July 2009 Archives

This week there was a lot of back-and-forth on health reform as both the House and Senate attempted to get a bill to the floor before the now infamous August recess (which for those of you not up on the Congressional calendar is August 1st to September 8th in the House and August 10th to September 7th in the Senate). While that self-imposed deadline was not met (due to issues generally not related to kids), there was significant advancement of health reform legislation this week.  

In the House, the Energy and Commerce Committee is finalizing mark-up of its health reform bill after reaching agreements with "Blue Dog" Democrats and others on, among other things, reimbursement rates in the public plan and Medicare payments to rural hospitals. Once the bill passes out of Energy and Commerce it will be merged with the versions passed by the other House Committees and should be brought to the floor for a vote in September.

The amendments have been flying and continue to do so even as I write this blog. But here are some highlights of amendments so far affecting children and families:

• An amendment by Reps. McNerney (D-CA) and Murphy (R-PA) was approved prohibiting states from establishing enrollment waiting periods for children in CHIP who: are under age 2, have lost employer health insurance, or have only unaffordable coverage options (defined as costs exceeding 10% of family income). A number of states currently allow such exceptions, but the amendment requires (while CHIP is still in effect) this important improvement for kids.  

• Rep. Rush (D-IL) submitted two amendments to make it easier for children to enroll in public benefits programs and to ensure that children in CHIP shifted to the Exchange receive comparable benefits and cost sharing protections. The amendments were withdrawn because they would have pushed the cost of the bill above an agreed-upon target and after Chairman Waxman made a commitment to work with Rep. Rush on these critical issues for children.

• An amendment by Rep. Capps (D-CA) that extends CHIPRA's development of Medicaid and CHIP quality measures for children to maternity and adult health services.

• An amendment by Rep. DeGette (D-CO) that would preclude the movement of children from CHIP to Exchange plans until it is certified that they will receive comparable coverage has not yet been acted upon, but still is widely expected to be adopted before mark up concludes. In addition, amendments were defeated that would have affected Medicaid rules on the circumstances under which immigrants can secure coverage and that required states to offer premium assistance.

In the Senate, things progressed more slowly as the Finance Committee continued its negotiations for a bipartisan bill, which is now expected in September. Once the bill passes out of Committee, it must still be merged with the Senate Health, Education, Labor, and Pensions Committee bill, which was approved on July 15, 2009, before being taken to the floor for a vote.

What's Next? We are busily going through the fast breaking changes being made in Energy and Commerce and will provide an update as soon as possible. To help you navigate the bills, we will also release a side-by-side of the key provisions affecting children and families in the House Tri-Committee and Senate HELP Committee proposals next week.

These are uncertain times for children and their families - the threat of job and health insurance losses haunt many. Health reform could provide the peace of mind families need, but it is important to keep in mind that children are just one piece of the family puzzle. Parents must not be forgotten as the details of health reform are worked out.

Currently, eleven million parents are uninsured and the problem is especially acute among parents with incomes below 150 percent of the federal poverty level (FPL), with 41 percent lacking coverage. Close to 4 million children enrolled in Medicaid have at least one uninsured parent and almost 1.5 million children enrolled in CHIP live in families where at least one parent is uninsured. However, very few of these parents currently are eligible for public coverage. The median Medicaid income threshold for parents (not reflecting earnings disregards) is 41 percent of the FPL and 10 states have a threshold below 25 percent of the FPL. Providing Medicaid to parents with incomes up to 133 percent of the FPL would increase the eligibility threshold in 39 states.

The health and wellbeing of children depends on whether they have access to affordable, high-quality health coverage, but also can be dramatically affected by the health of their parents and the financial stability of their families. A large body of research indicates that providing coverage to parents promotes coverage and access to care for their children as well.

Getting health reform done will offer a crucial lifeline to families during these turbulent economic times. Affordable coverage for parents needs to be a part of the discussion.

A quick addendum... It has been only a few hours since we posted our statement on California's decision to shut down new enrollment into its Children's Health Insurance Program even as most states have found ways to maintain or even strengthen their coverage of children.  In the interim, some more bad news has arrived from California.  According to our colleagues at the Children's Partnership in California, Governor Schwarzenegger has just announced further cuts on the program.  As a result, the program will be facing a shortfall of $194 million and the state will be giving up $360 million in federal CHIP matching funds which could have gone to covering its children.

During tough budget times, most states have maintained their commitment to covering uninsured children. At least eighteen states have even further strengthened coverage for uninsured children, despite budget problems, as the recession has increased the need.

While many states have prioritized covering uninsured children, California lawmakers voted to deny coverage to nearly 800,000 children. This decision ignores strong public support for providing affordable health coverage to children and families. This decision also undermines California's ability to access federal funds, just when the state needs them most. The Children's Health Insurance Program Reauthorization Act of 2009 made the federal government an even stronger partner for states that prioritize covering uninsured children. California's $144 million children's coverage cut will cost the state $267 million in federal funds.

This is a difficult time for state budgets but an even harder time for family budgets, and many states are responding to meet the need. Alabama, Washington, North Dakota, Colorado, Iowa, Kansas, Nebraska, Arkansas, West Virginia, and Montana have all expanded coverage; Oregon and Ohio are on the verge of doing the same. Other states have instituted reforms designed to make their CHIP and Medicaid programs more family-friendly, all with the goal of increasing access to affordable health coverage for children.

California faces unique public policy challenges that have contributed to this step backward for children. The state was hit particularly hard by the economic and housing crises. More importantly, California has legal restrictions that put large shares of the state's budget out of lawmakers' reach, as well as supermajority requirements for passage of budget legislation.

While the search continues for ways to help California restore affordable health coverage options for children and families and hope remains high that national health insurance reform will be enacted soon, California's decision should not diminish the accomplishments of the other states. It is critical that states keep working to strengthen and maintain the gains they've made in offering affordable health coverage options to uninsured children and that the federal government remain a strong partner in their efforts."

This past weekend some Governors attending their national association's meeting in Biloxi, Mississippi expressed concern over the future role of Medicaid in health reform. In particular, Tennessee Governor Bredesen, a former healthcare executive, stated that "it's not health care reform to dump more money into Medicaid." But indeed, investing more money in Medicaid by paying providers more appropriate rates in Medicaid could help reduce the cost-shifting that is driving up the cost of private insurance. It would also improve access to care.

Health reform shouldn't just "dump" more money into Medicaid. It should take what works and build upon it. In all of the political rhetoric, let's also not lose sight of the fact that Medicaid has proven itself to be the most efficient way to provide coverage to low-income Americans. It has lower administrative costs than private insurance and is better equipped to meet the unique needs of disabled Americans, seniors, and more than 20 million children.

Consider proven Medicaid care delivery models like Community Care of North Carolina (CCNC). CCNC is an enhanced medical home model that has greatly improved access and quality of care, while containing costs in Medicaid. A study by the Mercer consulting group estimated that the state's savings were between $150 and $170 million in FY 2006 alone. An evaluation conducted by the University of North Carolina demonstrated that asthma and diabetes patients had fewer hospitalizations and saw improvement in key health performance measures. Now that's the kind of health care reform we need.

And let's not forget that numerous studies have shown that families are grateful for the coverage they get for their kids through Medicaid. By covering kids from head-to-toe with child-appropriate benefits, by removing red-tape that keeps eligible children out and by improving provider payments, we can make great strides to improve the effectiveness and efficiency of Medicaid.  Hopefully other Governors will take a closer look at the successes of Medicaid and the willingness of the federal government to assume more financial responsibility for Medicaid before opposing a plan that would make a world of difference for those who cannot afford health coverage for themselves or their children.

Medicaid works, and it should be strengthened as part of health reform. By building on what works, we can capitalize on the infrastructure and experience states have developed in administering Medicaid over the past thirty-five years. In other words, let's not throw the baby out with the bath water; we should build on Medicaid's successes.

By Sara Gagné-Holmes, Executive Director of Maine Equal Justice Partners

In drafting a national plan, Washington should follow Maine's lead.
 
In the health care debate, most agree that costs will not be controlled until everyone is covered and able to access the right care, including preventive care and management of chronic illnesses, at the right time and in the right health care setting.  Otherwise, costs for expensive emergency and catastrophic care for the uninsured and under-insured will continue to be passed to those who are paying private health insurance premiums.

Affordability is the key to providing everyone coverage. Health reform must include guaranteed Medicaid (known as MaineCare in Maine) coverage for more low-income households and robust subsidies for moderate-income households so they can purchase insurance.

Maine has been successful in preventing high rates of uninsurance among low-income families with minor children by providing MaineCare to those with income below 200 percent of the federal poverty level ($36,620 for a family of three). Medicaid is the most efficient way of providing coverage to all low-income people. The infrastructure is in place; it costs less than private insurance and it provides for the unique needs of people with disabilities, children and the elderly, who tend to be disproportionately represented among low-income populations.

It was another eventful week for health reform. You only have to turn on CNN or read the blogs for the political ins and outs. On perhaps the less sexy side of things, we have been busy reading the House's new 1,018 page health reform bill, the America's Affordable Health Choices Act of 2009. The bill, released this week, is an updated version of the draft bill issued by the three House committees at the beginning of the month. We have released a new fact sheet, which provides an overview of the bill's provisions as they relate to children and families.

With the caveat that the shelf life of this list may be a few hours given that they are currently marking up the bill, here are some of the most notable changes for children and families (as well as some of the important provisions that were not changed despite enormous pressure to cut back the scale of health reform):

• Keeps Medicaid for everyone up to 133% FPL with 100% federal funding for those newly-eligible. States that have expanded Medicaid above 133% FPL must still maintain coverage.

• Maintains the creation of a national Exchange with a public plan option that provides subsidized coverage for those up to 400% FPL. The new bill modestly increases the premium contribution cap (e.g., families at or below 133% FPL would contribute up to 1.5% or their income, rather than 1%).

• Continues to require coverage of pediatric services in Exchange and employer plans, including oral, mental health, and equipment for children. Adds a new requirement that the coverage be based in part on what is provided by a typical employer plan.

• Still allows CHIP to expire in 2013, but now requires that HHS decide whether a state and Exchange have a good transition process in place before children are moved from CHIP to other coverage. (As with the original bill, it does not extend federal funding past September 30, 2013, nor does it directly guarantee that children will receive comparable coverage when they are moved from CHIP to Exchange plans.)

• Provides stronger "screen and enroll" provisions for Medicaid-eligible individuals initially applying for coverage through the Exchange.

• No longer allows states to let certain Medicaid enrollees shift to the Exchange (Medicaid-eligible childless adults moving from private coverage still can enroll in Exchange).

• Eliminates the asset test for children and most adults in Medicaid and requires 12-month continuous coverage for separate CHIP programs (but this new requirement does not extend to Medicaid).
  

We are continuing to digest this bill, and others.  We will be back in the near future to share our thoughts on how children are faring, and ways we might strengthen some of the bill's to meet the needs of kids.

This week has been a reminder of both the promise and peril of health reform--we have seen real progress but also real signs that the whole initiative could falter.
 
Health reform legislation passed two committees in the House--Ways and Means and Education and Labor, but there remains serious doubt about whether it has the necessary level of support in the key Energy and Commerce Committee.

Other issues are dominating the headlines, but there has been significant activity on kids' issues behind the scenes.  A number of adopted or expected amendments are of particular interest:

• In the Education and Labor Committee, Rep. Bobby Scott (D-VA), with support from Democrats and two Republicans, added an amendment to guarantee EPSDT benefits to all children covered in the Exchange.
  

• In Energy and Commerce, Rep. Bobby Rush (D-IL) is expected to introduce one or more amendments to: require all states to simplify the Medicaid enrollment process; strengthen benefits for kids, and expand affordable coverage for children through public programs.

• Also in Energy and Commerce, Rep. Diana DeGette (D-CO) is expected to offer an amendment to help assure that CHIP children will not be moved into Exchange plans until it is clear that the coverage they get will be comparable.
  

Despite all of this activity in the House, progress has slowed in the Senate Finance Committee as the search for a bi-partisan bill continues.  The Senate Health, Education, Labor, and Pensions Committee approved reform legislation this week, but nonetheless, there is increasing talk of missing the August deadline for a floor vote.
 
For those who want more details, here's a sampling of key press clips on health reform that give a strong flavor for the current status of the debate:

New York Times Editorial:  

"While the Senate continues to struggle over its approach to health care reform, House Democratic leaders have unveiled a bill that would go a long way toward solving the nation's health insurance problems without driving up the deficit. It is already drawing fierce opposition from business groups and many Republicans. This is a bill worth fighting for."

Politico by Patrick O'Connor:



"The grumbling is reminiscent of an internal fight earlier this summer over climate change, one that produced landmark legislation, despite heavy foot-dragging by rank-and-file Democrats. But finding the votes on health care is a much greater challenge. Because this is viewed as the must-pass bill for President Barack Obama's first year in the White House, lawmakers have a much greater incentive to shape this legislation and challenge their leaders. But if Democrats have more days like Thursday, they're in trouble."

New York Times by Robert Pear:

The House Ways and Means Committee approved legislation early Friday to overhaul the health care system and expand insurance coverage after a marathon session in which Democrats easily turned back Republican efforts to amend the bill.

Children's health advocates from 21 states descended on Washington to participate in the Georgetown CCF Finishline/Narrative Conference.  The highlight was a visit from our favorite health policy guru and newly installed Medicaid/CHIP Director Cindy Mann.  As usual, she lit up the room with her youthful energy and passion for children's health issues.  We were all thrilled that she took time out of her busy schedule to visit with old friends.  

I love these conferences - no really, I do.  Besides the fact that you can usually count on three square meals and lots of snacks, I like the energy and renewed enthusiasm I get from mingling with outside-the-beltway types.  I also like the thought provoking questions and brainstorming that happens all to infrequently in our work.  While health reform is working its way through the legislative process, trying to get a handle on it is a bit like trying to catch a greased-pig (maybe not the best word choice).  New developments were occurring on both sides of the hill at a rapid pace during the conference so it was a great time to really focus and get the perspectives of all the health experts in the room on what it could mean for children's health coverage. 

Jill Beckwith and Jessica Mack, Policy Analysts, Rhode Island Kids Count





Rhode Island has been a leader in making sure that children have health insurance, with 94% of our kids covered. Most are covered through employer-sponsored insurance, and about one-third through RIte Care, our state's Medicaid managed care program for children and families. Like so many states, Rhode Island is facing record budget deficits that are forcing difficult choices. 

Last year, we were all saddened when Rhode Island ended a long-standing state-funded policy allowing legal permanent resident and undocumented children access to RIte Care. We have oodles of data showing the positive health outcomes for children who are covered through RIte Care. Children's advocates, health care providers and others all agreed that these children would be worse off without coverage. But after CHIPRA's strengthened federal commitment to lawfully residing immigrant children, what a difference a year can make!



In March, Rhode Island Governor Donald Carcieri included coverage for lawfully residing immigrant children in the budget that he proposed to the state General Assembly. The Rhode Island Department of Human Services presented a strong case that because of higher federal Medicaid match rates for some children and pregnant women already covered through RIte Care, the state could afford to restore coverage to some of the children who lost it the previous year. Now that federal matching funds were available, Rhode Island didn't have to go it alone.  Rhode Island KIDS COUNT, The Poverty Institute, and the RIte Care Works Coalition worked to educate policymakers about the benefits of restoring coverage for these kids. After a long and difficult session in which budget concerns dominated most decisions, the General Assembly included coverage for lawfully residing immigrant kids in the budget passed two weeks ago.

What a victory for kids in a very challenging time! It has reminded us to savor the small wins during difficult budget times, sometimes moving inch-by-inch to cross the finish line for kids' coverage, rather than mile-by-mile. While we never lose sight of our goal to cover ALL kids (including the undocumented children who have not yet had their coverage restored), it's the small victories that will get us there. Take it from us here in Rhode Island: good things do come in small packages!

The views expressed by guest bloggers do not necesarrily reflect the view of the Center for Children and Families.

Edwin Park, Senior Fellow, Center of Budget and Policy Priorities

Even as each day brings new details about House and Senate health reform legislation and we all gird ourselves for the race to pass health legislation in each chamber before the August recess, a question might be lingering in the back of your mind:  what about the use of budget reconciliation to pass health reform?  If you remember, we heard a lot of debate about reconciliation this spring when Congress considered the FY 2010 budget resolution and whether to include the option of reconciliation for health reform (which the budget ultimately did).  So, you might be wondering about the likelihood of actually using the reconciliation process to pass health reform.  More important, is it truly a way - as Republicans charged - for Democrats to speed passage of comprehensive health reform legislation without needing any Republican support?  Some of these issues were discussed in a recent segment of MSNBC's The Ed Show but here are some more details. 

Yesterday HHS Secretary Kathleen Sebelius and Medicaid Director Cindy Mann announced the department's "Request for Proposals (RFP)" for a first round of outreach grants funded through CHIP reauthorization. Find more information here about this long awaited announcement.
 
It's encouraging that in the RFP the department has embraced a more appropriate definition of outreach which is "extending benefits or services" to a broader population.  Outreach may incorporate but is not synonymous with marketing and communications.  In this case, ensuring that eligible children get and stay enrolled as a result of outreach and enrollment efforts is a focal point of the grants.
 
It will come as no surprise if you've read my other blog entries that I'm thrilled to note that innovative applications of technology to facilitate enrollment and retention are encouraged in the RFP.  Web-based applications and telephone processes for enrollment and renewals, along with increasing ways for families to pay premiums, are examples of potential activities.  And to ensure that grants are successful in identifying best practices, grantees will be required to provide sound data demonstrating the connection between outreach efforts and enrollment and retention. To these ends, grant funds can be used to make data and systems improvements that are appropriate in the context of the proposed outreach strategies.
 
It seems that HHS is on the right track but this is a significant undertaking on an expedited timeline with proposals due in barely a month.  While a number of entities from government, community-based nonprofit and faith-based organizations to schools and safety net providers are eligible to apply, collaboration between the state and non-state applicants is strongly encouraged.  Stakeholders and advocates should weigh in with their state agencies to promote this spirit of collaboration.  After all, the best outreach efforts engage many partners in the process.
 
The outreach grants along with enhanced funding for translation and interpretation services, increased federal matching funds for certain systems changes, as well as performance bonuses for adopting streamlined enrollment and retention strategies and meeting Medicaid enrollment targets, provide new tools and resources to states and stakeholders to achieve our country's coverage goals.
 
Getting and keeping kids enrolled also helps prepare us for health care reform.  The lessons learned under an administration that wants to support and identify innovative practices in outreach and enrollment will add to our knowledge of how the system needs to be reformed. We can't afford to repeat the mistakes of a system that burdens families and state agencies with paperwork, creates administrative inefficiencies and serves as a deterrent to enrollment.

On Friday, almost two weeks ago now, the three major committees in the House with jurisdiction over health reform put out a draft legislative proposal, known as "The Tri-Committee bill."  We've now read the 852-page document a few times, and think it would make giant strides in providing access to coverage to millions more people and transforming the country's health care delivery system.  Of particular note for kids, it includes:

• Major expansions in access to affordable coverage for their parents and other adults.  (Click here for just a few of the articles showing a clear link between how children fare and the health and stability of their parents.);
  

• Continued coverage of children through Medicaid with its strong, child-specific benefit package;

• Increases in Medicaid reimbursement rates; and

• A guarantee that no child born in a U.S. hospital leaves without insurance.  (For more details on these and other provisions, see our Fact Sheet on the Tri-Committee bill.)

At the same time, the Tri-Committee bill could be further strengthened to ensure that all children have access to high-quality, affordable coverage.  Of particular note - the Tri-Committee bill allows the remarkably successful Children's Health Insurance Program (CHIP) to expire just as health reform becomes operational.  This means that some 9 million children will have to move from CHIP coverage to Exchange plans on Day 1 of health reform and, as of yet, there is no guarantee that the new coverage they get will be comparable.

It may well be the case that the CHIP program eventually becomes a charming relic under health reform, no longer needed in a country where there is access to comparable coverage for children and adults alike through an Exchange. But, it is risky to disband CHIP before being sure of this outcome, especially given the promise of reformers to allow people to keep their coverage if it is working well.  As President Obama said on June 11, 2009 in Green Bay, Wisconsin, "My view is that reform should be guided by a simple principle:  we fix what's broken and build on what works." 

The House bill would be stronger for kids if it took a few simple steps to build on the gains in children's coverage we've secured in recent years.  1) Guarantee that children will receive comparable coverage and cost-sharing protections if they are moved from CHIP to new Exchange plans; 2) Continue running CHIP until we have a few years of experience with the Exchange plans, and dismantle the program only after we know that the they work as well for kids, and 3) Develop a plan for a smooth transition of the 9 million kids from CHIP to the Exchange - we don't want to repeat the brutal mistakes of the past that occurred when we tried to abruptly move millions of low-income seniors and people with disabilities from Medicaid drug coverage into new Medicare Part D plans. (Read more about the Medicare Part D move here and here and from Robert Pear here.)  

Also, the Tri-Committee bill could go further in tackling the key reason that millions of our children remain uninsured - Nearly two-thirds of the nine million children without coverage in this country are already eligible for Medicaid or CHIP, but aren't enrolled because their parents face red-tape barriers to signing them up for and keeping them in coverage.  The good news is that there are tested and well-known strategies for tackling this problem, including use of "no wrong door" enrollment for people seeking coverage; providing 12-months of guaranteed coverage; requiring states to use simplified, electronic verification of eligibility information; and making maximum use of auto-enrollment strategies.  These are the quickest, easiest and most cost-effective way to cover most of America's uninsured children but they are not all included in the House bill. 

House leaders still have a few more shots at improving the strong start they've already made on health reform, and we're optimistic that they'll do so.  There is a deep, historical commitment in Congress to covering children and at the White House, and widespread support from the American public to ensure that all of our children have high quality, affordable care.  As President Obama said when he signed the legislation renewing the CHIP program on February 4, 2009, "I refuse to accept that millions of our children fail to reach their full potential because we fail to meet their basic needs.  In a decent society, there are certain obligations that are not subject to tradeoffs or negotiations and health care for our children is one of those obligations."

Carrie Fitzgerald, Senior Health Policy Associate, Child & Family Policy Center, Iowa




Liz Arjun has blogged about the fact that CHIPRA has encouraged many states to move forward on health coverage for children despite facing difficult budgetary climates.  We have posted guest blogs from children's health coverage experts in Colorado, Kansas and Oregon, a few of the states that have made commitments to cover more kids.  This week we examine another state that is moving forward through the eyes of Carrie Fitzgerald, an expert on children's health coverage in Iowa.

On Tuesday, May 19th Iowa's Governor Chet Culver signed Senate File 389 into law. This is the second major health reform bill in as many years that the Iowa legislature has passed and sent to governor Culver for his signature.  Today we are celebrating in Iowa, as some of the key provisions of the bill, including an expansion of coverage for children in families up to 300 percent of the federal poverty level and to lawfully residing immigrant children go into effect.  These expansions along with a number of other policies included in the bill are expected to result in 30,000 more Iowa children being covering in the coming years.

Following in the footsteps of last year's bill, SF 389 includes several provisions and one just about children and their coverage. State legislators, led by Senator Jack Hatch, included many provisions in the bill that continue and expand on the good work from 2008. I was asked to speak at the bill-signing event with the Governor. Here are some of my remarks:

With the passage of Senate file 389 Iowa leads the nation when it comes to reform for children's coverage.

One thing we know about children and their health and development:

If you don't get it right the first time you can't go back and correct it.  Getting it right the first time will save us millions of dollars.

In fact, in a new study in last Friday's issue of Academic Pediatrics, researchers at Johns Hopkins show that early childhood health interventions can save billions in later health care costs.
 
As a state Iowa is committed to "getting it right the first time"

That is what SF 389 will allow Iowa to do for children:

• Cover lawfully residing immigrant children;

• Cover children and pregnant women up to 300% FPL;

• Create a dental only option under hawk-i; and
  

• Streamline enrollment and retention to keep kids covered, this will assure that children have medical homes, and receive preventive care.
  

The bill focuses on efficiency and removing unnecessary expenses.

The simplification measures in this bill will take work to accomplish, and are the last pieces of the puzzle.

Our legislators deserve credit for listening to what families are facing in these most trying economic times and for responding to them.

This bill is a solid example of when Government works well:  When legislators, the Governor, and state agencies work together to accomplish what is best for children, families, and all Iowans.

I am proud to have worked on this bill and to be a part of this event.

Iowa is leading the nation in these efforts, and for that all of us should feel proud.