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Te Aordable Care AcA side-by-side comparison omajor provisions and theimplications or children andyouth with special health care

needs

UNIVERSAL AND CONTINUOUS COVERAGE

AFFORDABLE COVERAGE

ADEQUATE COVERAGE


2/162 UNIVERSAL AND CONTINUOUS | ADEQUATE | AFFORDABLE COVERAGE

CONTENTS

Introduction ..................................................................................................3

Provisions Related to Universal and Continuous Coverage ....................................4

Provisions Related to Adequate Coverage ..........................................................7

Provisions Related to Aordable Coverage .........................................................9

Additional Provisions o Interest ....................................................................11

A Few Denitions .........................................................................................12

Conclusion ..................................................................................................13

Sources and Selected Resources ...................................................................14

Charts

Distribution o Insurance Coverage or Children and Youth withSpecial Health Care Needs (CYSHCN) .............................................................6

Adequacy o Coverage or CYSHCN ................................................................10

CYSHCN Whose Families Pay $1,000 or More Out o Pocket... ........................12

CYSHCN Whose Conditions Cause Financial Problems or Their Family .............13


3/163UNIVERSAL AND CONTINUOUS | ADEQUATE | AFFORDABLE COVERAGE

INTRODUCTIONWho are children and youth with

special health care needs

(CYSHCN)?

According to the ederal

Maternal and Child Health

Bureau, CYSHCN have or are at

increased risk or a chronic

physical, developmental,

behavioral, or emotional condition

and also require health and

related services o a type oramount ar greater than required

by children generally.3 The

National Survey o CSHCN reports

that there are 10.2 million

CYSHCN or 13.8% o the

U.S. population under age 17.4

Children and youth with special health care needs(CYSHCN) require health care coverage that is universal and

continuous, adequate and afordable. However, there aremajor gaps in the current system o health care coverage andnancing that cause signicant problems or CYSHCN inaccessing care and nancial hardship or their amilies.According to the National Survey o Children with SpecialHealth Care Needs, over a third o insured amilies reporttheir childs coverage is inadequate to pay or the services theyneed and 18% say their childs health condition has causedtheir amily nancial problems.1 In 2008, over 20,000 healthinsurance policies in the individual market were denied tochildren based on pre-existing conditions, and over 18,000

were issued but had restrictions on covered benets or thesame reason.2

Te Patient Protection and Aordable Care Act (ACA),signed into law on March 23, 2010, oers opportunities toclose these gaps or CYSHCN. Tis brie oers a concisedescription o many o the provisions in the ACA along witha side-by-side analysis o their implications or CYSHCN.

1U.S. Department of Health and Human Services, Health Resources and Ser-

vices Administration, Maternal and Child Health Bureau. The National Survey

of Children with Special Health Care Needs Chartbook 20052006.

Rockville, Maryland: U.S. Department of Health and Human Services, 2008.

2Americas Health Insurance Plans Center for Policy and Research.

Individual Health Insurance, 2009: A Comprehensive Survey of Premiums,

Availability and Benefts. Washington, DC, October 2009. Retrieved online

2/2/11 from http://www.ahipresearch.org/pdfs/

2009IndividualMarketSurveyFinalReport.pdf

3McPherson, M, et al. A new defnition o childrenwith special health care needs. Elk Grove Village, IL:Pediatrics, 1998,102: 137-140

4U.S. Department o Health and Human Services,Health Resources and Services Administration, Ma-ternal and Child Health Bureau. The National Surveyo Children with Special Health Care Needs Chartbook

20052006. Rockville, Maryland: U.S. Department oHealth and Human Services, 2008.



PROVISIONS RELATED TO UNIVERSALAND

CONTINUOUS COVERAGE

Aordable Care Act Provision Details Implications

Pre-existing conditions

Section 1201/2704*

Eective plan/policy years begin-ning ater September 23, 2010

This provision prohibits privateinsurance companies rom denyingor limiting coverage to children un-der age 19 based on a pre-existingcondition.

Grandathered individual plans areexempt.

This provision will aectthousands o CYSHCN. In 2008more than 20,000 applications orchildrens coverage were denieddue to pre-existing conditions.

Pre-existing Condition Insurance

Plans (PCIP)

Section 1101

Eective July 1, 2010

A new coverage option or unin-sured youth and adults with pre-existing conditions. To be eligibleor coverage a person must: Be uninsured for at least six

months. Have had a problem getting

insurance due to a pre-existingcondition

This is a transitional benet avail-able through Jan. 1, 2014 whenthe ban on pre-existing conditionexclusions or limits goes into e-ect or adults.

Extension o coverage or young

adults on their parents policy

to age 26

Section 1001/2714*


Eligibility: The parent must be enrolled in a

amily or dependent plan (ratherthan an individual plan).

Parents must be allowed to

switch coverage rom an individ-ual to a amily plan i available.

Includes self-insured plans. In grandfathered plans, the

young adult must not have ac-cess to their own employer-spon-sored insurance (until January2014, then the provision appliesto anyone under age 26).

A major benet or CYSHCN tran-sitioning rom pediatric to adulthealth care systems who are noteligible or Medicaid.

This will not help some CYSHCNi insurance companies continue

to deny policies or limit benetsbased on a pre-existing condi-tion until January 1, 2014, whenSection 2704 goes into eect oradults.

*Where two or more sections are noted with / separating them, the rst reers to the Aordable Care Act (ACA) section and thesecond to the Public Health Service Act (PHSA) section. Amendments to any other existing legislation are noted within the text.



PROVISIONS RELATED TO UNIVERSAL AND CONTINUOUS COVERAGE (cont.)


Extension o Medicaid coverage or

ormer oster children to age 26

Section 2004Eective January 1, 2014.

States must continue providingMedicaid coverage to children whohave aged out o the oster caresystem but who are under age 26.

A major benet or CYSHCN in theoster care system transitioningrom pediatric to adult health caresystems.

Coverage rescission


Insurance companies cannot dropcoverage because o a mistake orinadvertent omission on an ap-plication. This provision applies toallhealth plans, including grand-athered plans, except in cases oraud.

Previously insurers could drop cov-erage ater a costly episode o careby nding a mistake on the ap-plication. This could be retroactiveto the beginning o the policy andcreate major nancial hardship.

Guaranteed issue and guaranteed

renewal

Sections 1201/2702 and 2703*

Eective January 1, 2014

A new policy must be issued andan existing policy must be renewedor anyone who meets the criteriaor coverage, regardless o healthstatus, age, gender, etc., except incases o raud.

Grandathered individual andgroup plans are exempt.

This prohibits denial o coverage ornon-renewal o coverage based onhealth status or high utilization ohealth care services.

Individual mandate to obtain

coverage

Section 1501


Individuals must have qualiedhealth coverage to avoid penal-ties under the individual mandate.Coverage that is considered quali-ed includes: A government-sponsored health

plan such as Medicare, Med-icaid, the Childrens HealthInsurance Program (CHIP) orTRICARE

Employer-based coverage, a planthat an individual or amilyreceives through an employer,including through the Exchanges

Individual coverage, a plan pur-chased in the individual insur-ance market, including throughthe Exchanges.

The requirement or individualcoverage helps spread the risk oinsurance across the population.Without this requirement, thereis concern that only those withknown health care needs wouldpurchase coverage, resulting inhigher than expected costs orhealth plans participating in theExchanges and threatening theirnancial stability.

Maintenance o Eort or Medicaid

and CHIP

Section 2001(b)

Eective March 23, 2010

States cannot reduce eligibilitylevels or make enrollment/renewalmore dicult or children in Med-icaid or CHIP through Sept. 20,2019. They canexpand eligibility.

This protection preserves the prog-ress made by states in expandingcoverage or children over the pastdecade and more.




PROVISIONS RELATED TO UNIVERSAL AND CONTINUOUS COVERAGE (cont.)


Eligibility simplifcation

Section 2002


State-determined income criteriaor Medicaid and CHIP are re-placed with a national standard:the Modied Adjusted GrossIncome (MAGI). A standard 5% oincome will be disregarded. Thisincome standard will also be usedas the test or subsidized coveragein the Exchanges.

Pros: This will level the playingeld across states in terms oeligibility or public coverage, andwill acilitate transitions betweenMedicaid, CHIP and the Exchangeplans.

Cons: CYSHCN who are eligibleor Medicaid based on criteriaother than income (or example,through a waiver, buy-in program,spend-down, etc.) may get lost inthe eort to streamline eligibilitysystems.

Coordination between Medicaid,

CHIP and the Exchanges in

determining eligibilitySection 1413


A single, simplied orm willscreen all applicants or eligibility

in the Medicaid and CHIP pro-grams and or premium tax creditsthrough the Exchanges and thenreer applicants to the program orwhich they qualiy.

This is important because chil-drens eligibility or dierent

programs may fuctuate due tochanges in their parents incomeand employment status. An im-portant renement to this provisionor CYSHCN would be to includedisability determination in theeligibility screening process, sincedisability is a pathway to manypublic benet programs.

UNIVERSAL AND CONTINUOUS | ADEQUATE | AFFORDABLE COVERAGE

U.S. Department of Health and Human Services, Health Resources and Services Adminis-

tration, Maternal and Child Health Bureau, The National Survey of Children with Special

Health Care Needs Chartbook2005-2006. Rockville, Maryland: U.S. Department of

Health and Human Services, 2008.

Private

UninsuredDual private/public

Public



PROVISIONS RELATED TO ADEQUATE COVERAGE


Essential benefts

Section 1302


Health plans must cover theseessential benets: Ambulatory patient services

Emergency services

Hospitalization

Laboratory services

Maternity and newborn care

Pediatric services, including oral

and vision care Preventative and wellness

services, and chronic diseasemanagement

Rehabilitative and habilitative

services and devices

Prescription drugs Mental health and substance

abuse services


Many o these benets are vitallyimportant to CYSHCN and some

are not currently covered in manyprivate sector plans.

The exact denition, duration andscope o benets in each o thesebroad categories is yet to be deter-mined by the U.S. Department oHealth and Human Services.

Removal o annual and lietime

beneft caps or children and adultsSection 1001/2711*

Eective September 23, 2010 orlietime benet caps and annualbenet caps under $750,000Eective January 1, 2014 or noannual benet caps

Insurance companies cannotimpose a lietime benet cap oran annual benet cap o less than$750,000. In 2014, no restric-tive annual benet caps will beallowed. Individuals who were

previously disenrolled rom a planbecause they met their lietimelimit are allowed to re-enroll i theyare still eligible. Applies to sel-unded plans.

Grandathered individual plans areexempt.

A step in the right direction orCYSHCN, but a potential missedopportunity to reduce underinsur-ance. Insurers can still cap beneftsthemselves (20 physical therapysessions per calendar year, or

example)




PROVISIONS RELATED TO ADEQUATE COVERAGE (cont.)


Medicaid coverage expansion up to

133% o the ederal poverty level

(FPL)

Section 2004


Medicaid eligibility will be ex-panded to anyone whose incomeis under 133% o the FPL, in-cluding low-income youth withspecial health care needs as theytransition to young adulthood,regardless o amily or disabilitystatus. Children in amilies withincome under 133% o FPL whoare enrolled in CHIP will switch toMedicaid coverage.

In states where CHIP is operatedseparately rom Medicaid,CYSHCN who are now eligible orMedicaid will gain access toMedicaids more generouscoverage under Early PeriodicScreening, Diagnosis, andTreatment (EPSDT).

Changes in hospice care or children

enrolled in Medicaid

Section 2302

Eective March 23, 2010

This provision allows both cura-tive and hospice care, also calledconcurrent care, to be oered atthe same time.

Previously, amilies had to de-cide to end curative care or theirchildren enrolled in Medicaid (andsome CHIP programs) beore theycould access hospice benets.

Now amilies do not need to ter-minate curative care to receive thesupports provided under hospice.

Health homes or chronic conditions

Section 2703


States can receive a higher ederalmatch or their Medicaid expensesi they amend their state plansto cover health home servicessuch as care coordination, healthpromotion, patient and amily sup-port and reerrals to communityand social services. Health homeenrollees must have one or more

selected chronic conditions suchas mental illness, substance usedisorders, asthma, diabetes, heartdisease, or being overweight.

Currently, this provision appearsto be more ocused on adults withchronic illnesses. However, thereis no age limit specied withinit and the Secretary o the U.S.Department o Health and HumanServices (HHS) may add to the listo chronic conditions that qualiyindividuals or health homes.

Medicaid primary care rate

increases

Section 1202 o the Health Careand Education Reconciliation Act(H.R. 4872)

Eective 2013 and 2014

The ACA provides enhanced Med-icaid payments or primary careservices, including those providedby pediatricians, o no less than100% o the Medicare rate.

This increase is intended to im-prove the participation o primarycare providers in Medicaid, thusexpanding access to care.




PROVISIONS RELATED TO AFFORDABLE COVERAGE


Premium Tax Credits

Section 1401


Families with incomes up to 400%o the FPL are eligible or premium

tax credits on a sliding-ee scalewhen they purchase coveragethrough the Exchanges.

A three-person amily making$24,000/year (just over 133%

o the FPL) can buy an insurancepolicy costing $11,500. Theirtax credit is $10,768, making thecost o the policy $732, or 3% otheir income.

Cost-sharing subsidies

Section 1402


Families with incomes under250% o the FPL are eligible orcost-sharing subsidies that reducethe cost o copayments, coinsur-ance and deductibles on a sliding-ee scale. They must purchasea silver category o coverage,

meaning that the plan covers, onaverage, 70% o the costs o careand the member pays the rest.

Cost-Sharing Subsidies

Family IncomePlan-Covered

Expenses

Up to 150% FPL 94%

151 - 200% FPL 87%

201 - 250% FPL 73%

Limits on out-o-pocket expenditures

Section 1402


Out-o-pocket expenditures arelimited to $11,900 in 2010 dol-lars (subject to change each year)or amily coverage.

In addition, amilies with incomesunder 400% o FPL who purchasesilver plans under the Exchangeswill have additional limits on theirout-o-pocket expenditures.


Out-o-Pocket Limits in

Silver Exchange Plans

Family IncomeOut-o-Pocket

Limit

Up to 200% FPL $3,927

201 - 300% FPL $5,950

301 - 400% FPL $7,973



PROVISIONS RELATED TO AFFORDABLE COVERAGE (cont.)


Help in understanding costs and

coverage

Section 1311


Exchanges must provide a calcula-tor to help individuals determinethe value o any credits or sub-sidies and the ultimate cost ocoverage

This calculator will enable com-parisons o both the benets andcost o coverage across plans.

Well-child visits and preventive

services without cost sharing as part

o coverageSection 1001/2713*

Eective September 23, 2010 ornew plans

New plansmust cover the ollowingwithoutcost sharing (e.g., copays): Preventive care/screening based

on Bright Futures,(http://www.brightutures.org )

Additional preventive care/

screening based on the U.S.Preventive Services Task Force(http://www.ahrq.gov/clinic/tchildcat.htm)

Immunizations recommended by

the Centers or Disease Controland Prevention (http://www.cdc.gov/vaccines/pubs/ACIP-list.htm)


This provision is designed toimprove the aordability o preven-tive care and promote its use.



U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau, The National Survey of Children with Special Health Care

Needs Chartbook2005-2006. Rockville, Maryland: U.S. Department of Health and Human

Services, 2008.

AdequateInadequate



Continued unding or state-based Family-to-Family

Health Inormation Centers (F2F HICs)

Section 5507Te ACA provided $5 million to continue unding orthe Family-to-Family Health Inormation Centers ineach state and the District o Columbia. Tese ad-ditional unds are authorized through 2012 and areadministered by the Maternal and Child Health Bureau(MCHB) o the Health Resources and Services Ad-ministration (HRSA), U.S. Department o Health andHuman Services.

Led and staed by experienced amily members o

CYSHCN, these centers provide an important resourceor help in navigating the state-specic system o cover-age and health care nancing by providing outreach,

peer support, and benets counseling.

ADDITIONAL PROVISIONS OF INTEREST

Creation o the Center or Medicare and

Medicaid Innovation

Section 3021Established under the ACA, the new Center orMedicare and Medicaid Innovation (CMI) will ocuson identiying and testing ways to enhance healthcare quality, improve the health outcomes o indi-

viduals and communities and reduce costs throughimprovements. A total o $10 billion dollars hasbeen appropriated to CMI between 2011 and 2019,

with at least $25 million designated each year or thedesign, implementation and evaluation o modelsthat achieve these goals.

Less than $1,000$1,000 or more


Maternal and Child Health Bureau, The National Survey of Children with Special Health Care Needs

Chartbook2005-2006. Rockville, Maryland: U.S. Department of Health and Human Services, 2008.



A FEW DEFINITIONSWhat is a plan/policy year?

While a ew o the provisions in the ACA went intoeect immediately, most are scheduled to roll out overtime and become eective on a variety o dates. Sep-tember 23, 2010 is an eective date that appears re-quently in the initial set o provisions; it is six monthsto the day ollowing the signing o the health carereorm bill into law. However, the majority o provi-sions associated with that date do not go into eective

precisely on September 23; they go into eect when anindividuals plan or policy year begins aer that date.For example, i your plan year begins on June 1, provi-sions that go into eect or plan or policy years begin-

ning aer September 23, 2010 will not take eect untilJune 1, 2011, when your new plan year begins.

Whats the dierence between a plan and a

policy year?

Plans cover people in large groups, such as those whowork or the same employer. Plans tend to renewat the same time each year or the whole group theycover, regardless o when an individual person enrolls.Policies cover individuals or individual amilies, andthey can renew at various times, depending on when

the policy was purchased and what was written intoit with regard to the renewal date. An awareness o

which provisions actually go into eect when will beimportant or analyzing the impact o the ACA onCYSHCN over time, monitoring compliance, ad-

vocating eectively or improvements to the law andproviding accurate benets counseling to amilies.

What is a grandathered plan?

Plans in the individual and group markets that werein eect on March 23, 2010, the day the ACA wassigned into law, are called grandathered plans andthey are rozen in time or exempt rom many, butnot all, o the provisions in the ACA as long as theykeep their grandathered status. Grandatheredstatus was a compromise implemented in an eortto reassure those who did not want to change any-thing about their existing coverage. A plan can loseits grandathered status and become subject to ACA

provisions by making major changes, such as signi-cantly raising premiums or reducing benets. For de-

tails on what constitutes signicant changes, see theederal Departments o reasury, Labor and Healthand Human Services interim nal regulations at:http://rwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2010_register&docid=DOCID:r17jn10-25.pd

Grandathering has important implications orCYSHCN. It is estimated that approximately 80%o people with employer-sponsored insurance will bein grandathered plans in 2011. Because the majority

o CYSHCN currently get their health care cover-age rom employer-sponsored insurance that will begrandathered or rom sel-insured plans, manyACA provisions will not apply to them. An aware-ness o which provisions have grandathering exemp-tions associated with them will be important oranalyzing the impact o the ACA on CYSHCN overtime, monitoring compliance, advocating eectivelyor improvements to the law and providing accuratebenets counseling to amilies.



While there is much to celebrate in the passage o theACA, the work in ensuring that CYSHCN have accessto coverage that is universal and continuous,adequate and afordable is not yet done. Tere areseveral provisions, particularly in the area o consumer

protection, that hold signicant potential or meetingthis goal. However, there are also some limitations,

primarily in the exemption o large-group, grand-athered and sel-unded plans (where the majorityo CYSHCN get their coverage) rom the EssentialBenets requirement. In addition, the ACA wasdesigned with the primary goal o expanding cover-age or the general population. Whether it will also

have a positive impact on reducing underinsurance orCYSHCN, the challenge the majority o them ace, isstill unknown.

CONCLUSIONAs the ederal regulations, guidance and claricationsto this historical legislation are being developed and

written and amendments to the ACA to improve gaps

in it or CYSHCN are possible, state agency sta andpolicymakers, child health advocates, clinicians, ami-lies and others interested in the health and well-beingo children in general and CYSHCN in particularmust be well inormed about the details o the various

provisions and the opportunities and limitations oeach. Only then can we be best prepared to eectivelyensure that CYSHCN have access to coverage or thecare they deserve so that they can learn, play and growto their ullest potential.


Maternal and Child Health Bureau, The National Survey of Children with Special Health Care Needs

Chartbook2005-2006. Rockville, Maryland: U.S. Department of Health and Human Services, 2008.

No nancial problemsFinancial problems



SOURCES AND SELECTED RESOURCES

The Patient Protection and Aordable Care Act o

2010 (Public Law 111-148)

http://www.healthcare.gov/center/authorities/patient_protection_aordable_care_act_as_passed.pdTis URL brings the user to the ull text o theACA legislation.

The Catalyst Center at the Boston University

School o Public Health

Te Catalyst Center is unded by the ederal Mater-nal and Child Health Bureau, Health Resources andServices Administration, Department o Health and

Human Services to serve as the national center onimproving nancing o care or children and youth

with special health care needs. We create publicationsand products, answer technical-assistance questions,research innovative state-based nancing strategies,guide stakeholders to outside resources, and connectthose interested in working together to address com-

plex health care nancing issues. See the Publicationsand More section o our website athttp://hdwg.org/catalyst/publicationsor more resources on health care reorm, including:

Presentation:National Health Care Reorm: WhatDoes it Mean to Massachusetts Children with SpecialHealth Care Needs? (October, 2010)

Fact Sheet:Health Care Reorm: Whats in it or Chil-dren and Youth with Special Health Care Needs?(A joint publication o Catalyst Center and As-sociation o Maternal and Child Health Programs)(October, 2010)

Presentation:Essential Elements o Health CareReorm or CYSHCN: Looking to the Future: Op-portunities and Challenges in Health Reorm or MCH(October, 2010)

Policy Paper: Te Afordable Care Act and Childrenwith Special Health Care Needs: An Analysis andSteps or State Policymakers(A publication by the National Academy or StateHealth Policy (NASHP, http://www.nashp.org)or the Catalyst Center) ( January 2011)

Archived Webcast: Te Afordable Care Act andChildren with Special Health Care Needs(associated with the above NASHP publication)(January 2011)

In addition to these materials, the Catalyst CenterWeek in Reiew oers a compilation o media itemsrelated to coverage and nancing o care orCYSHCN in general and ACA news in particular.Our monthly e-newsletter, Catalyst CenterCoverage, eatures more in-depth news and analysis,links to resources and original articles on related top-ics o interest. Sign up to receive both by providing

your e-mail in the eld in the upper right corner oour homepage at:http://www.catalystctr.org

Maternal and Child Health Bureau, Health

Resources and Services Administration, U.S.

Department o Health and Human Services

Inormation on the itle V Maternal and ChildHealth Services Block Grant and other related

programs and eorts is at:http://www.mchb.hrsa.gov

The Family-to-Family Health Inormation Centers

(F2F HICs)

Led and staed by experienced amily members oCYSHCN, the F2F HICs are an important resourceor help in navigating the complex system o cover-age and nancing in each state and the District oColumbia. For more inormation or to nd the F2FHIC in a specic state please visit the Family Voices

website:http://www.amilyvoices.org/page?id=0034



Association o Maternal and Child Health

Programs

Additional inormation covering key aspectso the ACA that pertain to maternal and childhealth populations is at:http://www.amchp.org/Advocacy/health-

reorm/Pages/deault.aspx

www.healthcare.gov

Te ofcial ederal website on the AordableCare Act rom the U.S. Department o Healthand Human Services includes easy-to-read de-scriptions o specic provisions related to theACA, along with a helpul glossary o relatedterms and links to other ederal resources.

Georgetown Center or Children and Families: Health

Reorm Implementation Center

Friendly and accessible expert policy analysis and opinion,written with a specic ocus on topics important to children,amilies and those who care about them. Sign up or CCFsSay Ahh!blog to keep up-to-date on the latest developmentsin health care reorm implementation or kids.http://cc.georgetown.edu/index/hcr

InsureKidsNow.gov

o nd state-specic inormation about Medicaid and CHIPprograms, use the map at :http://www.InsureKidsNow.gov/state/

Acknowledgments

Te authors wish to thank Catherine Hess, Kathleen Farrell,Diane Justice and Jennier Dolatshahi with the NationalAcademy or State Health Policy (NASHP) and SarahDeLeone, ormerly with NASHP and now with the Centersor Medicare and Medicaid Services or the work in develop-ing much o the original content or this brie, published inthe policy paper: Te Afordable Care Act and Children withSpecial Health Care Needs: An Analysis and Steps or State

Policymakers (A publication by the National Academy or

State Health Policy or the Catalyst Center) ( January 2011),available or download athttp://aca.catalystctr.org

We would also like to thank Lynda Honberg, MCHB ProjectOfcer, or her thoughtul contributions and ongoingsupport o the Catalyst Centers work on improvingcoverage and nancing o care or children and youth withspecial health care needs.

Tis work was made possible with supportrom the Maternal & Child Health Bureau,Health Resources and Services Administra-tion, U.S. Department o Health andHuman Services, under cooperative agreement#U41MC13618. Te contents o this publica-tion are solely the responsibility o the authorsand do not necessarily represent the views othe unding agencies or the U.S. government.

February 2011


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Health & Disability Working GroupBoston University School o Public Health715 Albany StreetBoston, MA 02118617.638.1936www.catalystctr.org

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