The Business Case for Protecting and Promoting Child and Adolescent HealthHealthcare Costs
In 2000, national healthcare expenditures for children and adolescents totaled $67 billion. Although
children with special health care needs make up less than 20% of the population, they account for
41% of all child health expenditures.^6 In fact, medical expenses for children with special needs are
over double the cost of children without chronic problems.^6
Unique Problems and Concerns
Children with special health care needs are an important part of an employer’s beneficiary population
because they:
• Experience complex, chronic, and severe health problems, which can be difficult to manage.
• Use more healthcare services than other children and thus have higher overall healthcare
expenditures.
• Experience more sick days and require additional office visits and hospitalizations than other
children, which results in lost productivity and absenteeism for their parents.
Healthcare Concerns
Access to adequate health care is critical for
families caring for a child with a special need.
By definition, CSHCN require healthcare
services of a different type, intensity, or scope
than their peers. Children with chronic
conditions enrolled in employer-sponsored
health coverage programs typically face
high deductibles and cost-sharing (due to
their increased service use). Many also face annual or lifetime limits on their benefits. Further,
many traditional employer plans use a definition of “medical necessity” that excludes treatment
for congenital anomalies, rehabilitation for developmental delays, and other services critical for
CSHCN.^109 These barriers prevent children with special needs from accessing necessary care. In
order to maximize the range of covered services and minimize out-of-pocket costs, some families of
CSHCN pursue a strategy of double coverage, or joint private-public coverage.^14
Work-Life Balance Concerns
Most employed parents worry at times about their children, and thus are sometimes less efficient on
the job. However, employed parents of children who are very ill or disabled deal with constant and
often intensive stress, both at work and at home. Such pressures can limit parents in their ability
to function at work. In extreme cases, parents may be forced to cut back their hours or leave the
workforce altogether in order to provide full-time care for their child.
Some of the stresses that cause parents to lose productive work-time, cut back on their hours, or
leave the workforce include the following^14 :
• Physically caring for a sick child, which can cause exhaustion, illness, and higher medical
claims.
• Worrying about the well-being of the child, which may result in a mental health problem
such as depression.
• Finding quality childcare services.
The Maternal and Child Health
Benefits Advisory Board developed a
new definition of “medical necessity”
that addresses the unique needs of
children, including those with special
needs. For more information, please
refer to the Plan Implementaion
Guidance Document in Part 2.