November 2009 Archives

I was thrilled to see two very capable public servants, Vikki Wachino and Barb Coulter Edwards, agree to return to public service as part of the Center for Medicaid and State Operations team. Both were appointed to their positions earlier this week by CMSO Director Cindy Mann.

Vikki will serve as the Director of the Family and Children's Health Programs Group, which oversees the children and family aspects of the Medicaid program as well as CHIP.  She is a nationally recognized expert on health coverage issues with particular expertise in Medicaid and Children's Health Insurance Program (CHIP) policy.  Vikki served as the lead consultant on CCF's Strengthening Medicaid project where we worked together on, among other things, a series of issue briefs designed to identify constructive ways to improve the Medicaid program. Her in depth knowledge, commitment to beneficiaries, and dedication to her work will be extraordinary assets to CMS as it continues to implement CHIPRA, works to strengthen the EPSDT benefit for kids in Medicaid, and, should something pass, plays a key role in implementing health insurance reform changes.

Barb will serve as the Director of the Disabled and Elderly Health Programs Group.  Barb is the former Ohio State Medicaid Director and is also a nationally recognized expert in Medicaid policy, including managed care, cost containment, long-term care, and State and federal health care reform. Barb also spent six months as the Interim Director of the National Association of State Medicaid Directors.  In the small world category, Barb actually co-authored a paper with Vikki for our Strengthening Medicaid series program management in Medicaid so the two of them will be ready to hit the ground running as a team!! 

Vikki and Barb will be invaluable to CMSO as it faces the many challenges and opportunities that lie ahead.  We applaud their return to public service and look forward to working with them.

Medicaid, and it's companion program, CHIP have had amazing success in reducing the number of uninsured children over the years. The recent Census numbers highlight this fact - in 2008, the number of uninsured children was at its lowest in 20 years, due in large part to public programs filling in the gaps of declining employer-sponsored coverage. Yet, far too many children remain uninsured, with more than seven in ten of them living in low-income families.

A recent study released by the Urban Institute looked at how many of these uninsured children are eligible for Medicaid or CHIP but not enrolled in coverage. As of 2007, five million uninsured children (64% of all uninsured children) were eligible, with over 90% living in families with incomes below 200% of the FPL.

Why are there so many eligible, but uninsured children? According to a recent survey, 90% of low-income parents with uninsured children said they would enroll their children in Medicaid or CHIP if they were eligible, However, close to half do not think their child qualifies (despite the fact that most children with income less than 200% of the FPL are eligible). Parents often lack accurate information about Medicaid/CHIP programs, don't know how to get information, and don't know how to enroll their children. Others find the enrollment process difficult.

Although states have made great strides in improving participation rates over the years, they continue to grapple with how to reach more of these uninsured children, enrolling them in the coverage they are eligible for. There are numerous strategies they can employ: application and renewal processes can be streamlined; states can link with other public programs in which children may be enrolled; and expanded outreach and educational efforts can inform more parents about program details. Millions of uninsured, eligible children stand to gain coverage as a result of such measures.

The Senate bill is finally out, and Majority Leader Reid is looking to get through a cloture vote on Saturday. The key parts of the bill that we've been tracking haven't changed too much from the Senate Finance version. One change of note, the implementation date for the coverage pieces in the bill was moved from July 1, 2013 to January 1, 2014.

Here is brief reminder of what's in the bill in terms of Medicaid and CHIP:

• As in the Finance bill, the new proposal creates a national Medicaid threshold for adults and children at 133% FPL. The newly eligible adults must be given a benchmark benefit plan. The bill also deletes Finance bill provision that would have allowed certain Medicaid adults to go into the Exchange.

• States must maintain current Medicaid eligibility and enrollment procedures for adults until the Exchanges are operational (with the exception that states with budget deficits can roll back on coverage above 133% FPL).

• The federal government still will pay a chunk of the costs for newly eligible adults. The new version provides 100% federal funding in 2014, 2015, and 2016. In 2017 and 2018, the percentage picked up by the federal government for the adults will vary, with more support initially provided to states without existing Medicaid expansions. By 2019, the federal share will level out to an increase of 32.3 percentage points for all states.

• Maintains Medicaid and CHIP coverage for children above 133% FPL through fiscal year 2019. States will receive an increase in the federal match rate for the CHIP-financed kids. However, no funding is provided for CHIP past its current renewal date (September 30, 2013). The bill clarifies that if not funded, children in stand alone CHIP programs can enroll in Exchange coverage and subsidies.

• Maintains no wrong door and single application process for Exchange subsidies, Medicaid and CHIP.
  

• Requires that health plans cover the preventive care and screenings identified in Bright Futures (the American Academy of Pediatrics' "gold standard" for preventive care). 

• Continues to provide subsidies to people up to 400% FPL but makes some changes to what families are expected to pay at different income levels. While families between 250% and 400% FPL will pay less than in the Finance bill, those with incomes below 250% FPL will pay more. See CBPP's analysis on this important issue.
  

It is also worth noting some of what is NOT in the Senate bill including an increase in Medicaid reimbursement rates for primary care services and automatic enrollment of newborns (both in the House bill). And, as noted, there are no funds and other improvements in CHIP past 2013.  We can expect these issues to pop up in the Senate floor debate and/or in conference.

Look out for our new summary of the legislation in the coming days.

As we all follow the twists and turns of health care reform in Congress, it's easy to forget that the critical children's health legislation that's already been passed this year--CHIPRA--is well on its way to being implemented.  CMS Medicaid and State Operations Director Cindy Mann (CCF's former fearless leader) took the time this week to update child health advocates on recent CMS actions and guidance on CHIPRA.  She highlighted that $10 million in outreach grants to tribal groups will soon be distributed.  She also passed on news that new guidance will soon be released on a variety of topics and was able to share several updates on issues raised by the new law:

• On dental coverage for kids:
• Dental provider lists are now available for each state at www.insurekidsnow.gov, but it sounds like there will be efforts to improve the quality and accessibility of these lists in the months ahead.  
• No state has submitted a plan amendment to alter its dental coverage in response to CHIPRA, but CMS has been talking individually to states. CMS also clarified that states won't be deemed out of compliance with the new dental benefits until it has officially promulgated regulations.
• The children of state employees can't be eligible for a CHIP-financed dental wrap-around, just as they are not eligible for CHIP itself.
• On the new option to drop the 5-year waiting period for lawfully residing immigrant kids and pregnant women in Medicaid and CHIP:
• The new option applies to children and pregnant women "lawfully residing" in the U.S., which is a broader category than the "qualified aliens" which the 5-year waiting period referenced. CMS is working with other agencies to develop an accurate definition.
• Eighteen states have plan amendments pending to exercise the new option; one state has been approved to date.  (Most of these states already use their own money to cover lawfully residing immigrant kids and pregnant women during the 5-year waiting period, but might have rolled back in the absence of the new federal help.)
• No "skipping" over Medicaid - states can't decide to cover lawfully residing immigrant kids and pregnant women in CHIP, but continue to impose the 5-year bar in Medicaid. 
• If a state does lift the 5-year bar in Medicaid, the good news is that it can secure the enhanced CHIP matching rate for the cost of covering these kids in Medicaid through the end of the 5-year period.
  
• On citizenship documentation
• CMS is moving quickly to test Social Security Number matching with the Social Security Administration and expects to have a matching system ready by January 1 for states that choose to use this option to document applicants' citizenship.
• On performance bonuses
• CMS is currently evaluating 18 states' applications for performance bonus funds; states may continue to apply.  The awards are expected to be announced by mid-December.
  

Families still reeling from the recession, feeling pessimistic about the future, and many of them struggling to cut back spending in order to cover health expenses - that is the portrait painted by the recent survey CCF conducted with Lake Research Partners.  This is worrisome news for the fragile economic recovery with so many families feeling burdened with such heavy health care expenses.

The survey also provides clues as to what the American public would like to see from health care reform by delving deeper into how families currently pay for health care and what the American people consider to be "affordable" health care coverage.   Here are some of the findings that emerged from the survey:

• Paying for health care puts families in a tight financial bind. In the last two years, many voters report that paying for health care has caused them to cut back on household spending (44%); build up credit card and medical debt (23%); use up all or most of their savings (21%); and have someone in their household do without health insurance (21%).

• The vast majority of Americans think bringing down health care costs is of greater concern to them than making sure health reform doesn't cost the federal government too much.  (In other words, they were more concerned with shoring up the financially strapped family pocketbooks than the federal purse.)

• The amount families consider to be affordable to pay for health care coverage is lower than what many are required to pay each month, and lower than some options being considered in health care reform.

• Two thirds of the voters surveyed said a $362 premium was too expensive for a family of three earning $45,000 a year (the estimated premium cost under the proposal passed by the Senate Finance Committee).  More than half feel $305 a month was too expensive for a family of three earning $45,000 a year (the proposed premium cost in the bill that passed the House in October).
  

I have been involved in many surveys over the years.  There is usually one finding that takes me by surprise.  I was amazed that such a large percentage of those surveyed reported that they had cut back their spending over the past year due to health expenses.  (Remember, most of those surveyed are insured.)  This point brought home for me how important it is for policymakers to get family health care costs under control in order to get the economy back on track.

More information about the survey is available on CCF's website.

With so much round-the-clock activity on health care reform, it is sometimes hard to keep all the facts straight on where things are for kids.  We released a fact sheet today that we hope helps to provide a roadmap on the child and family provisions in the leading health reform proposals: House bill (H.R. 3962) approved on November 7, 2009 and the Senate Finance Committee bill released October 19, 2009.  We hope you find this "cheat sheet" of the Medicaid, CHIP and subsidy pieces of the bills helpful as things progess (and we will update it once the merged Senate bill is released).  

An enthusiastic crowd of more than 500 gathered in Chicago last week for the National Children's Health Insurance Summit hosted by the Centers for Medicaid and Medicare (CMS). Attendees included CHIPRA outreach grantees, individuals from community-based and provider organizations, national and state experts, and officials from federal and state government. The purpose of the event was to reinvigorate outreach efforts and share best enrollment and retention practices in Medicaid and CHIP.

HHS Secretary Kathleen Sebelius and CMS Medicaid Director Cindy Mann kicked off the event by articulating the Administration's commitment to covering children and challenging attendees to find and enroll the estimated 5 million of the 8 million uninsured children who are eligible but not enrolled Medicaid and CHIP.

A recent study from Johns Hopkins found that children who enter the hospital uninsured are more likely to die than those who have coverage. In fact, uninsured children were found to have an in-hospital mortality rate 60% higher than their insured counterparts. Extrapolating their findings (and assuming that lack of insurance was the driving factor), the researchers estimate that approximately 17,000 in-hospital deaths may have been prevented over the last 18 years if these children were covered.

An interesting conclusion suggested by the paper is that these children were sicker before they were admitted. The rationale - uninsured children who died during their hospital stay were in the hospital for a shorter amount of time and the charges for their care were significantly lower. The authors propose that the uninsured children presented with more serious cases and, in many circumstances, it was simply too late to intervene.

This study adds to a long list of research showing the importance of health insurance, including findings that uninsured children are less likely to receive immunizations, prescription medications, asthma care, and basic dental care. Others have found that children who have coverage miss fewer days of school and have fewer avoidable hospitalizations. Importantly, they also tend to receive more timely diagnoses of serious health conditions, a point that this study seems to validate.

Yesterday evening, the House released revisions (referred to as a manager's amendment) to its health reform bill, H.R. 3962.  Leadership could now potentially bring the bill to the House floor by this weekend, but the schedule is still undecided.

CCF has released a fact sheet to help guide you through the bill's (with the new amendments) proposed changes to Medicaid and CHIP, as well as other provisions of particular importance to low-income children and families.  Here is a link to the fact sheet, and other related resources:

• Key Medicaid, CHIP, and Low-Income Provisions in H.R. 3962 by CCF

• CCF blog on H.R. 3962 that highlights changes from the previous bill

• Text of H.R. 3962 and the Manager's Amendment

• House Republican Health Care Reform Bills

• CBO Analysis of H.R. 3962

• CCF's Health Reform Resources
  

New Jersey is putting this idea to the test with its new "Insured for Sure" initiative that is being piloted in nine New Jersey hospitals. Hospital staff will check the insurance status of all newborns and provide data to the Department of Health and Senior Services  (DHSS) verifying a baby's coverage under the parent's insurance. If a child is uninsured, staff will help families complete a streamlined one-page online application for NJ FamilyCare. And it gets even better, there is no need to submit paperwork.

As NJ-DHSS Commissioner Heather Howard stated in announcing the program: "Having health insurance is the first step in ensuring...a healthy start in life." Health insurance is a young family's ticket to a medical home and the health support system they need to care for their infant including those critical well baby checkups. In the first year of life alone, the American Academy of Pediatrics recommends seven well-child care visits to ensure that newborns grow and develop appropriately and get the immunizations they need to prevent childhood diseases. Sadly, studies have shown that barely a third of uninsured children get the recommended number of well-child visits.

New Jersey isn't alone in its efforts to increase the number of babies who leave the hospital with health insurance. Oklahoma developed a web-based program for hospitals to directly enroll infants born to moms covered by Medicaid in its SoonerCare program.  This program known as eNB-1 adds newborns in real time and ensures that a medical home is selected for the baby. It also provides an immediate ID number, which simplifies the billing process for hospitals.

A newborn whose delivery is covered by Medicaid or CHIP by law is automatically eligible for a full year of coverage. Period. End of discussion. Unfortunately, in the past, some of these newborns have slipped through the cracks because of reporting or paperwork requirements. CHIPRA further clarified the importance of providing infants with insurance in this all-important first year of life. In particular, CHIPRA clarified that these babies have met the citizenship documentation requirement by virtue of the fact that they were born in a U.S. hospital, thus eliminating unnecessary paperwork.

If more states launch initiatives like "Insured for Sure" and eNB-1, backed by strong technology, we truly can make significant gains in covering children when they are most vulnerable. Making sure that no newborn leaves the hospital without health insurance is an idea whose time has come.