December 2009 Archives

This morning the Senate passed its version of the health care reform bill, the Patient Protection and Affordable Care Act. As we wind down the year here at CCF, comprehensive reform remains closer at hand than at any time in recent history. While the bill is far from perfect, children and their parents have an enormous amount to gain from reform moving forward. (For the full scoop on the latest Senate version, check out CCF's latest factsheet on all the relevant provisions.) We look forward to the New Year in the hopes that it will bring much needed change to our health care system. 

It is indeed fitting - with the holidays focused on children and giving -  that HHS Secretary Kathleen Sebelius awarded more than $72 million in bonus payments last week to nine states for their success in enrolling low-income children in Medicaid. Like little kids during the holidays, we have awaited the announcement of these performance bonuses with excitement and gleeful anticipation. Drum roll, please.....Alaska, Illinois, Louisiana, Michigan, New Jersey, New Mexico, Oregon and Washington earned bonuses ranging from $1.5 to $9.1 million but Alabama is the big winner earning more than half ($39 million) of the total award.

The performance bonus  is one of the new tools and options created through the Children's Health Insurance Reauthorization Act  (CHIPRA). It give states a financial incentive to meet specific Medicaid enrollment targets if they also adopt at least 5 of 8 enrollment and retention simplification strategies such as 12-month continuous eligibility and streamlined administrative renewals.  

States qualifying for the bonus receive payments equal to 15% of the annual cost of Medicaid services for the number of children enrolled above the target enrollment. To meet the target, a state's average monthly Medicaid enrollment for children in federal fiscal year 2009 (FFY 09) had to be approximately 8% above the average enrollment in FFY 07 with adjustments for any change (positive or negative) in the child population.

The significantly larger award was granted to Alabama because it was the only state to qualify for the higher "tier 2" bonus level. A state qualifies for the tier 2 bonus if the average number of enrollees exceeds the base (tier 1) enrollment target by 10%. At the tier 2 level, states receive a bonus equal to a joyful 62.5% of their share of Medicaid costs for the average number of children enrolled above the tier 2 target. For Alabama, this reduces the state's share of Medicaid for children enrolled above the tier 2 target to less than 9%.

In announcing the awards, the Center for Medicaid and State Operations within CMS issued a State Official Letter (SHO) explaining the performance bonus calculations and describing the eight enrollment and retention strategies. This was the tenth in a series of SHO letters, which provide guidance to the states in implementing the provisions of CHIPRA. The public announcement of the bonuses also coincided with the re-launch of "Insure Kids Now" as a more robust website focused on Medicaid and CHIP including state specific program information.

We send our congratulations to the State Medicaid and CHIP agencies in the nine performance bonus states for a job well done and our wishes to all for a holiday season filled with warmth and laughter.

Today on a snowy day in DC, agreement was reached on the Senate health care bill making it likely that Senator Reid has enough votes to pass the bill before Christmas. The Senator also filed his Manager's Amendment to the bill. The Congressional Budget Office followed soon after with the bill's score. 

Tucked between the more controversial provisions of the Manager's Amendment are some noteworthy improvements to children's coverage. This is good news for kids and due in large part to the efforts by children's groups to raise the profile of these issues within the larger debate and the leadership of Senators Rockefeller and Casey. Some of the changes include:  

• CHIP funding is continued for another two years (September 30, 2013 through September 30 2015). Originally, the bill provided funding only through September 30, 2013. This funding ensures that children can keep their CHIP coverage during a critical period when health reform is just getting off the ground. 

• States will still need to maintain current Medicaid and CHIP eligibility and enrollment procedures for children above 133% of the FPL through fiscal year 2019. However, the amendment clarifies that states must meet this "maintenance of effort" requirement or lose their Medicaid funding.

• States will still receive the 23 percentage points increase in their CHIP match rate but its timing was delayed for two years. Now the increase will go into effect October 1, 2015. Since the bill assumes coverage will be maintained through 2019 but there is no funding after 2015, Congress will need to further revisit these funding issues.

• As before, if there is no federal funding children previously eligible for CHIP will be enrolled in the Exchange. The amendment strengthens this provision by requiring that children first be screened for Medicaid and, if eligible, enrolled. For children not eligible for Medicaid, the state must establish procedures to enroll the children in comparable coverage. 

• The Secretary of HHS will be required to review and certify which plans in the Exchange provide CHIP-comparable benefits and cost sharing, but it is unclear what mechanism will be in place to ensure that these plans exist in the Exchange.

• Extends and increases funding provided in CHIPRA for Medicaid and CHIP enrollment and renewal activities. Now, $140 million (an increase of $40 million) will be available through 2015. 

• Creates a new option for states to provide CHIP coverage to children of state employees eligible for health benefits. These children can now enroll in CHIP if the employee's premiums and cost sharing exceeds 5 percent of the family's income. To utilize this option, a state cannot have decreased its premium contribution for family coverage below 1997 levels (adjusted for inflation).

• Requires the Secretary of HHS to issue regulations to establish a more defined process for public input for section 1115 waivers in Medicaid and CHIP.

• Makes technical changes to tighten up the definition of cost-effectiveness in the new CHIPRA premium assistance option and removes the requirement that Medicaid programs do premium assistance as part of the Medicaid expansion in the underlying bill.

• Immediately prohibits insurers from denying coverage to children for pre-existing conditions. The new regulation would go into effect for adults with the rest of the legislation, in 2014.

We are still combing through the Manager's Amendment and will keep you posted on other noteworthy changes.

The current health reform proposals have so many moving parts it's been hard at times to parse out where children will land. Thankfully, Jenny Kenney and Allison Cook at the Urban Institute have provided us with some guidance.

Using 2007 coverage numbers, they examine both the House and Senate bills to determine where current Medicaid and CHIP kids will end up.

[A quick refresher: in the House bill, Medicaid is expanded to 150% of the FPL and CHIP is discontinued; in the Senate bill, Medicaid is expanded to 133% of the FPL and CHIP is maintained (although with no additional funding after 2013).]

If the policies were implemented in 2007, here's what the transition would look like for children currently enrolled in separate CHIP programs (the authors suggest that adjusting forward to 2014, the numbers would be about 2.5 times higher):

A big caveat here - because the Senate bill does not currently provide funding for CHIP, the 2.3 million children who would have retained CHIP coverage would instead go into the Exchange. However, there are some efforts currently underway to provide funding for CHIP, at least on a transitional basis.

Health reform has a lot of moving parts and a lot of moving people. It is vital that a thoughtful and well-coordinated plan is devised to enroll and retain children in coverage; otherwise, it is quite possible that some children will fall through the cracks, possibly ending up uninsured. And those CHIP kids, wherever they land, it will be important that they get comparable coverage, both in terms of cost sharing and benefits to what they get now.

Donna Cohen Ross, Outreach Director, Center on Budget and Policy Priorities.



Editor's Note:  Donna Cohen Ross has been tracking state eligibility rules, enrollment and renewal procedures and cost-sharing practices in Medicaid and CHIP for more than a decade.  Her much anticipated annual survey was released last week by the Kaiser Commission on Medicaid and the Uninsured and the Center on Budget and Policy Priorities.  We asked Donna to give us the highlights in a guest blog entry.

What's most striking in this year's 50-state survey on Medicaid and CHIP is that despite the deep, deep "downs" of the economy, many states were reporting impressive "ups" for children's health coverage.  In fact, a substantial number of states did more than survive in the depressed economic environment -- they reached new heights (which is consistent with CCF's Weathering the Storm findings).  

How did they manage to do that?  Flip the pages of the calendar back to February 2009 for the answer.  That month, CHIPRA was signed into law, providing sufficient resources to cover, by 2013, an additional 4.1 million children under Medicaid and CHIP who would otherwise remain uninsured.  In addition, an Executive Order rescinded the August 17th directive, removing the constraints that had hampered states' ability to expand coverage to children in more moderate-income families.  Later that same month, the American Recovery and Reinvestment Act (ARRA) was enacted, infusing states with fiscal relief by bumping up federal matching funds for Medicaid and prohibiting states from cutting Medicaid eligibility or putting up procedural barriers to enrollment. (These eligibility and enrollment protections did not apply to CHIP, leaving that program vulnerable to cuts.)

It's now clear these measures were vital in helping health coverage programs rise to the challenge of providing coverage for low-income families as they faced what have been the toughest times many have ever experienced.  Let's take a look at the specific ups and downs of 2009:

The Ups:

• In 2009, more than half the states (26) took at least one step to advance health coverage for low-income children, parents and pregnant women, with children being the biggest beneficiaries.  Nine states expanded income eligibility for children so that the median income eligibility for children rose to 235 percent of the federal poverty line from 200 percent, and now 24 states (including DC) cover children in families at 250 percent of the federal poverty line or higher.

• Nine states took steps to simplify enrollment and renewal procedures -- notably, five adopted 12-month continuous eligibility, which guarantees eligible children a full year of coverage, an important step in fostering retention.
  

• There is no doubt that the tools and incentives states got from CHIPRA helped push them forward. More than one-third of the states (18) have submitted state plan amendments to cover immigrant children and pregnant women who have been legally residing in the U.S. for less than five years; and more than half the states (27) said they plan to conduct data matches with SSA to meet the citizenship documentation requirement, rather than requiring families to come up with documents like passports, original birth certificates and picture IDs.  State officials also said they were interested in trying out the new Express Lane Eligibility option and a handful said they will provide language and interpreter services (and get enhanced federal administrative match) for enrollment activities.  
  

The Downs:

• To be sure, there also were some "downs," with 15 states restricting access for children. Increasing CHIP premiums was the action states took most frequently in response to economic pressures. In some states the premium jumps were big, but even after these recent increases, overall, CHIP premiums remain modest with the median charge for two children in a family with income at 200 percent of the federal poverty line is $480 per year ($40 per month), just 1.3 percent of annual income.  Another "down" is that two states -- California and Tennessee -- froze CHIP enrollment for at least part of the year.  California reopened enrollment, but Tennessee remains closed.  Of greatest concern is that these access-restricting measures mean that eligible children can't enroll and will remain uninsured.  So, a sick child can't see a doctor or get the medicine she needs and her family may face compelling financial choices -- pay the rent or pay for a prescription -- even though the child qualifies for coverage.

Where do we end up as 2009 comes to a close?  The stabilizing effects of ARRA gave states the support they needed to safeguard coverage for low-income families and move forward. But, the federal fiscal relief and enrollment protections are scheduled to expire at the end of 2010.  If that happens, states will no longer have the emergency resources that have been instrumental in keeping their programs intact.  While there are indications that the economy may be beginning to recover, the recession continues to take a toll on families and communities across the nation.  If fiscal relief is not replenished and Medicaid is not protected as under ARRA, many states may buckle under the pressure they are facing to make substantial cuts in programs like Medicaid and CHIP.  Will the "ups" of 2009 turn upside down in 2010?

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Wendy Lazarus, Founder and Co-President, The Children's Partnership




As the health reform debate in Congress moves further forward than it ever has before, the potential real-world impacts on children and families are becoming clearer.  Even from 3,000 miles away, those of us in California - home of the nation's largest and hugely successful CHIP program - can see the promise and the perils ahead.  Although today I live and work in California, where one in every eight children in the US also lives, my perspective is shaped by having worked as a child advocate in four other states and in Washington DC, starting in 1973.  Based on these many years of being in the reform trenches, I can honestly say today feels quite different---something very real is emerging with the potential, still, to be a major gain for America's children or a monumental step backwards.

The promise lies in the enormous success that our nation generally, and California specifically, has made in covering children.  Like many other states, California has made great strides in covering children this decade.  Our uninsured rate has fallen from 10.2% in 2001 to 6.4% in 2007, thanks to Medi-Cal (our Medicaid program), and Healthy Families (our CHIP program), functioning as the effective safety nets they were intended to be. California children in families at or below 250% of poverty currently have access to coverage their parents can afford, that provides comprehensive benefits, and that protects families from high out-of-pocket expenses.  California has also implemented a number of pioneering reforms to help families find and keep coverage for their children, such as providing expedited "express lane enrollment" for children who receive free or reduced-price school lunch. Evaluation after evaluation has shown that more children in California are now healthier, are at less risk of suffering from preventable illnesses, have better access to needed health care services, and are better prepared to learn.

But as the health reform debate winds to its end, we cannot count on these good things to continue for kids. Unless the final bill includes the right choices on some still unresolved matters, devastating impacts on children's health and readiness to learn could result.  We have the knowledge and we still have the time to make sure the final package does, indeed, build effectively on the strong foundation that already exists.

To a great extent, the current House and Senate bills do build on that strong foundation.  Today's coverage standards would clearly be maintained or even improved for many children.  Because both bills expand and strengthen Medicaid, more children - more than 300,000 children in California alone, under the House bill - would gain access to the affordability and comprehensive benefits it provides, including important preventive benefits through the Early and Periodic Screening, Diagnosis, and Treatment program.  

But for millions of California children above the new Medicaid income thresholds, the results are not necessarily positive. Both the House and Senate bills create new coverage pathways, through some combination of parents' employer-based coverage, CHIP, and/or the new health insurance exchange.  The specifics differ under each bill and are very complex, but the essential element to watch for is this:  Do the reforms result in children in having access to at least the level of affordability and benefits that they have today?  The answer could be "yes" for any of the potential pathways if they were structured appropriately.  At the moment, however, neither bill has strong enough affordability and minimum benefit requirements for either employer-based coverage or coverage provided through the exchange to guarantee that current standards for children's coverage will be maintained.

Until the standards for employer-based and exchange coverage are strengthened, CHIP is left as the only coverage pathway for maintaining the successes that we, as a nation, have achieved for children.  Both the House and Senate bills maintain CHIP for some period of time for at least some children but important limitations exist in both bills that would leave children in California particularly at risk. Because the House bill only maintains CHIP in those states that implemented their programs as Medicaid expansions, California - with its stand-alone Healthy Families program - would, fairly soon after reform is implemented, need to move 1.7 million children from CHIP to Exchange and employer coverage. Under the Senate bill, California's CHIP program would be maintained through a transition phase - but without any funding after 2013.  Fully funding and guaranteeing CHIP coverage until at least the same benefit and cost-sharing protections are available in the Exchange would protect the gains made to date.

California's brinksmanship this year provides a sobering example of the perils to families if these funding concerns are not addressed.  Earlier this year, California enacted deep funding cuts for Healthy Families that resulted in the program being closed to new enrollees temporarily, leaving nearly 90,000 children on a waiting list for coverage in just 60 days and putting the coverage of nearly one million children at risk.  Fortunately, state leaders came together to find alternate funding sources to fill the shortfall and reopen the program. But these "fixes" were temporary, and with the state's continued fiscal crisis we are likely to see more cuts ahead.  

The lesson for health reform is clear: For the health bill that passes to be true reform, whatever pathways cover our children need to be modern, simple, sized right for children and available even in times of economic stress.

My garage is brimming over with files labeled "national health reform" that span three decades.  But it is the health reform documents being produced over the weeks ahead that will govern the fate of children born today and in the years to come.  We have decades of experience that tell us the right thing to do.  And we still have the time and the necessary leadership to do it.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Details are starting to emerge on what is in the new Senate deal on a public option, but we're still trying to figure out what it means for low-income children and families.  So far, we know it does not include a Medicaid expansion to 150 percent of the federal poverty level, which would have helped lots of additional children secure the EPSDT benefit (the "gold standard" of coverage for kids) and secure better cost-sharing and premium protection for their parents and other adults. (But, this issue likely will still be on the table for discussions between the House and the Senate - -the House bill includes the Medicaid expansion to 150 percent of the FPL.)

Also, sounds like it may include some improvements to the Children's Health Insurance Program.  Both the New York Times and Wall Street Journal are now reporting that the negotiators might include a 2-year extension of the Children's Health Insurance Program. It isn't clear yet what this means, nor whether it has implications for the efforts of Senator Bob Casey to pursue a far broader set of improvements for children's coverage. Stay tuned.

In the meantime, Donna Cohen Ross has come out with the latest in her definitive, comprehensive series of annual surveys for the Kaiser Commission on Medicaid and the Uninsured of where states are on coverage of children and families in Medicaid and CHIP.  She has promised to blog on the new findings later this week, but, for now, the bottom line is that "despite the economic downturn that's busting state budgets from Sacramento to Tallahassee, 26 states this year made it easier for low-income children, parents or pregnant women to get health coverage, according to a report released Tuesday by the Kaiser Family Foundation". Great news, but.. and you knew there might be a "but"... the report warns that this progress may be at risk if steps aren't taken to continue to help states with their budget crises past the end of 2010.  

Remember CHIPRA?  Wisconsin does and it's putting it to use to get closer to its goal of providing affordable health coverage options to ALL kids.  

CHIPRA, signed into law in February, provided states with the ability to cover lawfully residing immigrant children and pregnant women without a five-year waiting period.  Wisconsin Governor Jim Doyle has consistently said that the goal of "BadgerCare Plus (BC+)" is to make quality, affordable health insurance available to "all kids," regardless of income.  

The state made progress toward that goal this fall when the Wisconsin Department of Health Services announced that it was taking advantage of CHIPRA to get federal matching funds for extending health insurance to certain "lawfully residing" immigrant children and pregnant immigrant women.  As a result, those Wisconsin children and women will no longer have to reside in the U.S. for five years before they are eligible for BC+.   

Jon Peacock, research director for the Wisconsin Council on Children and Families, explained this policy in an interview as part of the CCF Postcard series.  Jon points out that removing the five-year bar makes hundreds of additional children eligible but it is also likely to produce a "welcome mat" effect for many mixed status families who may not have realized their children were eligible even under the old rules.

Join CCF in cheering on our friends in Wisconsin and wish them well as they continue to strive to reach the goal of covering all kids.  The lyrics to "On Wisconsin!" certainly ring true as the state moves forward and its flame (a symbol of welcome to immigrants) glows a little brighter with this change in policy.  

While not as riveting as the latest gossip on the White House "party crashers," the Senate began debate this week on its health reform bill. We have developed a fact sheet of the bill's key Medicaid, CHIP, and low-income provisions to help you navigate and understand where things stand for children and families.

Over the coming days, the Senate is expected to take up a number of amendments addressing the issues of interest. Most recently, Senator Casey introduced an amendment that would make a number of enhancements to CHIP (which is maintained in the Senate bill). These include providing full funding for the program through 2019, requiring states to cover children in CHIP up to at least 250% of the federal poverty level and providing EPSDT coverage to children in CHIP.

We will keep you posted as key amendments related to Medicaid and CHIP are introduced and move forward. In the meantime, a new report by Families USA provides a good overview of what issues are expected to arise.

An Interview with Brian Rosman, Research Director of Health Care For All in Massachusetts.

The success Massachusetts had in creating affordable, accessible, quality health coverage options for all residents of the Commonwealth has helped lead the way for national health reform. Now that we're getting beyond the larger conceptual phase of health reform and getting into the nitty-gritty details, we thought it would be helpful to check back in with someone in Massachusetts to enlighten us on how the Commonwealth was able to get over some of the stumbling blocks on the road to success. We tracked down Brian Rosman, research director of Health Care For All, to help us better understand how health reform worked in Massachusetts.


Cathy: How were you able to make health coverage affordable to families through the exchange?

Brian: An often-overlooked part of Massachusetts's health reform is the important role that Medicaid and CHIP played in providing affordable coverage options for children and families. We built on the strong base of underlying Medicaid coverage. The Commonwealth Care program filled in the gaps in coverage and a CHIP expansion for kids (up to 300% of the poverty level) allowed thousands of kids to get affordable coverage. The exchange, called the Health Connector in Massachusetts, offers subsidized coverage to adults only, through a program called Commonwealth Care. Under a reform instituted under Governor Patrick, who took over from Mitt Romney in 2007, CHIP premiums for children are waived if the parents are enrolled in Commonwealth Care. Medicaid, CHIP and subsidized coverage through the Health Connector have made coverage much more affordable for families.

Cathy: It's interesting that you mentioned CHIP as there's some disagreement in Washington about whether or not to eliminate CHIP and move children into the "Exchange" immediately. One reason to move CHIP eligible children into the "Exchange" immediately is to simplify the enrollment process for families. How has MassHealth managed to integrate CHIP and Medicaid with the Exchange?

Brian: Mass Health is what our state calls the combined Medicaid and CHIP programs. It operates as a unified program, and enrollees often don't know if they are in CHIP or in the Medicaid waiver program. It's all called MassHealth, and the program is consolidated. The Connector, which administers the Commonwealth Care program, uses the same application as MassHealth, and the MassHealth system processes the enrollment applications, as well as renewals and other systems. So it's seamless for enrollees, regardless of what program they are in.

Also, all of the MassHealth managed care plans are also available under Commonwealth Care, so families can be in the same health plan even if they are technically in different coverage programs.

Cathy: It sounds kind of complicated to integrate all those programs. How does it work for families?

Brian: Families aren't required to figure out the sometimes-complicated rules about program eligibility. They can file one application for everyone in the family, and the state's combined eligibility system will place each member of the family in the best program he or she is eligible for. For the most part, the family experiences seamless unified coverage.

Cathy: Another interesting aspect of Massachusetts' health reform plan is that it didn't mandate coverage for children but did mandate coverage for adults.What was the thinking behind that policy?

Brian:When Massachusetts passed its health reform legislation in 2006, we already had a very low uninsurance rate for children - just a few percent. The problem we had was growing uninsurance among low-income working adults. Since no state had ever required coverage before, there was reluctance to extend the mandate to children.

Cathy: How has it worked?

Brian:Since passage of the legislation, our child uninsured rate has dropped, even though kids were not included in the mandate. Parents have responded to the increased availability of affordable coverage, even without a mandate.

Cathy: Another hot topic in Washington these days surrounds the level of subsidy necessary to make insurance affordable.A family of three earning about $32,000 (or 175 percent of the poverty line) would have to pay about $1,738 per year under the bill currently being considered on the floor of the Senate.The family would pay about $1,360 under the House-passed bill. What would health coverage cost for a similar family under Massachusetts health reform?

Brian: For the two parents, the combined Commonwealth Care premiums would be $936 for the year. The parents would have a choice of up to 5 managed care plans. The plans have comprehensive benefits, no deductibles, and modest co-pays. The children would get MassHealth without any premiums.

Cathy: Do you think MassHealth would be as successful as it is at reaching so many families if it did not provide coverage at that rate?

Brian: The high premiums required of low-income families under the Senate bill concerns us greatly. We know many low-income families are stretching to survive, with higher fuel and utility costs eating into their tight budgets. The board of the Massachusetts Connector set the premium subsidies after we provided them with overwhelming evidence of the deep financial distress of many families in this income range. I worry that Congress is placing a burden on families that will not work.

Cathy: Finally, what will happen to the Massachusetts Connector if health reform passes?

Brian: The Connector is working to make sure that we don't lose the gains we have achieved. There is still some uncertainty, but we're hopeful that we'll be allowed to continue the programs that are working so well for kids and parents. 

Cathy: Thanks Brian.I also want to put in a plug for A Healthy Blog that was created by Brian's organization and is a great resource on what's happening with health coverage in Massachusetts.  Another helpful resources is the recently released Robert Wood Johnson Foundation's SHARE program report The Secrets of Massachusetts' Success:  Why 97% of State Residents Have Health Coverage.

For a change of pace, I thought I would post a video blog entry.  No, my intent is not to see whether Jocelyn had a good hair day or not, it's to see if a video can help jumpstart a dialogue better than written blog entries.  (We haven't inspired many of you to comment in recent months and we're not sure if that means you agree wholeheartedly and have nothing to add or whether we are just boring you.)  So, as an experiment, I decided to post this video to see if it will get readers to discuss important questions such as:

• Where are we with health coverage for kids today?
  

• What role have Medicaid and CHIP played in driving down the uninsured rate of children?

• What are some key lessons for health reform?

CCF Co-Director Jocelyn Guyer participated in an Alliance for Health Reform and Robert Wood Johnson Foundation sponsored briefing on the hill last month to address some of those questions.  Take it away Jocelyn ... (double-click the video to begin watching)

I hope you'll comment on the video even if it is just to say Jocelyn's hair looked great. If you want to see the other panelists, UT CHIP Director Nate Checketts and Urban Institute's Stan Dorn, please go to http://allhealth.org/briefing_detail.asp?bi=171