January 2010 Archives

"...let's talk about honoring our most important responsibility as Iowans. That is, our duty as parents, and as shepherds of our children's future. You know, I'm proud of the fact, that working together, we've made a long-term investment in the health and education of "all" children... Together, we must continue this investment, and my budget will reflect this."


I recently returned from maternity leave and had no idea what the state of children and family health coverage would be given the protracted battle on health reform and the challenges facing state budgets. I was pleasantly surprised to see that while there is still a lot of anxiety about current state budget woes and health care reform, that many lawmakers, like Governor Culver, are vigorously defending the improvements they've made for children's coverage in recent years. 

Most of us were glued to the TV set last night waiting to see what President Obama was going to say about the future of the health care reform bill given its now uncertain fate in Congress. As I settled in to watch with my husband and one of my girls (the other one sadly could not be pried away from reading New Moon), I found myself getting antsy.

Why do we find ourselves in this situation? Why isn't he announcing that he signed the bill today?

Passing comprehensive health care reform legislation is extraordinarily difficult. Passing any comprehensive bill is difficult these days. But I have very little patience at this point for the political pundits and everybody else assessing the political calculations of whether passing the bill is the right political choice. Personally I think it is. And I thought the President did a nice job in his speech last night in making clear that he wants to see a bill. But the public wants to see results -- results that will improve the lives of families.

Having worked on public policy issues affecting low-income families for the last twenty years in Washington it's easy to become cynical. It's almost embarrassing to let your compassion for people show through in public without citing research and data and carefully crafted messages. Here goes, I'm going to let the policy wonk take a backseat and talk about people because that's what this is really all about -- people who need results from our leaders.

Children need health care reform to ensure that they have access to affordable comprehensive coverage. Yes kids have done relatively well with our current assortment of public programs, but not everywhere. Some states are leaders, but other states will never catch up. And the current state fiscal crisis reminds us that until we have a universal, federal guarantee of comprehensive coverage for children we will be selling our kids short.

Parents need access to affordable coverage options that don't disappear when they lose a job or become sick. Coverage of low-income parents through Medicaid is inadequate at best and almost non-existent in some states. Children do better when their parents have health coverage. Expanding Medicaid coverage to all parents below a specified income level regardless of where they live, as both bills do, would be an enormous victory for the most vulnerable families in our nation.

So-called "childless adults" need access to affordable coverage options. OK the first two are kind of no-brainers for childrens' advocates. So why do I keep finding myself thinking about two "childless adults" that I met in 1991 when I was writing a report on homeless veterans? Childless adults are not politically popular. But I can't get the stories of these two men out of my head.

Both of these men were Vietnam veterans and had seen combat duty in Vietnam. One was white and one was black. One was a Member of Congress who was the primary sponsor of a bill to help homeless veterans (I'll call him Al) and one was a homeless veteran (I'll call him Bill) who was an eloquent spokesperson. At the time that I did the report, I met Bill who was living in his truck. He had, ironically, been working in the Senate as a maintenance worker who moved furniture around. But one night a woman got shot outside his apartment. A shotgun ripped off half of her face. Bill went out to help her (he had served as a combat medic in Vietnam), and she died in his arms. This tragedy triggered PTSD and his blood pressure soared. He lost his job and his health insurance and got little help from the VA. He ended up living in his truck. He was a "childless adult" with no insurance.

Now let's turn to the former Congressman. Surely he doesn't need any help from the pending bills?? Well it turns out that because this public servant was an extraordinarily dedicated guy, he turned down all of the perks of his job (the pension and the health insurance). Then, at an early age, he developed Parkinson's disease. And because he had the audacity to live longer than expected, Al has hit the lifetime cap on his insurance policy. Now people have to have fundraisers to pay his medical costs. Pending bills would remove lifetime caps.

So let's all redouble our efforts to pass health reform. For the kids, their parents and for Al and Bill.

The image of sweet little Sarah McIntyre immediately came to mind as I read the Pediatrics Journal's study that showed that children with special health care needs were 57% less likely to be uninsured in 2005 than those in 2001.  The Pediatrics report is great news but it should be taken with a dose of caution.  CHIP and Medicaid have helped improved access to affordable health coverage for children with special health care needs but those gains can be as precarious as their health so without continued vigilance, this trend could rapidly deteriorate. 

The precarious nature of health coverage for children with special health care needs is what brought Sarah to mind.  Sarah is a 3rd Grade girl from Yakima, Washington who was born with a hole in her heart and cysts on her lungs.  Her life depended on consistent, quality health care that she received through Apple Health for Kids, Washington State's Medicaid and CHIP program.  She lost her health coverage when her parents received modest raises that put their income slightly above the eligibility cap.  The McIntyre family went through a difficult period in which Sarah was uninsured.  Fortunately, Washington state expanded coverage to families earning up to 300% of FPL with the help of increased federal funding included in CHIPRA and Sarah was able to enroll in Apple Health for Kids once again.

There are many more Sarah McIntyre's out there.   According to another report in last month's Pediatrics, approximately 1 of every 7 children in the United States has special health care needs. Children with special health care needs are those who are at increased risk for a "chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally". They are at greater risk for unmet health care needs and, on average, expenditures for their care are about 3 times higher than for other children. Their families oftentimes must rely on Medicaid or CHIP programs to find coverage.  (Medicaid coverage is a better fit because it is more comprehensive than CHIP and provides an important lifeline to children whose health care needs are often greater than the norm and whose families' limited incomes make it difficult for them to afford uncovered health expenses.) There are also many children with special health needs who remain uninsured because insurance providers will not accept them with a pre-existing condition or because their families can't afford the high private health insurance premiums to get the coverage their children need.

Sarah's story and the Pediatrics reports remind us of what's at stake in the health reform debate for families of children with special health care needs. 

 

 

 

 

Like everyone else in D.C. health policy circles, I've spent much of the last few days obsessively checking for updates on whether there is a coherent plan emerging from the White House and Congress for moving forward on health reform. Not yet, which means that instead of rolling up my sleeves and thinking about how CCF might best help to implement health care reform, I have some time to contemplate all that would be lost if policymakers fail to move forward on reform or decide to scale it back.

The worst thought is giving up on the opportunity to create a more compassionate and fair health care system.If reform passes, we can expect millions of children to gain coverage as their parents come forward to apply for insurance. These children no longer will go untreated for medical conditions that could affect their trajectory in life.As importantly, if reform passes, children no longer would have to see their parents and other adults in their lives struggling with the untreated medical conditions or the medical debt that can come with being uninsured.  As my colleague, Martha Heberlein, has pointed out, the research is unequivocal on the point that children fare better when their parents also have insurance, presumably due to both the financial stability it confers and because it is tough to be an effective parent when coping with an untreated medical condition.

More immediately, the failure to pass reform would mean that children could still be denied coverage because they have a pre-existing coverage, such as asthma, diabetes, or autism. And, we wouldn't get the benefit of improvements to benefits for children contained in both reform bills, which means millions of children could miss out on hearing tests, eye tests, dental care, and, in more serious cases, developmental assessments that could dramatically affect their ability to grow and develop.
 
Finally, reform holds out the tantalizing prospect of stabilizing and strengthening the successful Medicaid and Children's Health Insurance Program, which together cover close to one in three of America's children. Medicaid is slated to receive a major investment of federal funds for extending coverage to more people, and, also, possibly, for increasing access by improving Medicaid reimbursement rates. If reform fails, we not only lose a valuable chance to stabilize and strengthen these programs, but face the prospect of states cutting back on Medicaid when fiscal relief runs out at the end of this year. We could see more states try to solve their state fiscal problems, in part, by putting uninsured children on waiting lists for coverage, as already has occurred in Tennessee and Arizona.

There has been a lot of rumbling about a scaled-back version taking on the necessary insurance reforms such as prohibiting insurance companies from denying coverage due to pre-existing conditions, but this isn't a viable option. Many have pointed out that those reforms will actually increase insurance policy costs if we don't also expand those who are insured by making insurance coverage more affordable. If it were possible to ban pre-existing conditions without having the harder debate about broader health reform, it likely would have happened long ago.

I'm still optimistic that the nation's policymakers will find a way to move forward on health reform that offers pathways to affordable coverage for everyone. The cost of failing to do so is simply too high.

The election of Scott Brown to the U.S. Senate changes many things, but it doesn't change one simple fact:  children and families still need better access to quality, affordable health coverage.  

While figuring a way out of this sticky situation is above my pay grade, there are a lot of savvy legislative strategists working on the next step for health reform legislation.   It's very likely that the reconciliation process will be part of the solution.  As we all anxiously wait to see what's next, we might want to channel our nervous energy into refreshing our understanding of the reconciliation process by re-reading last Fall's entry by CBPP's Edwin Park.  

Here's a condensed version of Edwin's earlier post:

 What is Reconciliation?

First, the basics.  A reconciliation bill is a single piece of legislation that typically includes multiple provisions (generally developed by several committees) all of which affect the federal budget -- whether on the mandatory (or entitlement) spending side, the tax side, or both.  Under House and Senate rules implemented when the Democrats took control of Congress in 2007, reconciliation cannot be used for legislation that would increase the deficit so any reconciliation bill must be fully offset, that is it must include mandatory savings and/or revenue increases that pay for any higher spending and/or tax cuts in the bill.  Reconciliation, of course, can also be used, as it was originally, to reduce the deficit.  Reconciliation is generally used to speed passage of legislation through the Senate by providing special procedures that make it easier for a bill to pass.

 

 

There has been much discussion about states' ability (and willingness) to help finance health reform, especially as it concerns an expansion of Medicaid. A little background data may help to illuminate the debate.

While significant, Medicaid's role in state budgets is far more modest than the headlines often suggest. Medicaid constitutes 16.2% of state general fund spending, leaving it well behind elementary and secondary education (in fact, as shown below, states spend nearly twice as much of their own money on elementary and secondary education (35.1%) as on Medicaid).

It is often, misleadingly, suggested that Medicaid consumes a larger share of state budgets than any other item. Misleadingly because the numbers cited to make this point include federal Medicaid matching funds states receive. So while this may be true for total state spending (if you include federal funds), it is not the case if you consider Medicaid spending as a share of a state's own general fund (basically just the state's money). In fiscal year 2009, state funds spent on Medicaid actually decreased by 2.2% from fiscal year 2008 due to the increased federal Medicaid support made available by ARRA - the federal stimulus legislation.

As the health reform debate continues, it is important to acknowledge state concerns regarding their dismal fiscal conditions and realize that there are certainly options to adjust the formula in order to make it more equitable across states.

However, it is also vital not to lose sight of the larger point - states are getting a pretty good deal out of health reform: near universal coverage with marginal costs. Yes, their budgets are in disarray and yes the federal government (not to mention their citizens) are expecting a bit more of them. But these requirements are years away, as states would not be expected to contribute to the cost of the newly eligible until 2015 in the House bill and 2017 in the Senate bill.

There's a risk of exaggerating claims without a full understanding of the fiscal implications of health reform (or current Medicaid spending). Everybody would be better served by having an honest debate about the true costs of reform and how best they can be shared.

(Editor's Note: John Bouman is the President of the Shriver Center. He is recognized for being one of the most effective and thoughtful public-benefit advocates in the country. Say Ahhh! asked him for his thoughts on national health reform.)



We all worry about our children so of course we are concerned about the treatment of children in health reform. There is worry about the House bill's ultimate elimination of the CHIP program and switch of covered children into either Medicaid or "the exchange". The exchange is said to be too uncertain, because premiums and co-payments could be too high and result in families not buying coverage, which could then result in the family's children becoming uninsured.

Those are legitimate concerns and worthy of the strong advocacy they are getting. Children's advocates have worked hard to preserve the CHIP program at least until the "exchange" plans prove themselves as vehicles for children's coverage. But it is also important to work to achieve the best possible affordability of insurance in the exchange. Arguably, it is the higher priority.

The best way for a child to be healthy is for the child to be part of healthy family. If the parents understand prevention and early treatment, and pursue their own health, the children are much more likely to be on that course themselves. For children to be healthy, they not only need coverage, but they need to be enrolled, connected to a doctor, and then actually conveyed to the doctor at the right time by their parents (or other caregivers), which is much more likely if the parents are healthy and focused on their own healthcare.

So the top option for a health system, from the children's point of view, is a system that serves families well, prompts smart healthcare behavior by the adults, and maximizes family health. If we can't have that, then the fallback is a system that at least does what it can to serve the children. That's the current U.S. system as it applies to low and moderate- income families. We fail the parents and young adults, but we do what we can through Medicaid and CHIP to help the children and a few adults. Because the system, by failing to cover adults, blocks most of them from establishing a medical home and pursuing the smartest health care possible, their children are denied the chance to live in a healthy family and thus denied the best chance to be healthy themselves. Because we have a fallback system, recently improved through CHIPRA, the children still have a chance for a healthy life, but it's a second best chance.

The best way to achieve children's health is through whole family health. Children's advocates should not leave advocating for a strong exchange to other health care advocates. A strong and affordable exchange should be the first priority for children because it includes the whole family, which is the healthiest situation for children. The children's groups should be leaders in support of the affordability of exchange policies, even as we continue to fight hard to make sure that CHIP is there for kids who need it.

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

Right after the question of how the incredibly busy OMB director Peter Orszag managed to find the time for such an exciting personal life, the major topic in D.C. policy circles is what will be in the final health care bill. For the latest "big pictures" stories, check out Politico and the New York Times. But, here is what we've been able to glean on issues of particular importance to kids and families.

On Medicaid. Long-time Medicaid champion, Representative Henry Waxman, Chairman of the House Energy and Commerce Committee, is pushing hard to address access concerns in Medicaid by increasing reimbursement rates for primary care services to Medicare levels. With Medicaid slated to be a cornerstone of health care reform, the argument is that now is the time to tackle this issue. In the House bill, the initiative was estimated to cost $57 billion, which means if it is in a final bill, it is quite possible that it will be in a scaled-back form with a less hefty price tag.

As for the larger question of whether the bill will take Medicaid eligibility to 150 percent of the federal poverty level (House) or 133 percent of the federal poverty level, we have no good clues. The Senate seems adamantly opposed and the nation's Governors already are up-in-arms about the fiscal impact on states of Medicaid expansions. On the other hand, it is less expensive to cover people through Medicaid than Exchange plans and right now, anything that helps lower the federal cost of health reform is likely to be considered.

On CHIP. It increasingly looks like the final bill may adopt the Senate's strategy of continuing CHIP, although nothing is certain at this stage. Over the weekend, Rebecca Adams with Congressional Quarterly reported the following: Many analysts expect that some version of the Senate language will prevail in the final bill. Not only do many child advocacy groups prefer it, but so do health insurers. Lobbyists for America's Health Insurance Plans, an industry trade group, say that shifting people into different programs could be disruptive and confusing, which could lead to some children ending up uninsured. And, Mike Lillis of the Washington Independent just ran a story entitled "Waxman Not Married to CHIP Repeal," in which he reports that while Waxman strongly favors his approach on CHIP, he may not insist on it. "I'm not drawing lines in the sand on anything," Waxman said.

On Affordability. Consumer advocacy and faith-based groups are pushing hard for improvements to the subsidy structure for low-income Americans and, in particular, for the final bill to draw on the House's approach for people below 250 percent of the federal poverty level. But, no hints are emerging in the public domain on where this is heading. It will come down to money.(As my kids routinely say to any and all bits of information that I share with them, "obvious.")

Where do you think these issues are headed? Any clues you'd like to share with the Say Ahhh community?

Each celebration of a new year brings a renewed sense of optimism and 2010 offers tremendous promise in mitigating the chilling impact of the citizenship documentation requirement imposed by the 2005 Deficit Reduction Act (DRA) on Medicaid. The citizenship documentation requirement not only made it more difficult for eligible citizens to enroll in Medicaid but states have also spent millions of dollars in administrative costs to comply with the regulation. The title of a study by the Government Accountability Office says it well: "States Reported that Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens." 

Michele Johnson, Managing Attorney, Tennessee Justice Center





In 2006, Governor Phil Bredesen pledged to make our state "an island of excellence" by making sure "every child in Tennessee" had health coverage. He established a new program, to be known as CoverKids.

CoverKids would be Tennessee's version of the Children's Health Insurance Program, or CHIP. The federal government covers 75% of the cost for CHIP in Tennessee, and even with that favorable funding, Tennessee remained the only state without a CHIP program. CoverKids would get Tennessee out of last place and put us "in the top ten states in the nation in terms of the percentage of children covered by health insurance."

Tennessee just became an "island" alright, but not the kind the Governor envisioned. On December 1, Tennessee became the only state in the country to close enrollment in its CHIP program. On that day, the state slammed the door of CoverKids to new applicants.  Far from ensuring coverage for "every child in Tennessee", as the Governor promised, CoverKids coverage is frozen at 49,000 children, leaving Tennessee's other 150,000 uninsured kids out in the cold.  

When that decision drew criticism, the state announced that another program, AccessTN, would enroll children. Sadly, that is more about providing cover for elected officials than coverage for kids. AccessTN sells insurance only to people who cannot buy coverage elsewhere because of pre-existing conditions. Last month, the head of AccessTN said the program had no money to help families afford AccessTN's high premiums. As a result, the program reaches less than 4,000 people statewide. AccessTN is no answer for uninsured children shut out by CoverKids.

Tennessee is the last state in the nation that can afford to neglect the health of its children. Infant mortality in Tennessee is worse than in many developing countries, and the rate of infant deaths in Memphis is the worst of any city in America. The Commonwealth Fund, a foundation that sponsors health quality research, recently ranked Tennessee 47th in children's health care, measured by the number of children who die of causes that could have been prevented by health care. A state this unhealthy for kids should be striving hard to improve children's health coverage. Instead, Tennessee has just become an island of neglect, in terms of the health of its children.

Shortchanging children's health is justified as a budget necessity imposed by the recession. But that is an excuse, not a reason. Every state has been hammered by the recession, some far worse than Tennessee. And unlike other states, Tennessee has $350 million in unspent TennCare reserves. The federal government contributes a higher share of CHIP costs in Tennessee than in most states. Yet no other has responded to its budget problems by abandoning its uninsured children. In fact, 26 states took steps to advance health coverage this past year, and our neighbor, Alabama, expanded eligibility in its CHIP program.

Other states' leaders know that, if times are hard for state governments, they are even harder for uninsured children and their families. They realize that playing Scrooge not only robs some kids of their health. It costs their states tens of millions of federal dollars and adds to social and medical costs for decades to come.

That's why, even in a recession, every other state makes children's health a priority. Tennessee should, too.

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

To learn more about the Tennessee Justice Center please visit their Website, Facebook page, and blog. 

While the rest of the nation took a break to celebrate the holidays, the gears in Washington continued the churn bringing us ever closer to health reform legislation being signed into law.   Now our attention turns to the House and Senate conference committee that has not yet been officially appointed but staff is already laying the groundwork for agreement.  

One big question the conferees will decide is what will happen to the children and families that rely on the Children's Health Insurance Program.  The House bill eliminates CHIP in 2014 and moves the children into Medicaid and the Exchange with a federal subsidy to offset the cost while the Senate would continue CHIP through 2019 (but, currently funds the program only through fiscal year 2015).  

David Herszenhorn writes in the NY Times Prescriptions that many children's health advocates are concerned about children losing coverage because it is unaffordable or that the shift from one program to another isn't done in a seamless manner.  He quotes Genny Kenney and Allison Cook's report for the Urban Institute "that some children who lose CHIP coverage could fall through the cracks and become uninsured." 

CCF's Jocelyn Guyer is also quoted in the Herszenhorn's blog pointing out that we've made remarkable gains in covering kids in recent years and that "it would be a major problem if health reform undercut these gains by shutting CHIP down too abruptly or by moving kids into coverage that isn't as affordable and as well-designed to get them the care they need to develop and grow."

Notably, Herszenhorn's blog also digs deeper into some of the other issues of equal importance to kids, including the fate of the House's efforts to increase Medicaid reimbursement rates for primary care.   With Medicaid already covering 7 to 8 times as many children as CHIP, it is critical that this program work well for children and their families (as well as the millions of uninsured adults who will be covered by the program under reform) and provide needed access to care.  And, of course, an overarching issue for all kids and their families is the affordability of coverage provided through the Exchange.

The conferees will have to resolve these different approaches and many other issues quickly if they are to meet the goal of getting the bill to President Obama in time for his State of the Union address.   What do you think they should do?