Health Care Reform Here And Now: First Up, The Kids

(June 12, 2010)


June 12, 2010

At 15, Miranda Ashland is chatty and outgoing, loves to ride horses, write fantasy fiction about dragons and prophecies, and sing in school musicals.

The Saratoga teen also may be among the first Californians helped by the health care overhaul that will guarantee children access to insurance coverage. Shortly after Miranda was born, doctors diagnosed her with biliary atresia, a blockage or absence of ducts that prevents bile from leaving the liver and leads to cirrhosis. Without a transplant, her liver would fail.

"They said, 'Your daughter has a condition that's incompatible with life,' " said her mother, Michele Ashland, 47.

Miranda got a new liver when she was 6 months old and is now a thriving freshman at San Jose's Lynbrook High School. Only two things remind the Ashland family of Miranda's long-ago health battle, her mother said — the daily pill to prevent her body from rejecting the transplanted liver and the $2,000 monthly insurance bill.

That's the premium for health coverage Kaiser Permanente charges for four of the five Ashlands, including Miranda.

"We are sinking," Michele said. When she tried to buy a more affordable Kaiser plan in 2008, she was told two members of the family wouldn't qualify because of pre-existing conditions: Miranda for her liver transplant and her father, Tom, who had a heart attack that year. "As a consumer I feel really powerless. They can decide anything they want, and that's it," Michele said. "Until we go bankrupt, we have to keep paying these premiums in order to keep having insurance."

Starting in September, families like the Ashlands may have another option. That month, a provision of the new federal health law will prohibit insurance companies from denying coverage to children with pre-existing conditions, which can range from Miranda's liver transplant to more common diseases such as asthma, autism and diabetes.

"We've also heard of children who were denied who had ear infections or acne, something that almost everybody gets," said Kelly Hardy, health policy director for Children Now, a national children's advocacy group based in Oakland.

Some 576,500 California children younger than 18 have pre-existing conditions regardless of their health insurance status, according to Families USA, a national health care consumer advocacy group.
It's not clear how many such children lack health insurance, but Hardy and other experts say the number isn't huge because most have coverage through their parents' plans or public programs such as Healthy Families and Medi-Cal.

Nonetheless, they say, this change will protect uninsured children and their parents, who risk financial ruin to pay medical bills.
"The idea that, as a parent, you would be able to have health insurance but your child cannot is just so wrong," said Beth Capell, lobbyist for Health Access, a statewide health care consumer advocacy group.

The population of children with pre-existing and chronic conditions has grown in part because of medical advances, said Lisa Chamberlain, a pediatrician at the Lucile Packard Children's Hospital in Palo Alto and an assistant professor at the Stanford University medical school.

"As pediatric medicine has gotten better, kids are surviving more. But they are surviving with some consequences," she said, such as monitoring and medication. "From the perspective of an insurance company "... they're still going to be seen as a higher-risk person to insure," she said.

After Congress passed the health care bill, some insurers argued that it did not require them to cover children with pre-existing conditions until 2014, when the major provisions take effect.
Health and Human Services Secretary Kathleen Sebelius quickly chastised them. She said that her department is drafting regulations to clarify the requirement, but:

•  As of Sept. 23, children with pre-existing conditions cannot be denied access to their parents' health insurance plans.
•  Insurance companies cannot insure a child but exclude treatments for his or her pre-existing condition.

The new rule applies to all employer plans and new plans in the individual insurance market, Health and Human Services says.
Health insurers pledged to cooperate. "We await and will fully comply with regulations" wrote Karen Ignagni, president and CEO of America's Health Insurance Plans, which represents insurers.
Some advocates and parents fear insurers will agree to cover the children, but with unaffordable premiums.

A legislative initiative is aimed at the same concern. Assemblyman Mike Feuer, D-Los Angeles, has proposed limiting premiums for children with pre-existing conditions starting next year until 2014, when the federal rules take effect. "The insurance companies will definitely argue that this will cost a lot of money," said Bruce Lesley, president of First Focus, a national child advocacy group.
He doubts that's really true. The population of children with pre-existing conditions is not large to begin with, he said, and public health programs have shown that insuring children with pre-existing conditions doesn't need to be costly.

The rule may actually save insurers, hospitals and others money, said Paul Knepprath, a vice president of the American Lung Association in California. "We know that emergency room visits are very expensive for everybody," he said. "Providing kids with asthma the opportunity to get treatment, get preventive care, will help save money for all."

Overhaul's effects
Tom Ashland owns a construction inspection firm and Michele runs the parent mentor program at the Lucile Packard Children's Hospital, but the couple had to take out a line of credit on their home to help pay their $2,000-per-month insurance premium. The family doesn't eat out, doesn't go to movies and drives 10- and 12-year-old cars, Michele said. "There's not a lot to trim."

When the Ashlands applied for less expensive coverage in 2008, Kaiser said no because standard health plan practices in the individual market base eligibility on medical history, said Jerry Fleming, senior vice president of Kaiser Foundation Hospitals and Health Plan.

Fleming said Kaiser welcomes the new rule requiring insurers to offer coverage this year to children with pre-existing conditions, and a similar mandate in 2014 that will apply to adults with pre-existing conditions. "Having all Americans covered will allow plans like ours to compete on quality and affordability rather than risk avoidance," he said.

Last week, Kaiser told Michele Ashland it had reviewed her application again and said it would accept Miranda and other members of the family in a less expensive plan. Husband Tom remained ineligible, Kaiser said, but could appeal. During the conversation, the Kaiser representative cited the health care overhaul as one reason for covering Miranda, Michele Ashland said.

A Kaiser spokeswoman later said that the health plan constantly revises eligibility guidelines. "Additional information from (the family's) physicians about their total health as of today" affected the company's decision, not the new health rules, said Gerri Ginsburg.

Michele Ashland is reviewing plan options. At a minimum, she said, the family could save $8,000 a year. The new health care rules "have helped us already," Michele Ashland said. "I really do think this will help a lot of families."