Federal government can play big role in improving vision coveragefor kids

Baltimore-Although vision screening is a state issue and not legislated by the federal government, there are many ways the federal government can influence medical care delivery for children.

Some examples include care for the uninsured, payments through medical assistance programs and the State Children's Health Insurance Program (SCHIP), legislative mandates, and policy objectives of the U.S. Department of Health and Human Services (HHS).

"The additional 7.5% of patients whose insurance is discontinuous are often forgotten. But the good news, if you will, is that the proportion of children who are not covered is only about half that rate for patients between 18 and 65, largely because of federal programs," Dr. Repka said.

Program coverage

Some of the factors leading to children in America having unmet health-care needs are being uninsured, including having only partial-year coverage, or being poor, even with coverage. Some gaps in coverage are filled by Medicaid, which is largely controlled at the state level with little federal involvement.

"Budgets have become very stretched and coverage is becoming a target for the bureaucracy to improve its cost-to-expenditure ratio," Dr. Repka said.

At any given time, approximately 23 million children are covered under Medicaid. Annual Medicaid spending in fiscal year 2003 was $266 billion, although the amount spent on children's medical care was only about one-sixth of that total.

"Children's eye care is a relatively inexpensive item, perhaps the bargain in this program," Dr. Repka said.

A proportion of Medicaid funding is allocated to blind and disabled people, but this money is largely spent on older patients.

Those deficits have led to promotion of the Medicaid State Waiver Program through which states can propose programs that improve their flexibility. In general, this program allows states to restrict the coverage given to Medicaid beneficiaries, Dr. Repka said. In addition, the deficits lead to reduced funding of programs to cover the uninsured.

"What the states get from participating in the waiver program is money in a block grant; the federal government loses control of how that money is distributed and where it goes in the state programs. That is something that everybody has to look at on an individual-state basis," Dr. Repka said.

The SCHIP program, which is known by various names in different jurisdictions, began in October 1997 to help states expand health-care coverage to uninsured children. It is available in some form in all 50 states and the District of Columbia, and each state sets its own guidelines regarding eligibility and service.

SCHIP covers well and sick care for children up to age 19; vision care is optional but generally an included benefit. The program has an annual budget of about $6 billion.

"The biggest problem for beneficiaries and payers is that within any given year, patients enter and leave this program," Dr. Repka said. "For instance in the first quarter of 2005, there were only 3.8 million lives covered, yet over the course of fiscal year 2004, 5.8 million distinct individuals went through this program. It is a huge hassle for our practices and I assume for the intermediaries who are handling this program."