March 2010 Archives

(Editor's Note:  While CCF staff had their noses buried in legislative language and watched the health reform debate from the comforts of their own homes, PICO's Gordon Whitman was out on the front lines. From what we saw on our televisions, there was a lot of commotion as protestors on both sides of the issue gathered on the Capitol grounds.  An immigration march also took place that day adding to the crowd. We asked Gordon to share his observations from the final climactic stages of the health reform debate.  The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.) 

By Gordon Whitman, PICO National Network of faith-based community organizations

Sunday, March 21st, was one of those days that remind you how change is not linear in our crazy mixed-up Democracy.  At five o'clock in the afternoon, as the House of Representatives inched toward a final vote on health reform, many of the estimated 200,000 people who were on the Mall to breathe life into immigration reform streamed up and around the Capitol.  These were mostly young Latino families, many waiving or draping themselves in American Flags.   It was surreal watching the immigration march - which was virtually invisible in the media (not unlike its protagonists) - flow around the several hundred people protesting against and for health reform.  

I watched an older Anglo women lecture (in Spanish) a group of young Latino men, who were sitting on the wall, behind the Capitol about the evils of Obama-care.  "Obama-care is Communism. You didn't come to this country for Communism, you came for liberty."  One man replied, "Ma'am, I'm not a citizen, so I don't think I can tell Congress what to do about health care.  But let me become a citizen and then I'll take a position."  Suffice to say, there wasn't a lot of persuasion taking place.

As a community organizer, (saying that used to provoke blank stares, now it feels like picking a fight) it was a bit odd to be escorted through the protests into the Capitol Building to watch the final vote from the Speaker's box in the House Gallery.  A year earlier, during the final vote on CHIP Reauthorization, I'd sat in the same spot with Rev. Heyward Wiggins, who pastors an inner-city church in Camden, New Jersey.  Rev. Wiggins co-chairs PICO's National Steering Committee and has led our work on health reform.  It was hard not to feel a bit vindicated, those of us who argued against much opposition that a victory on covering children would be an ideal stepping stone for broader reform, rather than an excuse for putting off the fight for universal coverage (it is nice to be able to use the word universal again).

It was quite an experience watching the social interactions among Members and staff on the floor.  You see how important senior staff are to the process; and how divided the chamber is physically and how much rancor there is between Republicans and Democrats. The Republicans were clearly frustrated and angry; and the Democrats were celebrating. Speaker Pelosi looked thrilled. She was able to round up the votes plus a bit of a cushion ahead of time, so the Leadership avoided what many people expected to be intense arm-twisting on the floor leading up the vote.

As the President said earlier in the month, after a year of debate, almost everything that could be said about health reform has been said; so much of what was being said on the House floor echoed the talking points that we've heard all year.  I thought Rep. Debbie Wasserman Shultz broke through emotionally when she talked about being a breast-cancer survivor and what reform would mean for women like her who have life-threatening pre-existing conditions.

The high emotion of this week reflects the reality of how close reform came to failing.  Doubt is an unavoidable emotion.  Avoiding death is an exhilarating experience.  As organizers, we believe that social change happens when people realize how much power they really have.  Coming up short on an organizing campaign (which almost always happens at some point) teaches us that we need more power; winning teaches us that we are more powerful than we ever thought.   The moral arc of the universe bends toward justice because we bend it as we grasp the power that comes from being human.  

The fight to make health care a right in the United States spans generations.  In 1965, a gifted President committed to lifting people out of poverty met up with a Civil Rights Movement at the height of its influence to create a remarkable environment for large-scale legislative change.  In the course of less than a year, Congress passed Medicare (and Medicaid) which broke the link between aging and poverty for tens of millions of Americas; the Voting Rights Act, which institutionalized the political liberation of African-Americans in communities across the United States; and the Immigration and Naturalization Act, which ended racial quotas in the immigration system and opened the doors of the nation to a generation of immigrants from Asia and Latin America.

In the 45 years between 1965 and 2010, Americans grew to love Medicare, but progress toward truly universal coverage was incremental and uneven at best.  Congress took important steps to expand the Medicaid program to cover more poor families; and in 1994 it created the State Children's Health Insurance Program.   Mostly, though, there were failures, most spectacularly the Clinton health reform debacle in 1993-94.  As Health Care Economist Len Nichols has said, not a single soul was covered as a result of the Clinton reform effort, and perhaps as many as one-quarter million people died prematurely as a result of that failure.

Between 1994 and 2004, most of the action was at the state level, as state advocates and organizers and state governments used Medicaid and SCHIP to cobble together initiatives to expand health coverage.   Our PICO network's involvement in the health reform movement began during these years, as our affiliates responded to the growing number of uninsured families by joining with advocacy groups to fight for more funding for safety net clinics; and to help create the first county programs that provided truly universal coverage to all children, regardless of income or immigration status.  

The media is not good at history and is virtually incapable of covering the patient, sometimes very impatient, work of building the foundation for the kind of fundamental change that took place this week in Washington, DC.  National health reform rests on the foundation of local and state organizing and advocacy.

There is no way that our network could have participated in any meaningful way in the national health reform debate without first having worked to pass a strong children's health insurance bill, and there is no way we could have done that without the policy analysis by CCF and the support from the Center on Budget Policy and Priorities, Community Catalyst and other organizations.

We sent out a thank you note to our grassroots leadership, thanking people for all of their work, especially their laser-like focus on affordability for lower-income families.  We did not get everything we wanted in health reform, but the late addition of $122 billion in additional subsidies to lower premiums and out-of-pocket costs for lower-income families; the increase in primary care provider payments in Medicaid; the $12 billion in funding for Community Health Centers and the continuation of CHIP through 2019 were all important improvements in the final bill that will make reform work better for low-wage working families, which has always been PICO's primary reason for being in this debate.

A right to health care in America is no small thing.  But we know that between organized campaigns to repeal and undermine reform and recalcitrant insurance companies our work is cut out for us.  As we learned from the Civil Rights Movement, redeeming the right is always more difficult than winning the commitment. 

On Tuesday evening, after the signing ceremony at the White House, I was at CVS arguing on the phone with my insurance company to get them to cover medication that my son's pediatrician had prescribed for a really bad rash.  Blue Shield insisted they could not cover it because there was a different cream (not a generic) that was cheaper and they believed worked as effectively.  After asking to speak to a supervisor and explaining that the doctor's office was closed and I wanted to get my son moving on the medication tonight, I found myself saying (not too politely) you are standing between my son and his pediatrician.  I was given a "pay and educate" lecture, which I had no patience for, but felt empowered (perhaps by health reform) walking out with the medicine.  When I came home and told the story to my son, he asked, "Why did that happen, I thought President Obama signed health care today?"

PICO is a national network of faith-based community organizations working to create innovative solutions to problems facing urban, suburban and rural communities.

It's appropriate that we are celebrating the passage of health reform while enjoying the first signs of spring. With snow banks receding and the sun warming, we happily anticipate the bounty of health reform as we watch the early sprouts emerge.

Ongoing state budget woes, however, remind us that a spring snowstorm can still bring a chill to the air. But like the hardy daffodil, early provisions in health reform are intended to fortify current programs so we can focus on moving forward without losing ground.

Health reform relies on Medicaid and CHIP as fertile soil to yield a bigger crop of insured low-income adults and children: 16 million more. Growth can only be assured if we protect the coverage gains states have achieved through current CHIP and Medicaid programs as we plant the seeds to provide affordable health coverage for all.

To protect current programs from the frosty state budget climate, the health reform law discourages states from pruning current eligibility levels and imposing new paperwork and other barriers to enrollment and renewal. To ensure we reap the harvest of a smooth transition to health reform, this MOE is applicable through 2014 for adults and 2019 for children.

MOE's are not new. For example, when CHIP was created in 1997, states were required to maintain their Medicaid coverage for kids in order to tap enhanced CHIP federal funding to expand coverage. States are currently subject to an MOE on Medicaid as a condition of accepting the enhanced federal Medicaid match (FMAP) through the American Recovery and Reinvestment Act (ARRA).

There is a significant penalty if states choose to disregard the MOE in health reform. Program changes in violation of the MOE will result in the loss of all federal Medicaid funding. It doesn't seem like a tough row to hoe for states to extend the MOE to their CHIP programs considering the more significant losses - that is all Medicaid funding compared to only the enhanced federal match provided through ARRA.

The MOE doesn't mean children and families can rest easy during this transition phase.  States can still scale back by eliminating optional benefits or reducing provider reimbursement rates, which can have a chilling effect on access to services like a late frost damaging fragile seedlings.

Ultimately, the Centers for Medicaid and Medicare (CMS) will determine whether or not a state is maintaining its effort. It is not yet clear how CMS will enforce the MOE for states that have not implemented an approved enrollment freeze or cap if they exceed state appropriations. While awaiting guidance from CMS, if you want to dig deeper into this issue, check out the recently released "Holding the Line on Medicaid and CHIP" memo from CCF and the Center on Budget and Policy Priorities.

For some reason or another, there always seems to be a lot of misinformation swirling around when it comes to Medicaid.  At CCF, we received a flurry of calls about how health reform's Medicaid provisions would impact state budgets.  One call came from WAMU (local public radio station) reporter Rebecca Blatt who was trying to explain to her listeners why Maryland was estimating that health reform would save the state money while its neighboring state of Virginia estimated that it would cost the state more money.

Here's Rebecca's report:

States are releasing their estimates of how much the new federal health care law will cost them. Virginia says it will amount to about $1 billion dollars over the next decade or so, but Maryland says the law will save it about $1 billion.

The key to the difference is the fact that Maryland already offers relatively generous benefits, while Virginia does not. For instance, to the tune of approximately $100 million a year, Maryland subsidizes insurance for high-risk people. John Colmers, Maryland's Secretary for Health and Mental Hygiene, says that will change.

"We will not have to do that when the insurance rules are rewritten to eliminate pre-existing condition restrictions," says Colmers.

There will be some cost to the new federal law. But Colmers says reductions in other services will more than make up for it in Maryland.

Not so in Virginia. Medicaid, the health insurance program for the poor, will be the Commonwealth's biggest expense. Virginia will have to cover many people who already would be covered in Maryland.

Joan Alker, co-executive director of Georgetown University's Center for Children and Families, says there are upsides to that. The federal government will pay for almost all the expansion.

"So for a state like Virginia, that has not been as generous as a state like Maryland in its coverage, they'll actually get more federal dollars and benefit more from the reform bill," says Alker.

But they'll also have to pay more. That's why the new law may cost Virginia money and save it for Maryland at the same time.

 (*Editor's Note: Health reform may benefit states far more than any of the early estimates predict -- particularly for those states that got out in front on covering uninsured residents.)

You can listen to the report on WAMU's website.

How is this issue being discussed in your states?  

Once President Obama signed into law the health care reform bill, we all started to dig a little deeper into what the provisions mean for those in the "real world."  One issue that has risen to the top is untangling the new rules governing when insurance companies have to cover sick children. So, let's break down what the bill does.

Soon children with employer-based insurance no longer can be subject to pre-existing conditions. For example, a child with asthma who is on a parent's employer plan cannot be denied coverage for services during any length of time related to his/her condition. This provision will be applicable in a new health plan year beginning after September 23rd. (Note: this specific change will not apply to children currently in individual market plans.)

The question many are asking is "what about a child that is not currently insured?" While the current legislative language is not clear on this issue, the White House has provided assurances that HHS will issue regulations to address it. HHS spokesman Nick Papas stated:

"... the secretary of HHS is preparing to issue regulations next month making it clear that the term 'pre-existing exclusion' applies to both a child's access to a plan and his or her benefits once he or she is in the plan for all plans newly sold in this country six months from today."

With this clarification, a new health plan would not be able to deny coverage for a child under either an employer or individual plan because of a pre-existing condition. For families with limited or no options to secure coverage right now when their child is sick, this change cannot come soon enough.

While this is all good news for families, how the insurance industry responds to these new protections for children will also be critical. Specifically, since the provision to limit insurers from charging different premiums based on health status doesn't go into effect until 2014, we need to monitor whether insurers will attempt to place the burden on families and raise premiums once these changes go into effect.

By Ann Bacharach, Pennsylvania Health Law Project

I went to Providence last week, just ahead of an historic weekend. No, I'm not talking about Rounds One and Two of the NCAA Men's Basketball Tournament or the upset of Georgetown by Ohio. No, I was there to attend the second of CCF's regional meetings: Transforming Health Care Coverage for Children and Families: A Convening of Northeastern States.

Many thanks to CCF and the New England Alliance for Children's Health for this gathering of experts; the meeting provided an extraordinary boost to my knowledge, my strategies and my morale. It's always helpful to have dedicated time to one topic and to have colleagues from Pennsylvania share the experience.  My longtime colleague and friend from the PA Chapter of the American Academy of Pediatrics, Suzanne Yunghans, came away from the meeting ready to incorporate new ideas into her chapter's work.

Aha! moments included:

• The cost of one ER visit is enough to cover 3 kids for a year and  taking out ads thanking elected officials for"... ensuring the health of generations to come" were two great ideas from the messaging strategies session
• More clarification as to what "counts" as implementing the 5 of 8 CHIPRA simplification options (can require a signature for administrative renewal, 1906 HIPP can be converted to 1906A as Medicaid premium payment) from Vikki Wachino's presentation.
• Start administrative renewal with children in households with a low likelihood of income changes from Tricia's presentation.
• Use the shorter 3-1-1 instead of an 800 number in outreach from Vinnie DeMarco's re-cap of Maryland's efforts.
• RIteSmiles is using a dental benefits manager to improve dental access from Elizabeth Burke Bryant, executive director of Rhode Island KIDS COUNT.

Those in attendance bolstered each other's work. I heard about new resources to reinforce the argument that retention is a critical element in expanding coverage: CCF's 5 Reasons Not to Add Red Tape to Your Child and Family Health Programs, Gerry Fairbrother's report on post-gap-in-coverage hospitalizations, California studies on gaps in coverage, research on the administrative costs to states and on 21st century technology.

And I came back with a list of to-do's: re-energize the Covering Kids and Families Coalition in Pennsylvania by holding a Children's Health Care Summit (find some funding for that), finish my paper on the five reasons retention is important to Pennsylvania's CHIP and Medicaid capitation rates, add CHIPRA outreach and enrollment to the Pennsylvania's Health Access Network's conference in April.

There was cautious optimism that we would see health care reform pass in the House by the end of the weekend. There was significant despair over the dire state budgets facing all of us as advocates and as taxpayers. But quite clearly there is work we can do now: reach the families of children who are eligible for Medicaid and CHIP but not enrolled.

In his remarks to House Democrats on Sunday, President Obama said, "Every once in a while a moment comes where you have a chance to vindicate all those best hopes that you had about yourself, about this country, where you have a chance to make good on those promises that you made ...We are not bound to succeed, but we are bound to let whatever light we have shine."

So if you get a chance to attend one of CCF's remaining convenings, don't pass it up.  Let whatever light we have shine.

Today, health reform is the new law of the land.  In a signing ceremony before an enthusiastic group of supporters, President Obama signed the health reform bill.  (While the House-passed reconciliation measure that makes some improvements to the health reform bill is still pending in the Senate, the key elements of health reform are now law.) 

President Obama said the new law recognizes the fact that "everybody should have some basic security when it comes to their healthcare."  

One of the more touching moments of the signing ceremony was when President Obama paid tribute to an eleven-year-old boy who lost his mother to an illness as she was uninsured and couldn't afford necessary treatment.  It drove home for me the point that the well-being of our nation's children depends not only on whether or not they have coverage but whether or not their whole family has access to affordable, reliable coverage.   If previous efforts to pass health reform had succeeded, Marcellas Owen's mother might still be alive and well today.

While many improvements to our healthcare system will be gradually and thoughtfully put in place, there are some very important changes that will take effect beginning this year such as:

• Young adults will be allowed to stay on their parent's policies until they are 26.
• Insurance companies no longer will be able to impose lifetime limits or restrictive annual limits, nor can they drop coverage when someone becomes sick.
• Children with insurance no longer can be denied coverage for a pre-existing condition.
• Seniors no longer will pay a copay or deductible for preventive care under Medicare (starting in 2011) and will start to see some early relief from the Medicare drug benefit's "doughnut hole."
• Starting today, states will be required to "hold steady" when it comes to providing Medicaid and CHIP coverage -- they must at least maintain the coverage that they have in place now and no longer can add new red-tape barriers that make it harder for families to sign up for coverage.

At CCF, we would add one more:

• Five million more uninsured children could start receiving affordable health coverage right now through state CHIP or Medicaid plans. (These children are already eligible but unenrolled).  With families expecting concrete gains from health reform, it is a wonderful opportunity to educate people about the chance to sign up uninsured children for coverage right away.

At CCF, we view passage of CHIPRA over a year ago, as the beginning of health reform.   Many of the improvements included in CHIPRA will lay the foundation for a successful transition to an era where everyone has access to affordable, reliable health coverage.  The better job states do right now in removing red-tape from the system and reaching out to eligible but unenrolled children, the stronger the foundation will be for them to seize the opportunity to transform our health care system into one that works better for everyone. 

 

The Center for Children and Families at Georgetown University Released the Following Statement on Health Reform Passed by the U.S. House of Representatives Today:

The House of Representatives has taken a historic step today in support of America's families by passing health reform today.

By creating reliable, affordable coverage options that won't disappear when a parent becomes sick or loses a job, the legislation protects and strengthens the well-being and financial stability of our nation's children and their families.

The key provisions for families and children include:

• Makes coverage more affordable for middle class families by boosting their bargaining power through new health exchanges and providing tax credits to those who need extra help buying insurance.
•  Provides Medicaid coverage to low-income families, allowing children and parents to be covered together.
• Continues the Children's Health Insurance Program (CHIP) which has successfully worked in partnership with Medicaid to drive down the number of uninsured children to its lowest level in over 20 years.
• Ends insurance companies' discrimination based on pre-existing conditions. Starting right away, children who have insurance can't be denied coverage for a pre-existing condition.
•  Allows parents to keep their college-age children (up to age 26) on their family health plans.
•  Requires insurance companies to provide pediatrician-recommended care for children so they can grow and thrive,

With health reform finally past it's last major hurdle toward enactment, efforts cannot start soon enough to make sure it delivers for American families who will be expecting results. As a first win for families, states can reach out to the five million uninsured children who already qualify for Medicaid or CHIP coverage to help sign them up right now.

Yesterday, the House of Representatives released a "reconciliation" or "fix it" bill with final changes to the health reform package. With these changes, we can now get a complete picture of what health reform could mean for America's families and children. The $940 billion package would cover 32 million uninsured people through Exchanges and an expansion of Medicaid, adopt broad-reaching reforms in insurance industry practices, make major new investments in public health, close the Medicare doughnut hole, and reduce the federal deficit (according to the nonpartisan Congressional Budget Office).

As everyone has probably heard by now, even those who would prefer to watch March Madness than the news, the House is heading toward a final vote on Sunday on the compromise package (both the underlying Senate bill and the "fix it" bill) and it is going to be very close. If it passes, the Senate will take up the "fix it" package as early as next week. In a sign of the high stakes, President Obama has canceled a trip to Asia to be present for the final stages of congressional action on health reform. 

The final health reform package adheres closely to the structure of the underlying Senate bill and incorporates most of President Obama's ideas for changes.  For funding, it relies less heavily on an excise tax on high cost health plans and more on Medicare savings. From a child and family health perspective, some of the key provisions include:

• Stronger affordability protections. The final package increases the adequacy of tax credits aimed at helping people purchase coverage through new "health insurance exchanges." For example, those up to 133% FPL would pay 2% of income and those up to 300% to 400% FPL would pay 9.5%. Cost-sharing assistance also would be stronger than in the Senate bill. Overall, 24 million people are expected to be covered through Exchange plans, 19 million of whom would receive a tax credit for their coverage.

• Expands Medicaid up to 133% of the FPL. The "fix it" bill eliminates the special deal for Nebraska and instead provides all states with an enhanced federal matching rate for people made newly eligible as a result of the Medicaid expansion. This new "super" matching rate is set at 100% in calendar years 2014, 2015, and 2016; 95% in 2017; 94% in 2018; 93% in 2019; and 90% in 2020 and future years. Overall, the federal government is expected to pick up 95% of the cost of the new Medicaid expansions and fully 98% of the cost of covering 32 million more uninsured people. 

• More equitable Medicaid financing for leading states. Due to a provision in the reconciliation bill, leading states that already cover adults (both parents and childless adults) up to at least 100% FPL will be treated more equitably. By 2019, these states will receive the same "super" matching rate for childless adults up to 133% FPL as states that never covered them prior to reform. Specifically, each of the "leading" states will see 50% of the gap between its regular Medicaid matching rate and the "super" matching rate addressed in 2014, 60% in 2015, 70% in 2016, 80% in 2017, and 90% in 2018. For example, a "leading" state with a regular matching rate of 60% will receive a matching rate for childless adults of 80% in 2014, 84% in 2015, 88% in  2016, 88% in  2017, 90% in  2018, and 93% in FY 2019.  The states that appear to meet the criteria of a "leading" state include AZ, DC, DE, HI, MA, ME, MN, NY, PA, VT, WA, and WI.

• Higher Medicaid reimbursement rates for primary care. As reform is being launched in 2013 and 2014, states will receive 100% federal funding for the cost of increasing their Medicaid reimbursement rates for primary care services up to Medicare levels. CBO estimates this change will cost the federal government $8.3 billion over 10 years and will have a positive effect on Medicaid reimbursement rates even after 2014.  

• Simplified enrollment procedures. Along with maintaining the Senate's provision requiring "no wrong door enrollment," the final package simplifies enrollment and allows for better coordination between Medicaid and the Exchange by adopting a uniform definition of income ("modified adjusted gross income"). In place of Medicaid disregards for various types and kinds of income, the final bill calls for using a uniform 5% income disregard. This provision applies to all Medicaid beneficiaries, except for those who also qualify for Medicare, as well as to CHIP.

• Continuation of CHIP. As expected, the final package continues CHIP through 2019, and provides new federal funding for the program from FY 2013 through FY 2015. States are required to maintain their CHIP and Medicaid coverage for children, and will receive a 23-percentage point increase in their CHIP matching rate beginning October 1, 2015.

Facing a $2.6 billion budget shortfall in fiscal year 2011, Arizona has resorted to $1.1 billion in cuts. In doing so, the state made the unprecedented move of repealing the state's Children's Health Insurance program, KidsCare. Estimates are that 47,000 low-income children will lose coverage as a result and another 13,000 children will be impacted by cuts to the state's Medicaid program. No state has ever eliminated its CHIP program. In fact, only one state has ever rolled back CHIP eligibility. (In 2004, Alaska reduced eligibility from 200% to 175% of the FPL.)

There have been instances where states have capped enrollment due to budget constraints, but they have always re-opened the programs once additional funding was secured (this recently happened in both Tennessee and California). However, by voting, not only to defund the program, but to repeal the statutory language authorizing its existence, reopening the program when the budget improves will be a much, much heavier lift.

Also in the state's budget are cuts to its Medicaid program (AHCCCS) - specifically, the state did not fund its Prop 204 expansion population, limiting spending to what the state has in tobacco settlement funds. (Prop 204, passed by a voter referendum in 2000, expanded Medicaid to all uninsured residents below 100% of the FPL.) It is not yet clear how the state will scale back AHCCCS to meet these funding restrictions. Estimates suggest that more than 300,000 people could lose coverage.

These cuts are likely to leave many uninsured, driving them to seek care in the emergency room or to simply go without necessary treatment.

There may be some hope for the low-income children and families who rely on the coverage they get through KidsCare and AHCCCS. Congress is working on extending the enhanced FMAP to states through the end of the fiscal year 2011 and this influx of federal dollars could be tapped to restore the devastating cuts in the state budget.

Arizona is the only state to ever make such a drastic and shortsighted cut to its CHIP program and it will be dealing with the fallout from this decision long after the state's budget situation improves.

The new game in DC these days seems to be naming every other bill coming out of Congress a "jobs bill."  While the provisions in each of these bills may indeed focus on job creation, it has become nearly impossible to keep the different bills straight. It becomes particularly perplexing when tracking an issue many of us have been watching: the six-month extension of increased Medicaid reimbursements that were initially part of the economic stimulus package.

Here is a Q&A to help you decipher where it stands.

Has the Senate passed an extension of Medicaid fiscal relief?
Yes. Last week, March 10th, the Senate passed HR 4213. The bill provides $26.7 billion in additional Medicaid fiscal relief funds through June 30, 2011 (the original provision was slated to expire at the end of this year). The extension would still require states accessing the funding to maintain their Medicaid eligibility and enrollment rules. The bill also extends unemployment benefits and COBRA subsidies through the end of the year.

Is this the same bill that President Obama signed today?
No. The bill that President Obama signed today does not include Medicaid fiscal relief but instead provides tax breaks to businesses hiring unemployed workers and extends infrastructure and transportation projects.

Has the House passed an extension of Medicaid fiscal relief?
Yes. In December 2009, the House passed a similar six-month extension of federal assistance for state Medicaid programs, and the "maintenance of effort requirement, as part of another "jobs bill," HR 2847.

Are there any differences between the House and Senate versions?
There is one difference between the House and Senate Medicaid fiscal relief provisions. The Senate bill includes a provision that would require Governors to affirmatively request the additional help from the federal government. There is some discussion on ways to ensure that this language does not unduly harm residents if a Governor does not want make such a declarative statement.

When will we see a final bill with the Medicaid fiscal relief provision?
The House and Senate need to reconcile their bills (which include many other provisions beyond state fiscal relief) before a final package can be sent to President Obama to be signed into law. The House could either pass the Senate bill or convene a conference committee. There is some urgency to moving this forward quickly since unemployment benefits and COBRA subsidies (included in both bills) are set to expire at the end of March. However, if Congress cannot reach agreement on a final bill before the two-week Easter recess they can pass a temporary extension of these benefits (which it has done twice before).  
 

For additional information, read CCF's analysis of the implications of the Medicaid fiscal relief on children and families.

Mom: "Did you brush your teeth?"

Child: "Yep."

Mom: "How come your toothbrush isn't wet?"

This is an excerpt from the script of the bedtime drama performed live nightly in the comfort of my own home.  Just between you, me and the tooth fairy ... after battling on the nutrition, hygiene and homework fronts, I don't have a lot of energy left to wage the toothbrush wars.  That's why I'm always a bit nervous about dragging my children to their 6-month dental check-ups.  Luckily, we have good dental benefits and an understanding dentist.  With the help of the dentist and dental hygienists, we've managed to get through with only a couple of cavities between all three kids.  (The nightly drama slacks off a bit after a good "education session" from the dentist.)

Other parents are facing the same obstacles to ensuring their kids have healthy teeth and gums but not all of them are able to rely on a dentist.   Even children with excellent brushing and flossing habits need to see a dentist because untreated dental disease and tooth decay can have devastating health consequences.  However, about one in five children in the U.S. do not receive dental care each year according to a new report The Cost of Delay: State Dental Policies Fail One in Five Children, by the Pew Center on the States.  The report points out that states play a key role in ensuring that low-income children have access to basic, preventive dental care and that more than two-thirds of the states are doing a poor job in this area.

The good news is that the Children's Health Insurance Program Reauthorization Act  provided states with new tools to help improve the oral health of children.  All CHIP programs are now required to cover comprehensive dental benefits. CHIPRA also allows states with separate CHIP programs to offer a dental-only plan for children who have other health insurance, but lack adequate dental benefits. Other oral health improvements include education for new parents, better access to benefit and provider information, and enhanced reporting on the quality of dental health services in Medicaid and CHIP.  CCF, the Kaiser Commission on Medicaid and the Uninsured, and the Children's Dental Health Project just released a "CHIP Tip" on CHIPRA's oral health provisions which is a good resource for those who want to see children receive better oral healthcare coverage.

 

Brace yourselves for a hectic few weeks leading up to the Congressional recess.  According to CQ, House leadership is preparing for a possible final vote on health reform as soon as next week.  It is still unclear whether or not they have the votes to pass the measure, which would actually be the Senate bill along with a reconciliation bill that includes agreed-upon "fixes" to the Senate bill.

The process of moving the legislation through the House is expected to begin Monday in the House Budget Committee. The next stop would be the Rules Committee then the floor.  We are expecting to see the actual legislative language of the final bill on Tuesday after which members (and the rest of us) would have at least 72 hours to review it before a vote is taken.

There are a number of procedural questions that remain to be answered but if all goes well, the bill could be on the House floor for a final vote around March 19th or 20th. Members have been told to prepare for a vote at the end of the week, staying through the weekend if necessary.  Then, of course, the Senate still would need to pass the "fixes" included in the reconciliation package.

Right about now, you probably have to "pinch" yourselves to make sure you're not dreaming this.  Believe me, I had to pinch myself while writing it.  In a sign that health reform really is moving forward again, President Obama postponed his March 18th trip to Indonesia so that he would be around for the final push for passage in the House. 

Now, back down to earth ... In other developments impacting health coverage, the Senate moved forward as expected on fiscal relief to states through an extension of the Federal Medical Assistance Percentage (FMAP) increase as part of the American Workers, State, and Business Relief Act (aka "jobs bill").  The House already has passed the FMAP provisions. The jobs bill is now moving through the final stages of the legislative process and, as always, it's not cut and dry.  However, the outlook for enactment of the FMAP provision still looks positive, which is good news for the country's children.  As we noted in a new analysis, when families lose their jobs, they often lose employer-based coverage and turn to Medicaid and CHIP, especially for their kids.  In fact, children represent more than 60 percent of those who have gained Medicaid coverage over the past year.  If the Medicaid program doesn't remain strong in the months ahead in the face of persistently high unemployment and ongoing state budget problems, we can expect that children will be particularly hard hit.

March 10, 2010 was a memorable day for children's health advocates in Ohio. Ohio became the first state to join HHS Secretary Kathleen Sebelius' quest to enroll all children eligible for Medicaid and CHIP. In accepting the challenge Secretary Sebelius issued to states in November at the National Children's Health Insurance Summit to enroll all eligible children, Governor Strickland announced that Ohio will take immediate steps to adopt key policies to advance coverage. 

In a symbolic gesture, Governor Strickland and our dear friend, Cindy Mann, CMS Deputy Administrator for Medicaid and CHIP, cut a red ribbon signifying the state's commitment to remove red tape that too often hampers families from accessing public insurance programs.

The Governor revealed that Ohio will implement three specific policies: 12-month continuous eligibility, presumptive eligibility and express lane eligibility.  These policies are among the eight program features that will help states qualify for the

CHIPRA performance bonus. Implementation of these policies will position Ohio to earn a bonus given that the state's enrollment in Medicaid has increased by 20% over the past three years, which exceeds the target enrollment established in CHIPRA performance bonus provision.

The Governor's announcement came on the eve of the Ohio Covering Kids and Families (OCKF) Annual Conference during which more than 200 attendees met to learn about best practices for enrolling and retaining all children in Medicaid and CHIP. Voices for Ohio's Children, which convenes and facilitates the OCKF Coalition, hosted a legislative reception during which Cindy Mann praised Ohio's commitment to reach all eligible but unenrolled children.

The events in Ohio this week remind us that strong leadership at the state level can make a difference even in challenging economic times. We commend Governor Strickland for accepting the Secretary's challenge and hope it inspires other Governors to do the same.

CCF is hitting the road!  We've scheduled four meetings around the country to bring together child and family health advocates to discuss opportunities and challenges for moving forward on coverage.

Our first meeting, for the Southern region, took place last week in Tampa, Florida and despite how difficult it is to hold a health conference with the uncertainty surrounding health reform, it went very well. But you don't have to take my word for it -- Michele Johnson of the Tennessee Justice Center blogged about her experience at the meeting.  You can also find the presentations and materials from the meeting on our website. 

Next week, we'll be in Providence, Rhode Island for the Northeast region conference and April will find us in Salt Lake City, Utah, for the West and Cleveland, Ohio, for the Midwest meetings.  It's a great opportunity to meet with your neighbors to discuss what's working in their states.  If you can't make it when we visit a state near you, check the CCF website for materials and related resources.

By Michele Johnson

Managing Attorney and Co-Founder, Tennessee Justice Center

The Southern Regional Meeting of Transforming Health Care Coverage for Children and Families was just what the doctor ordered.  For anyone feeling down about health reform or frustrated with the status quo, you need to attend this meeting!  The technical information about the health care bill, the messaging workshop and success stories from other southern states were so valuable and hopeful.

The messaging workshop put on by Ed Walz from Spitfire Strategies was full of practical tips about how to be heard by policymakers and the public. Ed, always entertaining and compelling, gave us the recipe for communicating effectively. Among other things, he taught us how to write effective blog articles (like this one, I hope!), letters-to-the-editor, and blast emails. By day's end, I not only felt like I could do it, but we had actually done it in hands-on activities.

The presentations about both the nitty-gritty of the health reform bill and the opportunities of CHIPRA were extraordinary. They contained crucial data about the demographics of the eligible but uninsured children who are waiting for us to reach them now.  They laid out who will be helped by reform and how. What useful tools to have at our fingertips as we try to raise resources to reach these children! The health reform waiting game has seemed paralyzing in so many ways, but these presentations gave me a "to do list" of practical and immediate steps to enroll children and keep them enrolled.

My favorite part of the conference was seeing and hearing about the experiences of my southern sister states.  I heard from friends, old and new, about the challenges they are facing and overcoming. Sometimes working for health care for children in the South can be isolating and demoralizing, so hearing from others facing similar hurdles was moving. Amazing work is going on in our region!  I left the conference reminded of Anne Frank's quote "How wonderful that nobody need wait a single moment before starting to improve"...healthcare for children in the South!

Thanks, Georgetown Center for Children and Families and partner organizations for using your extraordinary talents to improve policies every single day for children in Tennessee and all over America. 

Editor's Note: Say Ahhh! readers aren't fooled by Michele's modesty as we've seen some great blogs out of her before.  With all the nice things she's saying about CCF and our friends, we just might have to make her a regular.

A recent subtext in the debate on health care reform has been about Medicaid's alleged failure to provide its enrollees with access to care - the argument goes that the parents and childless adults who would be added to Medicaid as a result of leading proposals would mean that 15-18 million people would be dumped into coverage where they wouldn't be able to see a doctor. As often is the case in Washington, the facts are considerably more nuanced than the talking points. 

First, research is very clear that Medicaid has increased access to care and reduced unmet health needs for both children and adults. In fact, in terms of primary and preventive care, access to care in Medicaid is approximately equivalent to that in private insurance. Access to care issues in Medicaid are more likely to arise in certain specialties (most notably such as access to dentist care) and in certain geographic areas and they most certainly exist. But having Medicaid has been critical in improving low-income children's access to needed care.

We're all aware (perhaps from our own experience of trying to find a doctor who will take our insurance) that having an insurance card does not necessarily ensure access to care. I have virtually given up finding an internist that will take my Georgetown University Blue Cross plan. Doctors and hospitals pick and choose which insurance plans they'll take.  A recent Center for Studying Health System Change survey asked physicians whether or not they were accepting new patients. Their answers varied by patient insurance type: 

Yes, there are more doctors who are not accepting any new Medicaid patients, compared with those accepting new patients covered by Medicare or private insurance. But overall, more than 70% of doctors are accepting at least some new patients covered by Medicaid.

Part of the issue with the slightly lower physician participation in Medicaid could have to do with lower reimbursement rates, which are about 72% of those paid in Medicare (and these rates are supposedly lower than private rates, but a true comparison is tough since that information is deemed "proprietary"). 

Now, people may legitimately say that adding an additional 15-18 million people to the program is likely to exacerbate access problems. It is true that adding that many people into the system requires consideration of the program's capacity to provide the care people will need. The most obvious solution -- an increase in reimbursement rates.

And there may be hope on the horizon for just such a solution. Following the health reform summit, the President has appeared to embrace this idea. The House included a provision in its health reform bill for a phased-in increase in Medicaid reimbursement rates and it also seems to have bipartisan support (Sen. Grassley (R-IA) raised it as an issue at the summit).

Medicaid has been instrumental in meeting the health needs of millions of children and families, and through health reform, the program would be expanded to meet the needs of millions more. So let's think about how to do that most effectively, but let's not use the access challenges, which happen in private and public coverage alike, to become an excuse not to do meaningful reform.

 Thanks to Martha Heberlein for helping with the research for this entry.

Having just survived a truly impressive tantrum this morning from one of my sons who was deeply committed to going to school this morning without shoes, I'm feeling primed for what promises to be a raucous final stage of the health reform debate. 

As far as we know, Congress is still proceeding with the plan of the House passing the Senate health reform bill (with many members kicking and screaming as vigorously as my son this morning), then the House and the Senate passing a smaller reconciliation package designed to improve the Senate bill and make it more palatable to House members.  I just hope we get through the week without anyone throwing shoes at an authority figure (at home or in Congress).

This week, RollCall reports that by the end of the week we may see the actual legislative language of the reconciliation bill and a CBO score, allowing us to fill in final details of what health reform might look like.  The White House continues to press for a final vote in mid-to-late March.

In the meantime, everyone is digging deeper on the arcane rules of budget reconciliation.  Our friends at CBPP have shared the gory details before, but the question of the day seems to be whether using reconciliation actually allows health reform proponents to proceed with a straight up-or-down vote.  The issue has flared up because there is a 20-hour limit on debate over a reconciliation bill, but the rules may allow opponents of health reform to offer an endless series of amendments OUTSIDE of the 20 hours of debate. If they take this route, Senate leaders will need to decide whether to call in Vice President Biden to declare the string of amendments "dilatory" and to dismiss them. 

Also, this week we'll be tracking where things are heading with a 6-month extension of Medicaid fiscal relief, which has enormous implications for the capacity of states to continue to sustain and strengthen their gains for kids and families.  The Medicaid fiscal relief is included in a jobs bill making its way through the Senate right now. To make things confusing, the term "jobs bill" has been used to describe three separate bills currently in motion: 1) a $17.6 billion package that mostly creates a tax credit for companies that hire unemployed people; 2) a short-term extension of unemployment insurance, COBRA and a few other items through end of March/early April (this is the one that Senator Bunning single-handedly held up on the Senate floor last week); and 3) a much bigger extension through December 31, 2010 of unemployment insurance, COBRA, and a few other items.

It is this THIRD so-called "jobs bill" that includes a 6-month extension of Medicaid fiscal relief from December 31, 2010 through June 30, 2011.  Congress Daily reports that the jobs bill (the third one) will be up on the Senate floor this week, and then it will need to go to the House for action. The House already has twice passed an extension of Medicaid fiscal relief in other bills and President Obama supports it, which means the prospects for passage are bright if it makes it through the Senate. 

The pressure to extend the temporary increase in the federal medical assistance percentage (FMAP) for Medicaid included in last year's stimulus bill is building. Widely credited with helping states through one of the worst fiscal crises on record, the provision also has been vital in stabilizing Medicaid coverage for children and others in families facing job loss. Currently, the provision is slated to expire December 31, 2010, right in the middle of most states' fiscal year. With most state legislatures in session right now trying to craft next year's budgets, they are looking for some assurances that the federal government will continue the extra help with Medicaid.

It looks increasingly likely that the nation's lawmakers may adopt an extension. In December of 2009, the House of Representatives passed a six-month extension that would provide states with fiscal relief through June 2011, which coincides with the end of most states' fiscal years. President Obama included the same proposal in his budget in February.

Now the Senate, which has been the most skittish on the issue, is planning to take the extension up as part of a larger jobs bill. On Monday, Senate Majority Leader Reid and Senate Finance Committee Chairman Baucus included the 6-month extension in a jobs bill. This bill also continues COBRA benefits and unemployment insurance through the end of the calendar year. (And, nope, this isn't the same jobs bill that Senator Bunning of Kentucky has been holding up on the Senate floor. The bill that caused Senator Bunning to miss the Kentucky-South Carolina game extended COBRA subsidies and unemployment insurance only for a few more weeks and does not include an extension of Medicaid fiscal relief.)

Outside the Beltway, a bipartisan group of 42 Governors of states and five Governors of U.S. territories have signed a letter in support of the FMAP extension. They state that "the length and depth of the recession means states and territories will continue to face significant budget shortfalls long after the enhanced FMAP provisions expire at the end of this calendar year." 

As in the past, Congress expects states to hold steady on their Medicaid eligibility levels and enrollment procedures in exchange for the extra federal help. One new twist to the "maintenance-of-effort" provision may be the addition in the Senate of a requirement designed to prevent Governors from having their cake and eating it too. Stung by criticism of the stimulus bill last year by Governors who willingly accepted the federal dollars, the amendment will likely require Governors (or possibly State Legislatures) to specifically request the additional help from the federal government. 

With unemployment benefits and COBRA subsidies now expected to expire at the end of March/early April, there will be pressure for Congress to act again quickly. This time, it looks more likely that Congress will include an extension of the FMAP if it can find its way forward on the next jobs bill. 

Following last week's health care summit and release of his health care reform proposal, the President today urged Congress to end the debate and bring health reform across the finish line. In his remarks, the President painted a vivid picture of what it means to not pass health reform, including more uninsured families, additional people denied coverage because they are sick, and skyrocketing premiums. Yesterday, we reported on what doing nothing would mean to families.

The Proposal

The President did not release a revised health care proposal but said he will incorporate at least two Republican ideas brought forward at the health care summit. This includes sending in "secret shoppers" to Medicare and Medicaid providers to combat fraud and abuse (an idea offered by Sen. Coburn) and providing a funding appropriation of $50 million in state demonstration grants to find alternatives to resolving medical malpractice disputes (similar proposals have been included in Republican bills).

On Tuesday, the President also sent a letter to congressional leaders outlining two other ideas that he is willing to consider for inclusion. One idea was suggested by Sen. Barrasso to allow the Health Savings Accounts (HSAs) in the Exchange. 

The other idea (which was initially raised by Sen. Grassley at the summit) would address what the President acknowledged are "inadequate" reimbursement rates in Medicaid. Improving doctor reimbursement would help increase access to care for the millions of new families entering Medicaid under health reform. As you may recall, the House bill already includes a phased-in increase in Medicaid reimbursement rates (tied to those offered in Medicare) for primary care services, with the federal government picking up the tab for most of the increased costs. It is not evident whether this or a similar provision will ultimately make it into a bill but the President's recognition of the issue is a positive sign. 

We expect legislative language soon and will provide more details then.

Timing/Process

President Obama is expected to make his much anticipated health reform announcement at 1:45 pm today in the East Room of the White House.  He will be flanked by HHS Secretary Sebelius and health care professionals. He is expected to encourage Congress to move forward swiftly.  Say Ahhh! bloggers will share our perspectives following the event.

As leaders in Washington debate the future of a plan to get our nation's arms around the colossal health care system, it's worthwhile to take a look at how things would be different today if some past health reform efforts had succeeded.

What if ... President Nixon's plan had passed before he left office?  According to The Commonwealth Fund, if President Nixon's plan had passed, the United States might be spending a trillion dollars a year less than it does now.

What if....President Clinton's efforts to pass health reform had succeeded?  President Clinton's plan would have reduced spending by an estimated $500 billion a year according to The Commonwealth Fund report.  

What if ... this latest attempt to get a handle on the health care system doesn't succeed? 

•  Will typical family premiums double in ten years to $24,000 as predicted? 
•  Will the number of uninsured really increase from 49 million today to between 57 million and 66 million by 2019?
•  Will states struggle to meet the staggering increases in the number of people who must rely on Medicaid and CHIP for affordable coverage?People think if we do nothing, we will have what we have now," said Karen Davis, the president of the Commonwealth Fund in an interview with the New York Times. "In fact, what we will have is a substantial deterioration in what we have." 

If Congress and the Administration are unable to find a way to follow-through on health reform this time around, only time will tell how this missed opportunity would impact all of us, our children and our grandchildren. Let's hope they are able to rise to the challenge so future generations won't look back on this moment in history and think to themselves how much better life would be "if only ..."