CHAPTER 1 AT A GLANCE[Not all features are available in this version - See PDF version or hard copy report] Contents
ThemeChildren who grow up in divorced, separated, or never-married families are at risk for not having health care coverage. Private health care coverage is highly related to income and many single-parent households have lower incomes than two-parent households. Even if income is not an issue, it is usually more difficult for parents to coordinate resource investment in their children when they live apart. Recognizing these risks, Congress established the Medical Child Support Working Group (the "Working Group") to make recommendations for improving health care coverage for children. |
Access to health care services is a complex issue and the focus of frequent debate by scholars, policy makers, headline writers and the general public. As a society, we continue to struggle with the delivery of adequate medical care to all citizens. While opinions and approaches vary, there is universal accord on one issue: for children, health care is critical.
Children without health care coverage have substantially less access to health care services, including preventive care that ensures childhood immunizations are up to date, vision and hearing screening and corrections have occurred, and routine dental care has been provided.1 Care for uninsured children is also far more likely to be delayed due to cost.2 Unmet health care needs reduce children's ability to learn and to grow into healthy and productive adults.
Making sure that children stay healthy is an important goal for all segments of society. Healthy children are important to employers because sick children reduce employee productivity. Healthy children are important to the health care industry because they increase profitability. Healthy children are important to public health programs and providers because improving child health is part of their basic mission. Healthy children are important to the child support community because it is responsible for helping to improve the lives of children who live apart from one of their parents. And most important, healthy children are important to parents because they love their children and want them to have the best life possible. Healthy children are important for all of society, because they are our future.
Many of the issues related to the lack of health care coverage for children are structural. That is, they are related to larger changes in our society. For decades, the cost of health care has been rising at rates higher than inflation. These rising health care coverage costs have made private family health coverage more expensive for both employer and employee. In response to rising health care costs, our society has moved from a health care insurance model where there was usually a choice of providers (often referred to as fee-for-service plans) to extensive use of health care maintenance plans and other types of plans that put limitations on the choice of provider.
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“I would ask you to remember our focus is uninsured children.
But children do not buy health insurance. Parents buy health insurance
for their children, and they buy it with the help of employers and through
employers. Granted, the children are also covered through the government,
but the government is the conduit of money from employers and parents in
order to pay for that health coverage. Either way you look at it, it's
the parent and the employer, through taxes or directly, that pays for health
coverage. And to the extent that health-care coverage is affordable,
there's a direct relation to the extent that there will be coverage for the
uninsured children.”
~ Terry Humo, General Counsel, Intermountain Administrators, Inc. |
In recognition of the reliance that American society has on private group health care coverage, there have also been many legislative and regulatory interventions to try to make the system work better for employers and insurers, as well as for employees and their dependents. These efforts have affected the tax code, regulated employers, made changes in benefit packages and insurance industry practices, and offered coverage protections to certain classes of employees and dependents. All of these efforts have had the laudatory goal of improving health care coverage. However, taken in their totality, these legislative and regulatory changes have not always been consistent with each other, have sometimes created confusion among both the regulators and the regulated, and may have discouraged participation by some employers and some employees in group health care coverage. These efforts may also have had the unintended consequence of increasing health care costs.
Changes in the labor market have affected health care coverage as well. It is less likely today for workers to stay in the same job for long periods of time. There are fewer blue-collar jobs with generous benefit packages for low-skilled workers. More workers are working part-time, on a temporary basis, on a contract basis, or are self employed. This may mean that workers do not qualify for health benefits because they work too few hours or have not worked long enough.3 Individuals whose low level of skills and/or education makes it difficult to move out of the low-wage segments of the labor market are least likely to have coverage. These workers often find that their employers are less likely to offer health care coverage or that, if offered, they cannot afford to take advantage of the coverage.4
The changing structure of the family has also had an impact on children's health care coverage. High rates of divorce and non-marital child-bearing have meant that an increasing number and proportion of children live with only one of their parents. Recent studies have shown that children who live in families with two employed parents are more likely to have health care coverage than children who live in one-parent families, even if that parent is employed.5 Studies have shown that it is often difficult for parents who live apart to work together on behalf of their children.6 After divorce or a break-up of a romantic relationship, one parent may move a long distance from the other and their children, one or both may get remarried and have multiple family responsibilities, and often acrimony continues to exist from the break-up of the relationship. All of this makes it more difficult for parents to work together for the sake of their mutual children.7 Additionally, single-parent households often have low incomes. Children in lower-income households are less likely to have private health care coverage and more likely to rely on public coverage than middle- or upper-income children.8 (See Child Support-Eligible Children box.)
"Child Support-Eligible Children"As used in this report, child support-eligible children are children under the age of 19 whose parents are divorced, separated, or never-married (and not living together). Not all child support-eligible children live in single parent households, about 17 percent live in married stepparent families. In this report, 21 million children living in single or stepparent households are considered to be eligible for child support. Additional child support-eligible children live with a related adult, a guardian or foster parent. Our data is not able to count these children. (See APPENDIX D: Health Care Coverage for Child Support-Eligible Children, page A-32.). |
There are also changes in the structure of single-parent households. For example, they are not limited to female-headed households. While mothers are still more likely to have sole custody, approximately 15 percent of all custodial parents are fathers.9 The structure of single-parent households has also been affected by the fact that more parents have shared legal custody for their children. This means that it is the right of both parents to be involved in important decisions, like health care, even when the children reside primarily with one parent. In addition, some parents are deciding to each take primary physical responsibility for one or more of their shared children, and some states are no longer using the term "custody," but instead are allocating "parenting time" between the mother and father.10 These changes all affect children's access to health care coverage.
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Over time, Federal and State governments have responded to the need for health care coverage for uninsured children in two ways. First, Congress authorized publicly-subsidized health care coverage through the Medicaid program in 1965 and then through the State Children's Health Insurance Program (SCHIP) in 1999. Both Medicaid and SCHIP are need based programs, primarily serving families with incomes under 200 percent of poverty. Approximately 61 percent of the children in these programs live in single-parent households.11 Second, in 1984 State child support enforcement ("IV-D") programs12 were given the responsibility to include medical support establishment and enforcement as part of their child support efforts. States were required to include provisions for health care coverage in their child support guidelines and the IV-D programs were required to pursue private health care coverage when such coverage was available through a noncustodial parent at a reasonable cost.13 All 21 million children under age 19 not living with both their biological or adoptive parents are potentially affected by State child support guidelines.14 About 13.5 million children are part of families receiving services through the IV-D program.15
In 1987 and 1989, the Office of the Inspector General (OIG), Health and Human Services (HHS) published two studies on medical child support that indicated there was room for substantial improvement in child support enforcement program efforts to obtain private health care coverage from noncustodial parents for their Medicaid-eligible children. These studies indicated that only 24 percent of child support orders (for Medicaid-eligible children) included provisions requiring medical support. These studies also indicated that as of 1989, in 48 percent of reviewed cases without a medical support provision, fathers actually had access to dependent coverage.16
In a soon to be released follow-up report to assess the child support enforcement program's progress in obtaining medical support for Medicaid-eligible children, the OIG found that as of 1998, 93 percent of child support orders had provisions requiring medical support for dependent children. In addition, the OIG found that undetected dependent coverage available in Medicaid-eligible child support cases from the noncustodial parent through employment had been reduced from the 48 percent noted in 1989 to approximately 30 percent. Finally, the study notes that the change in health care coverage service delivery-from primarily fee-for-service to primarily managed-care-presents new issues for the cost-recovery strategies to be used when Medicaid-eligible children also have access to private health care coverage.17
Past efforts have made a difference. Eighty-six percent of child support-eligible children have private or public health care coverage or both.18 Still, more needs to be done given the critical importance of access to health care for children. In addition to the issue of undetected health care coverage identified in the OIG report discussed above, two recently released Federal government reports indicate that other critical issues are lack of access to employment-based health care by some employees and the cost of health care coverage, especially for lower-wage employees.
In 1998 the General Accounting Office (GAO) issued a report on the availability of employment-based health insurance. This report indicates that while most workers have access to employer-based health care coverage, a substantial minority, 28 percent, do not. Lack of access to coverage is affected by the size of the employer, the type of industry, the status of the employees, geographic location, and the cost of coverage relative to employee wage levels and size of firm.19
In the second report, OIG examined the availability of private health care coverage for children receiving Medicaid benefits. This single-State, small-scale study found that health care coverage was not being provided by 45 percent of noncustodial parents because it was not affordable or not available. The report concluded that the State should consider requiring noncustodial parents to contribute towards the cost of Medicaid premiums or to a (lower-cost) statewide health insurance plan for children that the State should establish.20 Clearly, for some children, alternatives to employer-based health care coverage are still needed.
The National Child Support Enforcement (IV-D) ProgramIn 1975, Congress added Part D to Title IV of the Social Security Act, thereby creating the child support enforcement, or "IV-D" program. Although the program has been expanded and enhanced many times over the last 25 years, its goals remain to ensure that both parents financially and emotionally support children and to help reduce welfare expenditures. The IV-D program locates noncustodial parents; establishes paternity; establishes and modifies child support orders, including medical support provisions; collects and distributes child support; and enforces medical support provisions in child support orders.21 The child support enforcement system is built on a series of partnerships among Federal, State, and local governments, and the judiciary, as well as cooperative relationships with employers and social service agencies. State and Federal legislation establishes the basic framework, while courts, State offices of child support enforcement, the Federal Office of Child Support Enforcement (OCSE), and other public agencies work together to serve the needs of America's children. OCSE sets program standards and policy, evaluates States' performance, offers technical assistance and training to States, and audits State program activities. The Federal government also pays the predominant share of the cost of funding the program. Each State has a child support enforcement agency (also called "IV-D agency"). These agencies are housed in varying locations at the election of State government, including the State human or social services department, the Office of the Attorney General, or the State Revenue Department. Some State IV-D agencies provide localized services by operating State-run offices throughout the State. Other States provide local services through contracts with local government entities (e.g., counties, district attorneys) or private contractors. Still other States have a hybrid system of local offices, with some operated by the State and others operated by local government/contractors. There is also substantial variation between States in what authority is responsible for establishing and enforcing child support orders-including orders for medical support. Whether a court or an administrative agency issues the order, the decision maker must apply the State's child support guidelines and issue an order for income withholding. Eligibility for IV-D ServicesAll families may apply for child support services.22 Families that are receiving Temporary Assistance for Needy Families (TANF) must cooperate with the State child support agency to establish paternity, collect child support, and obtain health care benefits except for "good cause" reasons, such as serious threat of physical violence. There is a similar requirement for Medicaid, except that Medicaid-eligible children cannot be denied for failure to cooperate, and pregnant women eligible under the poverty level eligibility group are not required to cooperate as a condition of eligibility. Families who do not receive public assistance receive services upon application. While the application fee is minimal, States are permitted to recover costs and thus the applicant may be responsible for additional costs or fees. |
In 1996, approximately three million children not living with both of their biological or adoptive parents had no health care coverage throughout the year. Some of these children had no private health care coverage available through either their mother's or father's employment. Others had private health care coverage available, but neither the parents nor the local child support enforcement program were able to break through the barriers that make it difficult to get health care coverage for these children. Still others were eligible for publicly-sponsored coverage, but their parents did not know how to apply for coverage or that such coverage was even available. Yet other children had coverage for only part of the year23 and they, too, needed help filling the coverage gap.
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“Your task is, quite simply, to keep the kids in mind and to think
broadly beyond the scope of the work you all individually do to what's a
good and workable solution to the issues that face you.... It's not
just about the coverage; it's about better health outcomes for the
people—for these kids.”
~ Kevin Thurm, Deputy Secretary, HHS May 12, 1999 |
New strategies and new approaches are needed to ensure that children are held harmless from the potential adverse health care consequences of family break-up. All 21 million child support-eligible children will be affected by the recommendations presented in this Report. For these children, getting and keeping health care coverage is complicated and resource intensive. The Working Group believes that the recommendations in this Report will make getting children into health care coverage easier and more cost-effective for parents, employers, plan administrators, insurers and government. If fully implemented, these recommendations will result in more children having the best private health care coverage available through their parents and fewer children having no health care coverage at all.
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Congress recognized both the nature of the problems and the willingness of the various communities to deal with them in a coordinated fashion. To encourage these efforts, it created the Medical Child Support Working Group ("Working Group") as part of Pub. L. 105-200, the Child Support Performance and Incentive Act of 1998 ("CSPIA").24 Jointly established by the Secretary of Health and Human Services and the Secretary of Labor, the Working Group includes representatives of the Federal government, employers, health plan administrators, the health insurance industry, child support professionals, SCHIP and State Medicaid programs, unions, courts, and advocates for parents and children. These representatives committed themselves to work together to develop solutions that expand health care coverage for children and that are sensitive to the needs of all the stakeholders in the support enforcement arena.
Congress charged the Working Group with developing specific recommendations that address the six areas outlined below. The Working Group was charged with identifying impediments to effective enforcement of medical support by State agencies administering the programs operated pursuant to Part D of Title IV of the Social Security Act.
As the list above shows, the CSPIA legislation provided a very specific mandate for the Working Group. This mandate focused activities on improving the enforcement of medical support by State IV-D agencies and provided a list of specific issues that should be addressed by the Working Group's deliberations. The Working Group responded to this charge by framing their recommendations to improve medical support enforcement within the context of a broader vision.
This vision incorporated as its target population all 21 million children under age 19 potentially eligible for child support services, not just those currently receiving services through the IV-D system. State and Federal child support rules and activities affect children whose parents do not use the IV-D child support system as well as those who do. For example, a child support order established as part of a divorce action might be enforced in the IV-D system. It is also important to recognize that families move in and out of the public child support enforcement system. For instance, any parent not on welfare who applies for IV-D child support services can terminate receipt of those services at any time.
The Working Group concluded that "enforcement of medical support" required securing health care coverage for as many child support-eligible children as possible. This would include establishing medical support when private health coverage is available and appropriate, and securing public health care coverage when private coverage is not an option. Getting and maintaining health care coverage for all child support-eligible children was the ultimate mission of the Working Group's activities. (See Mission Statement of the Medical Child Support Working Group box.)
Mission Statement of the Medical Child Support Working GroupThe mission of the Medical Child Support Working Group is to identify and address impediments to the effective establishment and enforcement of medical child support and the successful promotion of health care coverage for children who are receiving or are eligible for child support enforcement services under Title IV Part D of the Social Security Act. Adopted by the Working Group May 12, 1999. |
The Working Group drew upon the expertise of its members, brought in outside speakers and experts, had access to staff at the Departments of HHS and Labor, shared research and policy papers and reports, and relied on the laws and policies that States have already developed and implemented in framing its recommendations. This Report presents an examination of expanding health care coverage for children from the perspectives and concerns of all the stakeholders, and offers recommendations that the Working Group believes will help expand health care coverage options for all 21 million children at special risk because of their family circumstances.
Overall, the Working Group agreed that although public family health coverage is increasingly available to children who do not have private coverage, child support orders should include-and the child support enforcement program should try to secure-appropriate private insurance whenever possible. This Report thus recommends reforms that will increase children's access to private insurance and will expedite processing of medical support orders. However, since private coverage is frequently unavailable or insufficient, this Report also recommends reforms that will improve the delivery of publicly-provided health care coverage.
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Chapter organization, as well as the "theme" of each chapter, is summarized below.
Chapter 1: Lack of Health Care Coverage - High Risk for Child Support-Eligible Children
Children who grow up in divorced, separated, or never-married families are at risk for not having health care coverage. Private health care coverage is highly related to income and many single-parent households have lower incomes than two-parent households. Even if income is not an issue, it is usually more difficult for parents to coordinate resource investment in their children when they live apart. Recognizing these risks, Congress established the Medical Child Support Working Group (the "Working Group") to make recommendations for improving health care coverage for children.
Chapter 2: Partnership for a New Medical Child Support Paradigm
The Medical Support Working Group offers a new paradigm for ensuring health care coverage for children. Many of the old notions of how to get children into coverage needed to be examined and discarded in light of the complex interplay of trends in health care, labor market characteristics, public program eligibility and participation, and family structure changes. The new paradigm looks to the private health care coverage resources available from both parents and to the availability of public health care coverage when private coverage is not available; it also gives the IV-D program responsibility for coordination of information between the providers of public and private health care and parents. Only by working in partnership will coverage be expanded and maintained.
Chapter 3: Taking the First Step: Establishing Health Care Coverage in Child Support Orders
The place to start reform is at the beginning, with order establishment. State child support guidelines are required to address how health care coverage will be provided, and it is important that each order include the health care coverage that is best for the child. The guidelines presented in this chapter lay out a matrix that directs the decision maker to consider the entire range of coverage options available to the child, including private coverage from either parent and, when appropriate, public coverage. In determining which coverage is best, the decision maker should consider not only availability, but other factors that influence the likelihood that the child will be appropriately and consistently insured, such as accessibility, comprehensiveness, and affordability. When the child is ordered into the appropriate coverage from the start, it will not only benefit the child, but will also reduce administrative and enforcement activity on the part of the IV-D agency, the insurer, and the parents.
Chapter 4: Implementing a New Tool: The National Medical Support Notice and Related Issues
The National Medical Support Notice is intended to provide a standardized means of communication between State child support enforcement agencies, employers, and administrators of group health plans regarding the medical support obligations of noncustodial parents. The Notice will facilitate the process of enrolling children in the group health plans for which their noncustodial parents are eligible. While the Notice that has been proposed would go a long way towards improving medical support enforcement, there are changes that can be made that will further simplify and streamline the process and make it less burdensome to all the parties involved. Steps also should be taken to make the Notice applicable to the Federal civilian and military health care plans.
Because circumstances of families change, orders often seem out of date before their provisions are even put into place. Sometimes orders have to be changed, but often the issues can be solved by having reasonable and realistic enforcement rules that help IV-D agencies and employers apply the provisions of award over time even though individual fact patterns have changed. This chapter includes recommendations for two of the most difficult enforcement issues-the Consumer Credit Protection Act limitation on wage garnishment and the Priority of Withholding-as well as recommendations for other enforcement issues.
Under the current system it is very easy for children to have periods in which no health care coverage is available. The extent to which this happens could be decreased by building feedback loops into the information flow between IV-D agencies and the public health care providers, Medicaid and SCHIP. Additionally, IV-D, Medicaid, and SCHIP agencies need to be working from a common understanding when obtaining private or public health care coverage or both are in the best interest of the child. IV-D should work with Medicaid and SCHIP, as well as with private insurers, to assure that the child is enrolled in appropriate health care coverage.
To improve the establishment, implementation, and enforcement of medical child support, the Working Group has made recommendations that will considerably enhance the responsibilities of child support enforcement agencies. IV-D agencies may need to undertake significant restructuring in order to incorporate new options, and new tools, into their core functions. Without sufficient resources, the Working Group's recommendations cannot be implemented and many of the identified barriers to medical child support enforcement will remain. This chapter lays out a Federal funding scheme to support, and ultimately reward, successful implementation of these recommendations by IV-D agencies.
Chapter 8: Shaping the Future: Strategies for Ensuring Ongoing Improvements
To give children the opportunity for health care coverage will require the development of new strategies that keep up with the changes in the labor force, health care, family structure, and public programs. Research and demonstration activities can help improve coordination of coverage, fill gaps, and identify new and better ways to get coverage to children. Collaborations within and among Federal and State agencies can help contain costs, identify problems, and make mid-course corrections. Like the old paradigm for Medical Support, the new ideas presented in this Report will become obsolete; knowledge development and coordinated efforts will keep our joint efforts relevant to changing conditions.
Chapter 9: Conclusion/Postscript
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[1] Hoffman, Catherine. Uninsured in America: A Chart Book. The Kaiser Commission on Medicaid and the Uninsured (June 1998), 40. See also Weissman, J.S., C. Gatonis, and A.M. Epstein. “Rates of Avoidable Hospitalization by Insurance Status in Massachusetts and Maryland.” JAMA (1992) 268: 2388-94.
[2] Child Health Facts: National and State Profiles of Coverage. The Kaiser Commission on Medicaid and the Uninsured, Figure 10. http://www.kff.org/content/archive/2105/childchart.html#fig10
[3] O’Brien, Ellen and Judith Feder. Employment-Based Health Insurance Coverage and Its Decline: The Growing Plight of Low-Wage Workers. The Kaiser Commission on Medicaid and the Uninsured (May 1999), 18. Also see Employment Based health Insurance: Medium and Large Employers Can Purchase Coverage, but Some Workers are Not Eligible, HEHS-98-184, General Accounting Office, Washington , D.C. 07/27/98.
[4] Employment Based health Insurance: Medium and Large Employers Can Purchase Coverage, but Some Workers are Not Eligible, GAO, HEHS-98-184, General Accounting Office, Washington, D.C. 07/27/98.
[5] Weinick, Robin and Alan C. Monheit. “Children’s Health Insurance and Family Structure.” Medical Care Research and Review, 56:1 (March 1999), 66.
[6] Doherty, William, Edward Kouneski, and Martha Farrell Erickson, Responsible Fatherhood: An Overview and Conceptual Framework, Report prepared for the Department of Health and Human Services under contract HHS-100-93-0012, Washington, D.C., 1993; Furstenberg, Frank and Andrew Cherlin, Divided Families, What happens to Children when Parents Part, Cambridge, Mass: Harvard University Press (1991); The Future of Children: Children and Divorce 4 (1), Spring 1994, Center for the Future of Children, The David and Lucille Packard Foundation; Weitzman, Lenore, The Divorce Revolution: The Unexpected Social and Economic Consequences for Women and Children in America, New York: The Free Press (1985).
[7] Weinick and Monheit, 56.
[8] U.S. Department of Commerce, Bureau of the Census. “Children Without Health Insurance.” Census Brief CENBR/98-1 (March 1998).
[9] Lyon, Matthew. “Characteristics of Families Using Title IV-D Services in 1995.” U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (May 1999), Table 1.
[10] Connecting with Your Kids: A Guide to Establishing, Modifying and Enforcing Parenting Time in Colorado, Denver: Colorado Foundation for Families and Children (1999).
[11] See APPENDIX D: Health Care Coverage for Child Support-Eligible Children, page A-32.
[12] In 1975, Congress created the child support enforcement program with the passage of Title IV-D of the Social Security Act, hence the reference to the “IV-D” program. This program provides a Federally-funded and State-administered system through which families may establish, enforce, and modify child support obligations, including medical support. Families receiving TANF benefits are required to cooperate with State or local officials to secure support for their children. Other parents may apply for these services. A more detailed discussion of the IV-D program and its responsibilities with regard to securing medical support is contained in Chapter 2.
[13] 42 U.S.C. §652(f)(1999).
[14] See data tabulations in APPENDIX D: Health Care Coverage for Child Support-Eligible Children, page A-32.
[15] Lyon (1999), Table 1.
[16] Child Support Enforcement/Absent Parent Medical Liability, Office of the Inspector General, Department of Health and Human Services (September 1987) and Coordination of Third Party Liability: Information Between Child Support Enforcement and Medicaid, Office of the Inspector General, Department of Health and Human Services (December 1989).
[17] Medical Support for Dependents Receiving Child Support, Office of the Inspector General, Department of Health and Human Services (forthcoming, June 2000).
[18] See data tabulations in APPENDIX D: Health Care Coverage for Child Support-Eligible Children, page A-32.
[19] Employment Based health Insurance: Medium and Large Employers Can Purchase Coverage, but Some Workers are Not Eligible, GAO, HEHS-98-184, General Accounting Office, Washington , D.C. 07/27/98.
[20] Review of Availability of Health Insurance for Title IV-D Children, A-01-97-02506, Office of the Inspector General, Department of Health and Human Services, Washington, D.C. (June 1998).
[21] 42 U.S.C. §§651 et seq. (1999).
[22] 42 U.S.C. §654 (1999).
[23] Wheaton, Laura, “Noncustodial Fathers: To What Extent Do They Have Access to Employment Based Health Care Coverage?” The Urban Institute (forthcoming, June 2000). Prepared under contract HHS-100-95-0021 for the Department of Health and Human Services.
[24] Pub. L. 105-200.
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