In my last post, I wrote that health care reform proposals need to focus on the patient side of the health care delivery system by designing systems that eliminate the cumbersome, even tortuous routes that patients must travel to enter that increasingly privileged space – a person with health insurance.
An illustrative example is the Qualified Medical Child Support Order (QMCSO). QMCSOs apply to those children who live with one parent but the court orders the other parent to provide the health insurance. The parent who has custody of the child is called, logically, the custodial parent. The other parent is called, can you guess, the non-custodial parent.
Every child support agency in every county and state in the country has a bureaucracy for the purpose of enforcing and administering QMCSOs. It does not matter why the parents are not together. Some are divorces, but some were never married. For a group of 25,000 Participants, my staff probably spends one to three days per month on issues related to QMCSOs.
Very little of that time is spent processing the paperwork. Most of it is dealing with custodial parents, non-custodial parents, child support agencies (issuing agencies in bureaucratese), carriers, attorneys and other stakeholders. In other words, our staff’s time is matched by someone else’s staff time. I did an extrapolation to the US population. It assumes our population is a representative sample of the general population. By my estimate, it is costing the United States economy $100,000,000.
Now by standards of the health economy that is not a lot of money. For example, to cover the uninsured you would need to add three more zeros to that number by some estimates. To build a hospital you could easily spend five times that amount. On the other hand, my estimate is conservative because I am counting only the time I see. I will not pretend to know how much time is spent by child support agency staffs, lawyers, judges, and other stakeholders in the process. How much time is lost to work as both sides of this parental equation battle this out away from work. Dare we pump that number up to a billion dollars? And let’s not forget the time invested by lobbyists, legislators, and regulators. A billion dollars may not be far fetched.
If you think, per chance, that I exaggerate this bureaucratic imbroglio visit the Department of Labor (DOL) web site on the subject. They list the following other stakeholders in the process:
- Employee Benefits Security Administration –
- Office of Child Support Enforcement –
- Centers for Medicare & Medicaid Services –
- National Child Support Enforcement Association –
- The Eastern Regional InterState Child Support Association (ERICSA) and the Western InterState Child Support Enforcement Council (WICSEC)
- Each State has a child support enforcement agency. Sometimes this agency is located in the State attorney general’s office, but it is frequently found as part of the State’s department of social or human services.
And what do we get for this billion dollars – eligibility to enroll a child in a health insurance plan. It does not include the cost of the actual coverage — only the cost to put the child’s name on the roster of eligible participants in a health plan. After that come the premium bills.
But wait, even that eligibility is circumscribed. Eligibility only if the non-custodial parent is eligible for health insurance; and can enroll children in the health insurance program; and meets the withholding limits established by the various states.
But here is the kicker. There is no requirement that the child, once enrolled, has effective coverage. More than half our membership is enrolled in HMOs. A child living with a custodial parent outside the service area of one of the HMOs effectively has no coverage. The non-custodial parent is not required to switch to a plan that would cover the child where he or she lives. Given the adversarial nature of these proceedings, it is not surprising that some non-custodial parents will make no effort to change their coverage for the benefit of the out-of-area child.
Fortunately, we find most non-custodial parents are eager to provide the coverage for their child. We have had situations where the custodial parent will not cooperate with our office in any way for fear that the non-custodial parent will learn more about the child, than the custodial parent is willing to reveal. And it is these sad and difficult situations that usurp the most staff time.
There has to be a better way. I endorse an eligibility system, what I am calling a patient delivery system, which is not tied to employment or to income. An eligibility system that is determined by membership in the community – however the political process wants to define that word community.