Health Insurers Increasingly Prevent Care for Children, New Congressional Report Finds

One of the most important Capitol Hill initiatives around health care is House Energy and Commerce Committee Ranking Member Frank Pallone’s ongoing investigation into aggressive prior authorization used by health insurance companies. Prior authorization is a slippery practice, and when doctors are forced to get approval from an insurer before treating their patients and get a denial, many patients sadly accept the outcome and do not appeal, often putting their lives in jeopardy. It is commendable, therefore, that Pallone has dedicated resources to unpacking this practice, in detail, to ultimately create legislative remedies that will prohibit insurers from using prior authorization to prevent necessary care. 

As final findings take shape, Pallone has issued a report that is worthy of special attention. Those who know my story know Cigna’s refusal to pay for Nataline Sarkisan’s care played a major role in my decision to leave Big Insurance. It is especially sickening, then, to hear that poor children are now being prevented from accessing the most basic, fundamental kinds of care in our system.

Read the Government Accountability Office’s report titled Managed Care Plans’ Prior Authorization Decisions for Children Need Additional Oversight.

The Government Accountability Office found private insurers that manage state Medicaid plans do not share a standard for prior authorization of preventive and diagnostic treatment for children. Medicaid has a specific “Early and Periodic Screening, Diagnostic, and Treatment” benefit requirement to ensure that kids’ health issues are identified early, which is essential to improving outcomes and lowering overall system costs. 

The GAO found that in several states, insurers are inconsistent in how they approve – and often deny – coverage for early screenings and treatments for children. The long-term impacts of this practice are hard to quantify, though surely, children in low-income families across the country are not getting routine, preventive care that is so valuable to young patients, both now and later in their lives. 

In their earnestness to deploy prior authorization as widely as possible, GAO found that while states do not have regulations requiring pre-approval for these preventive tests and procedures, insurers still mandate prior authorization. One of the report’s recommendations – which I hope we can all agree is not controversial – is for the Centers for Medicare and Medicaid Services to examine whether insurers can even require prior authorization for this care when no federal or state regulations and coverage guidelines say such a step is required.

Keep in mind that these big insurers are the same ones that also use prior authorization aggressively in the Medicare replacement plans they market as Medicare Advantage. By contrast, prior authorization is exceedingly rare in the traditional Medicare program. 

HEALTH CARE un-covered will continue to monitor this congressional inquiry, particularly including findings where public programs like Medicaid and Medicare are being cannibalized by insurers to maximize profit and prevent care for patients.