Advocating for the Ensuring Lasting Smiles Act (ELSA) to Cover of Congenital Anomalies

Editor’s note: The 14 ACS Advisory Councils, which serve as liaisons in the communication of information to and from surgical societies and the Regents, periodically submit articles on the notable initiatives taking place in their respective specialties. This week’s issue features a submission from the Advisory Council for Plastic and Maxillofacial Surgery.

Arun K. Gosain, MD, FACS, FAAP

Most private health plans provide coverage for the surgical treatment of congenital anomalies, and many states require that insurers provide coverage for any health services related to congenital anomalies or birth defects. Although crucial to the overall lasting success of treatment, health plans often deny claims and appeals for oral or dental-related procedures, claiming these services are cosmetic.

Furthermore, when private insurance denies a child’s reconstructive surgery, families often end up turning to Medicaid, the State Children's Health Insurance Program—insurance coverage for children whose families earn too much to qualify for Medicaid, but who cannot afford private coverage—or other state-sponsored programs for coverage.

To address this ongoing challenge, Senator Tammy Baldwin (D-WI) introduced the Ensuring Lasting Smiles Act (ELSA), requiring private insurers to provide comprehensive coverage for congenital anomalies to include surgical and other healthcare that is required to achieve optimal outcome for these deformities. The ACS, American Academy of Pediatrics, and numerous medical organizations have provided strong support for passage of ELSA. After introduction in the Senate, the bill was passed by the 117th Congress. Congress subsequently determined that the bill required modifications, and a reintroduced bill was referred to the Subcommittee on Health, where it remained and has yet to be reintroduced in the 118th Congress.

Passage of ELSA will alleviate financial hardship for people with congenital anomalies, ensuring they have continued support for medical and dental needs beyond childhood for the best long-term outcomes. The ACS and other national organizations must continue to work with legislators to re-introduce and pass ELSA in both the House and Senate during the 118th Congress.