Ensuring Lasting Smiles Act: A Necessary Step for Healthcare Reform

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It is fundamentally unreasonable that insurers can label surgeries required for essential functions in children, like eating or breathing, as merely cosmetic. This issue has persisted for years. However, the Ensuring Lasting Smiles Act (ELSA) presents a congressional solution. ELSA aims to ensure that children and adults born with facial conditions such as cleft lip or cleft palate receive the necessary medical care, countering wrongful insurance denials that often lead families to incur exorbitant costs.

Despite existing laws like ‘Wendolyn’s Law’ in Arkansas, patients still face insurance hurdles. Approximately 4% of U.S. children are born with congenital anomalies affecting basic functions like swallowing, chewing, breathing, and hearing, yet insurance denials persist against state regulations. One in every 1,000 U.S. births involves cleft lip or palate. Despite being less common than congenital heart defects, children with craniofacial conditions frequently encounter coverage denials, even post-procedure.

Imagine insurers claiming pediatric heart surgery as unnecessary. ELSA addresses coverage for medically necessary interventions, ensuring surgeries to restore functions like chewing and swallowing are classified correctly. Insurers often misallocate coverage to dental insurance, leading to further denials. Expert teams affirm medical necessity, yet insurers sometimes reject claims, reviewed by non-specialized family physicians instead of qualified experts.

Insurance debates over a child’s health and facial structure are unwarranted. Assistance requests flood nonprofits nationwide, highlighting stories from diverse families and affiliations. Tales include denied coverage for crucial secondary bone graft surgeries or children experiencing breathing issues and social ridicule due to untreated cleft defects.

ELSA garners widespread bipartisan support. Over 70 societies and patient groups, including Senators Tammy Baldwin and Joni Ernst, and Representatives Neal Dunn, M.D., and Kim Schrier, M.D., advocate for this act. ELSA is not disputed; it is vital. Children undergo numerous procedures, none cosmetic, to address congenital issues. Without timely care, they risk enduring physical and psychological harm.

Congress must act to pass ELSA, preventing financial distress and supporting children deserving healthy lives. Adam Levy is the executive director of the American Cleft Palate Craniofacial Association. He represents a leading network for healthcare providers treating cleft and craniofacial differences.