members enrolled in Medicaid or CHIP and Blue Shield of North Carolina, are reimbursing providers other publicly funded programs across 10 states. In for obesity-related primary care and dietician visits and preparation for the Medicaid expansions in 2014, SSB are training providers on body mass index screening. formed a National Medicaid Advisory Panel to help fos- • WellPoint’s Maternity Depression Program was created ter dialogue about public health care delivery and to alleviate barriers in identifying and treating perinatal leverage the collective insights, expertise, and guidance and postpartum depression. The program includes train- of physicians, policymakers, and public and private ing and toolkits for providers on depression screening, stakeholders. The group is advising WellPoint on and works directly with members to link them to treat- implementation of new programs and strategies that ment by assisting with referrals and providing can help ensure high-quality, cost-effective delivery information on mental health benefits and the financial models created under health reform. impact of treatment options. • Blue Cross and Blue Shield of Florida recently announced plans to enter the Medicaid managed THE ROLE OF PHILANTHROPY care market in Florida and is poised to serve the In addition to supporting implementation of the ACA, numer- Medicaid population as the state transitions current ous opportunities exist for grantmakers to work with health beneficiaries to managed care and as federal expansions plans in efforts to ensure access to affordable health insurance take effect. As the state’s largest insurer, the plan is a and reign in health care spending. Potential roles for funders well-known brand and has established relationships include: with health care providers across the state benefiting consumers who enroll in their Medicaid managed • supporting community outreach and enrollment efforts to care plan. ensure those eligible for Medicaid or CHIP are in fact enrolled in health insurance; ® Understanding Health Insurance Options. When the health insurance exchanges are up and running, each state • educating consumers on how health insurance works, is expected to have a consumer portal that will function as including what options are available to them – now and in an on-line marketplace and also provide backend support the future – as reform provisions are rolled out; for eligibility determination, plan enrollment, and admin- • funding evidence-based efforts related to preventing chronic istration. Health plans currently utilize several strategies to conditions, including addressing childhood obesity, promot- educate consumers about health insurance coverage ing breastfeeding, and identifying and treating mental health options, facilitate enrollment, and share information about conditions; their benefits and rights under the ACA. • supporting medical education and provider training to help • The Blue Cross and Blue Shield Association has created develop a strong workforce to implement preventive care; the interactive, on-line tool “AskBlue Healthcare Reform” for individuals and businesses to learn how • monitoring the impact of the ACA on access to quality of insurance works and what types of plans fit their care for women and children; and medical needs and budget. It will also help consumers • coordinating with health plans, other funders, and federal understand how the ACA will affect how they access, and state governments to leverage resources. SOURCES Birnbaum, H.G., S.A. Leong, and P.E. Greenberg, “The Economics of Women and Depression: An Employer Perspective,” Journal of Affective Disorders 74(1):15-22, 2003. Dor, A., C. Ferguson, C.L. Langwith, and E. Tan, A Heavy Burden: The Individual Costs of Being Overweight and Obese in the United States (Washington, DC: The George Washington University School of Public Health and Health Services, September 21, 2010). Finkelstein E.A., J.G. Trogdon, J.W. Cohen, and W. Dietz, “Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates,” Health Affairs 28(5):w822-w831, September 2009. The Henry J. Kaiser Family Foundation (KFF), “Impact of Health Reform on Women’s Access to Coverage and Care,” Focus on Health Reform, <http://www.kff.org/womenshealth/upload/ 7987.pdf>, December 2010. The Lewin Group, Medicaid Managed Care Cost Savings - A Synthesis of 24 Studies (Washington, DC: America’s Health Insurance Plans, updated March 2009). NIHCM Foundation, “Understanding U.S. Health Care Spending,” NIHCM Data Brief (Washington, DC: July 2011). Views from the Field is offered by GIH as a forum for health grantmakers to share insights and experiences. If you are interested in participating, please contact Faith Mitchell at 202.452.8331 or fmitchell@gih.org.