Clotie Robinson has tried for four years to buy health coverage for her 8-year-old daughter who suffers from depression and other mental illnesses, but she's been consistently rejected by insurance companies.
As a result, Robinson has been unable to pay for some medicines and medical tests her daughter needs.
The DeSoto, Texas, mom had hoped the new health overhaul law that President Barack Obama signed Tuesday would immediately stop insurers from denying coverage to children with pre-existing medical conditions. Several speeches by Obama and explanations of the bill issued by congressional Democrats left the impression the law would do just that.
But health advocates and some insurers say the law does not clearly state that such protection starts this year. If it doesn't, uninsured children with pre-existing conditions might not get help until 2014, when the law requires insurers to issue policies for all applicants regardless of health condition. There is no doubt that for children who are enrolled in insurance plans, the new law bars insurers from excluding coverage of any pre-existing conditions.
Responding to the concerns, Obama administration officials said Wednesday the law does prohibit insurers from denying children coverage starting this year, but they will issue clarifying regulations. "The law is clear: Insurance plans that cover children cannot deny coverage to a child because he or she has a pre-existing condition," Health and Human Services spokesman Nick Papas said. "To ensure that there is no ambiguity on this point, the Secretary of HHS is preparing to issue regulations next month making it clear that the term "pre-existing exclusion" applies to both a child's access to a plan and to his or her benefits once he or she is in the plan."
Reps. Henry A. Waxman, Sander M. Levin, and George Miller, the Democratic chairmen of the three committees with jurisdiction over health policy in the House of Representatives, said Wednesday that the administration response should be sufficient.
"Under the legislation ... plans that include coverage of children cannot deny coverage to a child based upon a pre-existing condition," the joint statement said. "We have been assured by the Department of Health and Human Services that any possible ambiguity in the underlying bill can be addressed by the Secretary with regulation."
America's Health Insurance Plans, the main insurance lobbying group, says through a spokesman that it interprets the new law as not requiring insurers to cover all child applicants this year.
Health insurers worry that if they're forced to cover all children regardless of health condition, higher rates will result, because only the families of sick kids would apply. That problem, they say, could be largely avoided if the requirement went into effect in 2014, when most Americans will have to have coverage under the law. AHIP says higher rates resulted when New York and a handful of other states enacted "guarantee-issue" laws requiring insurers to offer coverage to all applicants.
"It is important to keep in mind the experience in states that implemented guarantee - issue laws without getting everyone covered, and the impact those reforms had on the affordability of health care coverage," said AHIP spokesman Robert Zirkelbach.
Randy Kammer, a vice president for Blue Cross and Blue Shield of Florida, the largest health insurer in that state, said she interprets the law as allowing insurers to reject coverage for children in some cases until 2014.
The issue mainly involves parents who buy coverage for children on the individual market and whose children have been uninsured more than two months. Federal law requires insurers to cover children who do not have a large gap in coverage.
Price May Be Higher
One thing is clear: The law does nothing to stop insurers from charging higher rates for children with pre-existing illnesses until 2014 when insurers can no longer use health status in setting premiums.
Earlier this week, some health advocates said they worried the health overhaul might not do what was intended. "This could be a large loophole," Janis Gurney, public policy co-director of Family Voices, said Tuesday. The organization, based in Albuquerque, N.M., represents families of children with special needs.
Joan Alker, co-executive director of the Center for Children and Families at Georgetown University in Washington D.C., is among those worried about the language. After learning of the administration's comments Wednesday, she said, "It is clear they are looking at this, which is good, and it is a very complex and technical issue so I think at this point we will wait and see what happens."
Parents whose kids are turned down by an insurer would still have a fallback under the law, even without a regulatory fix. They could seek coverage through an insurance pool for people who can't obtain coverage. The federal government will support the pool with $5 billion.
It's not known how many children are currently denied coverage because of pre-existing conditions. But it's a common complaint.
Toby Serrano, an auto mechanic in Denver, has been trying unsuccessfully for nine years to get insurance coverage for his daughter, Maria, who is now 15. She was born with a blood vessel disorder and underwent numerous brain surgeries in the 1990s.
Though she's now healthy, he says, more than a dozen insurance companies have told Maria's family that her pre-existing condition excludes her from coverage. So when his daughter wants to see a doctor for even a common cold, the family pays the full cost.
Serrano says he's excited by the prospect of the new law requiring insurers to cover children like Maria, but it'd be "real frustrating" if they had to wait until 2014.
This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.