S-1677-119
Committee on Health, Education, Labor, and Pensions. Hearings held.
Sponsored by Tammy Baldwin (D-WI)
What it does
This bill would require group health plans and individual health insurance issuers to cover outpatient and inpatient diagnosis and treatment for congenital anomalies or birth defects that primarily affect the eyes, ears, teeth, mouth, or jaw. Covered services would include reconstructive procedures, dental and orthodontic support from birth through completion of treatment, and follow-up care for secondary conditions. Cost-sharing (copays, deductibles, coinsurance) would be permitted, but only at levels no more restrictive than those applied to other medical and surgical benefits. The bill would take effect for plan years beginning on or after January 1, 2026, and would require HHS to report to Congress by December 31, 2027 on provider network adequacy and changes in patient out-of-pocket costs.
Who benefits
Children born with conditions such as cleft lip and palate, microtia (underdeveloped ears), anodontia (missing teeth), and other craniofacial anomalies — estimated to affect roughly 1 in 33 births in the U.S. (CDC). Their families, who currently may face large out-of-pocket costs when dental, orthodontic, or prosthodontic care is excluded from standard health plans. Reconstructive surgeons, oral surgeons, orthodontists, and prosthodontists who treat these conditions. Adults who were born with birth defects but whose treatment was incomplete or delayed. Insurers who gain regulatory clarity on what must be covered.
Who is hurt
Health insurers and self-insured employers who would bear new mandatory coverage costs, which may be passed on as modest premium increases across all enrollees. Small businesses offering group health plans that could face higher plan costs. Enrollees who do not have children with birth defects but may see incremental premium increases. Providers in areas with thin specialist networks may face increased demand they cannot meet. Grandfathered health plans, short-term limited-duration plans, and other coverage types not subject to the Public Health Service Act or ERISA mandates would not be required to comply, potentially leaving some enrollees without the new protections.
Supporters argue
Supporters argue that birth defects affecting the face, mouth, and jaw — such as cleft lip and palate, which affects roughly 7,000 U.S. births annually — require years of coordinated surgical, dental, and orthodontic care, yet many health plans exclude dental and orthodontic services even when they are medically necessary to treat the underlying defect. They contend this creates an arbitrary coverage gap that forces families to pay out of pocket for care that is functionally identical to covered reconstructive surgery. The bill's broad bipartisan sponsorship — including members from both parties across ideological lines — reflects consensus that denying coverage for medically necessary treatment of a condition a child was born with is inconsistent with how health insurance is supposed to work.
Opponents argue
Opponents argue that every new mandatory coverage requirement raises premiums for all enrollees, including those who will never use the benefit, and that Congress should allow insurers and employers to design benefit packages that reflect the needs and budgets of their specific populations. They contend that the bill's broad definition of "congenital anomaly or birth defect" — which includes conditions identified at any point in life and of unknown cause — could generate coverage disputes and litigation over what qualifies, increasing administrative costs. Critics may also argue that the bill does not address the underlying shortage of craniofacial specialists in rural and underserved areas, meaning mandated coverage may not translate into actual access to care.
Constitutional context
Congress regulates group health plans and insurance markets through the Commerce Clause (Art. I, §8, cl. 3) and the Taxing and Spending Clause (Art. I, §8, cl. 1), the same authority used to enact the ACA and ERISA mandates. NFIB v. Sebelius (2012) affirmed broad congressional authority to regulate existing commercial activity in insurance markets. Post-Loper Bright (2024), any HHS regulations implementing the bill's notice and network adequacy provisions would face independent judicial review rather than automatic deference.
Checks and balances
Congress gains authority to mandate a new insurance benefit; HHS and the Departments of Labor and Treasury share implementation and enforcement authority across their respective jurisdictions; courts retain review power over agency regulations under the post-Loper Bright independent judgment standard.
Historical precedent
The Women's Health and Cancer Rights Act of 1998 established a directly analogous federal mandate requiring group health plans to cover reconstructive surgery following mastectomy, including procedures on the other breast to achieve symmetrical appearance — the same logic of requiring coverage for medically necessary reconstruction of a body part.