April 2010 Archives

While the federal government still has a great deal on its plate in terms of implementing health reform (we at CCF are eagerly awaiting every bit of guidance and regulation CMS can throw at us!), many key tasks now move to the states.

Should we set up a new high-risk pool? What should our exchange look like? Who should run it? How do the new insurance reforms interact with our current protections? To help sort through all these complicated and intertwined issues, seven states have set up commissions, advisory councils, or offices of health reform to take a look at their options and help guide implementation.

Connecticut was first out of the box, with the Governor establishing a 15-member board (the Connecticut Health Care Reform Advisory Board) way back in July. Since then, Colorado, Maryland, Michigan, Washington, and Wisconsin have stepped forward. And, just last week, the Governor of Maine signed an executive order establishing the Health Reform Implementation Steering Committee.

These commissions/offices are comprised of agency heads (like the Secretary of Health and Human Services and the Insurance Commissioner) and sometimes include other interested parties (such as representatives of the hospital industry). While none include a consumer or advocate voice on the panel itself, most provide some sort of mechanism for public comment. Take Colorado as an example - where the board can establish task forces that include outside groups, including consumer advocates.

As health reform moves toward implementation, it's important to keep tabs on what your state is doing. Have they established a commission? Are consumers and advocates represented on these boards? If not, is there a way to expand representation or does the public have another outlet to provide comments?

Depending on the state, these commissions may yield a great deal of power in influencing what reform looks like. It's important that all voices are heard in the process.

If you want more details on the various commissions and links to the executive orders, check out RWJF's State Coverage Initiatives' States Take Different Approaches to Respond to Federal Health Reform.)

About 55 percent of Americans say they are confused about the new health reform law and more than half say they don't yet have enough information to understand how it will affect them personally according to Kaiser's latest tracking poll.  As was clearly evident during the health reform debate, people take their health coverage very personally.  In order to ensure that the promise of health reform becomes a reality for all, we must help people develop an accurate understanding of the bill and how it will touch their lives.

The following resources are a good place to start:

• The New York Times posted a simple, easy-to use graphic that is a great launching off point for those trying to figure out how health reform will impact them.  
• The Obama Administration maintains a site that shares the latest news on health reform and tracks how it is being implemented in each state.  The site is also the place to go for weekly webchats on health reform.  This Friday at 2:30 EDT, HHS Secretary Kathleen Sebelius and other health reform experts will focus on how stronger insurance company oversight will protect consumers.   You can submit questions by clicking here and watch it live here. 
• PICO, a national network of faith-based community organizations, created an informative poster to help community leaders and others reach out to help people understand and benefit from the new health reform law.
• Consumer Reports hosts a website dedicated to helping consumers navigate the changing health care system.  Award-winning reporter Nancy Metcalf accepts questions from consumers and posts the answers online. 

For those of you who are more concerned about the question of "what's in it for others", there have been a number of touching personal stories that demonstrate how the new law is already transforming lives. 

The McClatchy News wrote about a 12-year old boy from Fort Worth Texas with a seizure disorder whose family was unable to obtain insurance coverage for him from a private insurer.  His father agreed to a 50% cut in pay so that his son would qualify for CHIP coverage.  The enactment of health reform means the boy will either be able to move to private coverage under the elimination of pre-existing condition discrimination or a high-risk pool.  This will free up his father to earn a fair salary and start saving to buy a house (not only good news for the family but for the Ft. Worth housing market and U.S. economy).  

The Delaware News Journal ran an extensive story on the benefits of the new law and how it could help a single mother and her son who was diagnosed with diabetes just a few months before she lost her job.  

The Fiscal Times provided a very interesting snapshot of how the new law would impact coverage for individuals and families in a variety of circumstances.  

Finally, I was really impressed with the example set by a county councilwoman in Washington state who used her weekly column to help her constituents develop a better understanding of the new law.   Instead of passing the buck to federal and state lawmakers, her column demonstrates that she understands that we all have a part to play in making the promise of health reform a reality.  

All of us at CCF would be interested in hearing about what's going on in your communities to help people better understand and benefit from the new health reform law.  Please send us your comments.

So in the almost final installment of my musings on premium assistance, I am going to cover two issues and then wrap up this scintillating series (I hope - this might get toooooo long and we may have to go to Part 4 which would ruin my whole LOTR analogy.). The first question is about the new options available under CHIPRA to do premium assistance, and the second is to return to the question posed at the beginning of this series about the future of premium assistance post health reform.

CHIPRA created two new options to do premium assistance - the first through Section 301 in Title III which establishes a new option for states that have separate state CHIP programs, and the second, also found in Title III, established a new option that was added to the Medicaid statute - the elusive "1906a." This creates a new child-only option to do premium assistance in Medicaid. And other parts of Title III, as I discussed in the second part of this series , seek to remove barriers states face in running premium assistance programs. The intent of the new options was to provide federal support for the kind of premium assistance programs that make the most sense - kids receive coverage that is just as good or better - and federal and state dollars are used in a clearly cost-effective manner.

The language of these two sections is quite similar though differences in the underlying programs means in practice there are some ways in which they differ. Both options clearly require that kids have a "wraparound" benefit for services and cost-sharing protections so that they are not worse off in a premium assistance context. Both prohibit the subsidization of coverage in the individual market which is likely to be less comprehensive, more expensive, and by definition does not have an employer contribution to bring the costs down. Both require a 40% employer contribution to ensure that the coverage is cost-effective. (Note: I personally think it would be fine to get rid of this 40% requirement and just make sure that states have a rigorous cost-effectiveness test.) And the definition of cost-effectiveness is altered to explicitly include administrative costs.

Let's spend a minute on this last point - the inclusion of administrative costs in the cost-effectiveness definition. This is an important change because today some states include these costs and some don't in their assessments of cost-effectiveness. In programs with low enrollment and often-high administrative costs, this could be a very important piece of data to determine whether the program is a worthwhile use of public funds. Apparently Congress agrees, because the Patient Protection and Affordable Care Act (i.e. the health reform law) extends this new CHPRA definition to existing Section 1906 Medicaid programs, which as we discussed in Part 1, 29 states have today. (PPACA also makes some technical changes to the CHIPRA cost-effectiveness definition to clean it up but it would be REALLY boring and TMI to explain those.)

So are these new options really going to work? The language is fairly complex and states are not rushing to pick them up - wisely, I would say, given the limited payoff we have seen from premium assistance programs in the past. So far only one state, Okahoma, has had a state plan amendment approved to operate a new Section 301 premium assistance program. However, another feature of the CHIPRA law did lead to a mini-burst of interest because, in yet another example of somewhat irrational public policy making when it comes to the politics of premium assistance, having one of these new options in place helps a state to qualify for a CHIPRA performance bonus. I say irrational because the intent of the performance bonus provision is to streamline enrollment procedures, and adding a premium assistance program certainly does not do that. But there it is, so a number of states were intrigued by comments made by CMCS Director Cindy Mann, who suggested at our recently held regional meeting in Tampa, that a state could flip their 1906 program to a 1906a program in order to meet this test.

To date Wisconsin and possibly Washington have received approval to do so. But it's not quite as easy as it sounds at first blush. Two issues may deter states from making the switch. The first is that 1906a appears to include language that says that parents who are enrolled in the employer-sponsored coverage must also receive wraparound coverage even if they are not otherwise eligible for Medicaid. In states where parent eligibility is lower than kids, this is not likely to be a popular idea -even though it would be nice for parents to have those added cost-sharing protections and benefits that their private insurance might not cover. In fact there are a few states that we have heard from who are not pursuing the flip for this reason. Second, enrollment in1906a is voluntary whereas 1906 is not, so states will have to offer families the opportunity to opt-out on a monthly basis. This may have other repercussions especially for those families who are using the subsidy to purchase their coverage through a small employer - these policies often include requirement that the employer must cover a certain number of lives for a 12-month period. So some states might find this disruptive.

So it remains to be seen whether these new options really take off, and there are reasons to think that they won't. It may be that the old tried and true Section 1906 option in Medicaid remains the most viable route for states seeking to do premium assistance. And, yes, I think I am going to have to conclude this series in a 4th installment bringing us full circle to the future of premium assistance in 2014 when health reform kicks in.....

Welcome to Part 2 of my musings about the state of premium assistance. Part 1 left us with the teaser that CHIPRA includes new premium assistance options, which the new health reform law incorporates and expands to all Medicaid beneficiaries as of January 1, 2014. So let's take some time to explore where things stand with Title III of the CHIPRA law which is all about the integration of public and private coverage.

In our analysis of CHIPRA released in April 2009 we covered many of the key features of Title III the new law on p. 16. So I won't cover old ground but will pick up with some updates.

First, CHIPRA required the GAO to do a report on state premium assistance programs. That report was released in January 2010. The report is a nice summary of where states are with respect to premium assistance, although many key questions remain unanswered.  As I have found doing my own research on premium assistance states often do not keep good data on the costs of their premium assistance programs and they rarely track what kinds of coverage families are receiving. Since some premium assistance programs (generally those authorized under waivers) require families to pay all of the cost-sharing that their private plan requires, we don't know if these costs and benefit limits are preventing kids from getting the care they need.

But I digress. One of the most interesting aspects of the GAO report was that it was the first time that a 50-state survey has been done which asks states if they are subsidizing coverage under Section 1906 of the Medicaid law. This option allows states to require families to enroll in their group coverage if it is cost-effective for the state. All Medicaid beneficiaries who are enrolled in this coverage must receive wraparound benefits and cost-sharing subsidies. So this is premium assistance done right.

When I talk to state advocates who are thinking about pursuing premium assistance as a strategy, or are dealing with state policymakers who are thinking about it, especially if they are talking about pursuing a waiver, my first response is to say that your state may already be doing premium assistance through Section 1906 and it doesn't need a waiver. So now we know - 29 states are operating this kind of program. So the GAO report is a good place to start when thinking about premium assistance.

Another feature of  CHIPRA's Title III was that certain barriers to doing premium assistance that required federal statutory change were lifted. In particular, Medicaid and CHIP eligibility is now a "qualifying event" under federal law and plans have to offer a "special enrollment period." These are terms of art that mean certain happenings (like a birth or a death and now Medicaid/CHIP eligibility) allow you to enroll in a group health plan even when it is not open enrollment. Previously, in most cases, families that became eligible for premium assistance would have to wait until their open enrollment period. Now they don't.  And a child who loses Medicaid eligibility because their parents get a raise can be signed up for the employer's plan right away and not have to wait for open enrollment.

My final point of the second part is that Title III also created a Working Group which will issue a report the Secretaries of Labor and Health and Human Services and has two substantive charges:
1) To develop a model coverage coordination disclosure form and;
2) Identify impediments to the effective coordination of coverage between group health plans and Medicaid and CHIP.

Federal guidance on the special enrollment periods and information on the Working Group is available here http://www3.cms.gov/CHIPRA/09_Section311.asp

The Working Group is having its first of two meetings this coming Monday, April 26th and yours truly is a member. If you have any suggestions or thoughts to share please email me in the interim at jca25@georgetown.edu.

And as you Rings fans have already guessed, Whither Premium Assistance has evolved into a trilogy. So you will have to wait until the final installment to learn more about the elusive 1906A......

I started studying premium assistance programs in Medicaid and CHIP a decade ago with a large dose of skepticism. The idea of buying private coverage with public dollars when it is more expensive and typically covers fewer benefits than Medicaid struck me as a bad deal for beneficiaries and taxpayers alike. In many cases this is so. And most low-income families do not have access to decent employer coverage which has contributed to very low enrollment in most premium assistance programs. And because of the optics, many policymakers wildly over promise with respect to what premium assistance programs can deliver and pay scant attention to whether it will actually work and save money.

But over the years I have developed a more nuanced view about premium assistance - in some cases, if done right, premium assistance has advantages for families.  If families (and the taxpayers) don't have to pay more, and the benefits are just as good, premium assistance programs may offer a wider choice of providers and coverage for a parent who is otherwise ineligible because children's eligibility allows a family to pick up employer-sponsored dependent coverage for the whole family.

There are still many premium assistance proposals that come across my desk which reflect a rigid ideological bent and are not well conceived - the Florida legislature for example is currently considering a proposal for a waiver request to give all Medicaid beneficiaries a voucher to go out and buy private insurance - or as the Appropriations proviso reads "to allow Medicaid recipients to be integrated into the private insurance market". Hmmm.  Medicaid covers folks whose incomes are too low to be able to afford the costs of private insurance or whose chronic health care needs are often not covered by private insurance so how is that going to work without them losing access to the services they desperately need?? Sadly, rational discussions about premium assistance in the legislative world are few and far between.

But in light of the passage of health reform and CHIPRA it seems like a good time to re-evaluate where premium assistance is headed. Today let's cover the new health reform bill and tomorrow I will take a look at CHIPRA where there are some interesting developments.

The underlying health reform bill, which passed the Senate on December 24th, included a requirement that states do premium assistance if it is cost-effective. In fact Section 2003 of the bill is titled "Requirement to offer premium assistance for employer-sponsored insurance." This section amended a relatively obscure part of the CHIPRA law that created a new premium assistance option in Medicaid (known to policy wonks as "1906A") for kids, broadened it to all Medicaid beneficiaries and mandated states to do it as of January 1, 2014.

However, some Senators were not happy about this requirement, and the Manager's Amendment in Section 10203 which extends CHIP funding and includes "other CHIP-Related Provisions" deems the mandate "null, void and of no effect" in paragraph (b)(2)(B). So this leaves states with the same options they currently have under CHIPRA with an opportunity to apply the Medicaid option more broadly to all Medicaid beneficiaries as of January 1, 2014.  So in my "Whither Premium Assistance" blog part 2 I will explore the new CHIPRA options including the scintillating topic "Section 1906A" in more detail.

One of the exciting new options provided by the Children's Health Insurance Program Reauthorization Act (CHIPRA) is the ability of states to use an existing electronic data exchange with the Social Security Administration (SSA) to document citizenship. All states have entered into agreements with the SSA to use this new capability starting January 1, 2010. To date 27 states are actively using or testing the system.

The Center on Budget and Policy Priorities (CBPP) has released a report describing the early positive experience of states in using the electronic match in lieu of complex paperwork requirements to document citizenship. Author Donna Cohen Ross has followed the impact of the citizenship documentation requirement since it was implemented in 2006.

The report is the last publication written in Donna's capacity as Director of Outreach at CBPP. Later this month, Donna will join the staff in the Office of External Affairs at the Centers for Medicaid and Medicare (CMS). We are pleased to have another experienced and knowledgeable friend at CMS advocating for the systemic changes and simplification policies that will make a difference in enrolling and retaining all eligible children and individuals in Medicaid and CHIP. We wish Donna the best in her new role and thank her for this final report demonstrating successful strategies to reduce paperwork and make it easier for eligible individuals to secure Medicaid and CHIP coverage.

(Editor's Note:  Donna has been a frequent contributer to this blog and we will really miss her voice on outreach issues.)

Our friends at the Center on Budget and Policy Priorities have joined the blogosphere and they have a lot to say.  The blog was launched at 8:30 a.m. and they had already posted three entries by lunchtime.  Those of you familiar with CBPP know what a bright and talented group of experts they have on staff and what an important contribution their new blog will make to ongoing policy discussions. Hope you'll check out "Off the Charts".  

Throughout the debate on health reform, states have asked, "how much will this cost us?" Now that health reform is the law of the land, several have put out their own estimates. However, as there is no agreed upon independent arbiter to tell us what states will be spending - sadly, CBO doesn't look at state-by-state spending (although they did suggest that state spending on Medicaid/CHIP would increase by $20 billion over ten years and we've heard through the grapevine that they assume about a 50% participation rate) - there is no consistent set of rules and assumptions in developing these estimates.

As some of the estimates that have been publicized have serious flaws, it's even more important to know where the numbers came from and how they were calculated. Here are a few key questions to ask as state governments and other interested parties put out their "official" numbers.

1. What participation rate are they using for Medicaid enrollment? Does this make sense in terms of historical enrollment and enrollment in other programs (even with accounting for the mandate)? For some context, a recent study found an 81% participation rate among children in Medicaid and CHIP.

2. Are there different participation rates for the newly-eligible population compared to those already eligible, but unenrolled in coverage? Are they taking into account the "welcome mat" effect?

3. In terms of enrollment increases, CBO estimates that 16 million more people will enroll in Medicaid/CHIP over the next ten years. Does the enrollment increase in your state fit within this larger context?

4. In estimating the cost, which per capita cost are they using? Are they using an average across all populations or applying a different per capita estimate for each population (e.g., one for the elderly and disabled population, another for the child population)?

5. The $20 billion figure from CBO will not be evenly distributed amongst the states, but it's highly unlikely that one state would account for the vast majority of spending. Again, does the share of spending in your state fit within this larger context?

6. What federal matching rate (FMAP) are they applying to a particular population in each fiscal year? FMAPs vary depending upon the population, the fiscal year, and the state, so it's important to apply the correct match rate.

7. How are they (if at all) accounting for administrative costs?

8. Are they including costs they shouldn't (for example, the increase in Medicaid primary care provider rates is 100% federally funded)? Are they including any savings (for example, a decline in uncompensated care)?

There may not necessarily be "right" answers for all of these questions - it may depend upon what data are available and the particular circumstances of the state. However, when evaluating the accuracy of the estimates, it's vital to know what the underlying assumptions are - otherwise, we really can't evaluate what the true costs might be.

As for us at CCF, we're still working on fully absorbing the impact of health reform on the states (after all - it's a pretty big question!).  This is a good place to start thinking and we'll continue to share our thoughts on the topic of cost.  

Today, CCF released a new issue brief that takes a look at some of the most immediate changes in health reform for children and families. While many of the sweeping changes to the insurance industry and other major provisions do not go into effect until 2014, children have some much earlier "wins" to look forward to. 

High on the list of early benefits from the legislation is the strengthened opportunity families now have to enroll their uninsured children in Medicaid and CHIP. Out in the "real world", where people don't have time to read legislation, many families are seeking information on what the law means to them today. This creates an opportunity to raise awareness among eligible families that their children can obtain coverage through Medicaid and CHIP. Let's not forget the experience in 1997 when CHIP was created - with the excitement of the new law many new families came forward to enroll in coverage, only to find out that they were already eligible for Medicaid. 

In addition, health reform includes two provisions to assist families in obtaining coverage. States are required to "hold steady" when it comes to Medicaid and CHIP coverage for children until October 1, 2019 so families can count on the coverage being there when they need it.  In addition, Health and Human Services must set up a new web portal by July 1, 2010 to provide information to families on state-level health insurance options. A boost in enrollment, or as we like to call it, the "welcome mat effect", could be a potentially powerful tool for increasing the number of insured children in the nation, and setting the stage for health reform.

Other health insurance reforms discussed in the paper that quickly go in effect include:

• By July 1, 2010, uninsured children and families with pre-existing conditions can seek coverage through newly established 50-state high-risk pools.
• For health plan years beginning after September 23, 2010, everyone signing up for a new health plan will receive preventive services at no cost, insured children cannot be denied coverage for a pre-existing condition, and young adults up to age 26 can obtain coverage through a parent's plan.
• New health insurance reforms make it easier for people to use and keep thier insurance (various implementation dates).

While we have to wait until 2014 to see some of the more dramatic changes to how people receive health coverage in this country, these early reforms are "not anything to sneeze about" and, in fact, could have a real impact on the lives of children and their families.

On the very first day of Say Ahhh!'s existence, Cindy Mann wrote:

"The health care policy field is filled with engaged, bright, and talented people and I find it invigorating to get out and talk to them while traveling to various states to promote children's health coverage. I see this blog as a great place to tap into that energy without leaving my desk. While it won't provide frequent flier miles, it should prove to be a very worthwhile journey."

And a worthwhile journey it has been. Say Ahhh! has amplified the voices of children's health advocates from across the country on topics such as meeting the needs of children and families through health reform and CHIPRA implementation. We deciphered the various proposals and highlighted data and family stories that reminded readers of the fact that the status quo wasn't working.  Say Ahhh! also followed the ups and downs of children's health coverage on the state level.  Bloggers helped call attention to Tennessee's decision to freeze enrollment in children's coverage and applauded the state when it reversed the decision.  Say Ahhh! was there when Iowa, Oregon, Kansas, Colorado and Wisconsin successfully expanded or improved their children's coverage.  We blogged about California's decision to close and re-open enrollment in its CHIP program (Healthy Families) and about the Virginia Assembly's decision to stand up to the Governor by refusing to deny families access to its CHIP program (FAMIS).   Say Ahhh! has applauded state innovations from Louisiana to Wisconsin and several places in between.  

By David Blatt, Director, Oklahoma Policy Institute 

This week I had the pleasure of attending a gathering of policy analysts and advocates from 15 states on "Transforming Health Care Coverage for Children and Families," convened by Georgetown University's Center for Children and Families. The conference, which focused on the opportunities and challenges of providing coverage to the uninsured while the new health care reform law is being implemented, featured a keynote address by Cindy Mann, Director of the Center for Medicaid and State Operation within CMS, the Centers for Medicare and Medicaid Services. This post shares some of her key points.

Mann started out by reminding the attendees that Medicaid is already a key source of health insurance, providing coverage to nearly 63 million Americans over the course of the year in 2008. Currently, Medicaid is of particular importance for covering children in low-income families, and has been primarily responsible for the substantial progress made in reducing the rates of uninsured children to below 10 percent nationally in 2008.  Enrollment in Medicaid and CHIP, the program that covers children from moderate-income families in some states, grew by 2.6 million children in 2008-09, picking up the slack for declining employer-based coverage during the initial phase of the economic downturn.

With health care reform and the emergence of a health care system that is intended to provide universal coverage, Mann stressed that Medicaid will increase in importance, serving as one leg of a "three-legged stool" of coverage for the non-elderly, along with employer-based insurance and the new health insurance exchanges for individuals and small businesses. Of the 32 million Americans expected to gain coverage under the new law, a full fifty percent, or 16 million, are expected to be added to the Medicaid program.  Most new Medicaid beneficiaries will be low-income parents and childless adults, who are currently ineligible for Medicaid in most states and are most likely to be without insurance.

Mann acknowledged that this expansion will create challenges for state-run Medicaid programs. In particular, states will need to develop efficient and well-coordinated application and eligibility systems to help individuals and families determine which insurance program they are eligible for and to facilitate enrollment and renewal. The goal will be to develop a single system out of different components. In addition, Medicaid programs will have to ensure that beneficiaries have access to the full range of health care services and benefits. Mann acknowledged that access to some services, especially dental care and specialists, is a problem in some states, although she emphasized that, according to most key measures, access to care for Medicaid beneficiaries is comparable to those with private insurance.

While health care reform is ramping up for 2014, Mann emphasized that there is important work that can and must be done now to expand enrollment within the substantial population of children who are already eligible for coverage but remain uninsured. Of the 6 million uninsured children in America, it is estimated that 80 percent, or nearly five million, are eligible for Medicaid and CHIP. Last year's law reauthorizing the Children's Health Insurance Program, known as CHIPRA, provided states with important new tools for enrolling eligible children. States that enacted a number of specific best practices for simplifying enrollment and maintaining eligibility are eligible for significant performance bonuses in the form of higher federal match. The federal government has also awarded $40 million in outreach grants, including $988,177 to the Oklahoma Health Care Authority, with an additional $50 million still to be awarded. This past February, Health and Human Services Secretary Kathleen Sebelius issued "The Secretary's Challenge: Connecting Kids to Coverage," calling on states and local communities to engage in an effort to enroll all eligible children in coverage over the next five years.

Overall, Mann's main message was a reminder that making more people eligible for health care coverage, while a huge achievement, in many ways is only a prelude to the really hard work ahead to make universal coverage a reality in practice. This effort will require aggressive outreach combined with simplified enrollment processes and integrated information systems. For governments, advocates, and providers, the work starts now.

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

By John McInerney, Health Policy Director, The Commonwealth Institute for Fiscal Analysis

Families in Virginia can breathe a bit easier these days, as efforts by Governor Bob McDonnell and the House of Delegates to tighten eligibility in the states' CHIP program have failed.

Virginia's program is called Family Access to Medical Insurance Security (FAMIS), and it covers children and pregnant women up to 200 percent of the federal poverty level (FPL).  While the eligibility standard is among the lowest in the nation (Virginia has a gross income standard, with no deductions), the program has still been able to enroll a lot of low-income kids.  Over 155,000 received FAMIS coverage at some point in the 2009 federal fiscal year.  For the past several years, FAMIS has enjoyed overwhelming support from lawmakers and the public as a cost-effective and efficient way to cover low-income children and pregnant women. 

This year, however, Virginia faced a two-year budget shortfall of over $4 billion. Instead of taking a balanced approach, the Governor targeted education and health care for cuts (the Governor and the General Assembly rejected options to preserve these important priorities by raising additional revenue).  Health care is the second largest share of Virginia's budget, although we are less generous than most other states.  In fact, Virginia is one of the 10 wealthiest states in the country, but ranks 48th in per-capita Medicaid expenditures. The state only covers children up to the federal minimum of 133 percent of FPL.  Parents fare even worse, with eligibility only extending up to 29 percent of FPL, just over $6,000 a year for a family of three. 

With very few optional Medicaid spending programs to cut, Governor McDonnell proposed in February to freeze enrollment in FAMIS, a change that would result in a reduced enrollment of over 28,000 kids and pregnant women within two years.  A few days later, the House of Delegates released their budget proposal, rejecting the Governor's proposed freeze and instead proposing to lower income eligibility from 200 percent to 175 percent of FPL.  This proposal would kick about 30,000 children and pregnant women from FAMIS and would reduce state spending by over $37 million over two years.  If enacted, Virginia (again, one of the 10 wealthiest states) would be competing with North Dakota for the most restrictive income eligibility in the nation for our CHIP program. 

Fortunately for supporters of the program, the Virginia Senate did not seek to reduce FAMIS eligibility in their version of the state budget (In fact the Senate passed, but did not fund, legislation to increase FAMIS eligibility to 225% FPL.). Thus, in a compromise, the final budget deal reached on March 14 postponed the cuts to FAMIS until July 1, 2011 and stated that the reduction would be completely reversed if Congress passed a six-month extension in enhanced federal Medicaid assistance that could provide Virginia approximately $370 million in additional  federal funding for the overall program. 

The news improved even more on March 23 when President Obama signed the Patient Protection and Affordable Care Act (ACA).  The maintenance-of-effort requirement in the new law will protect state Medicaid and CHIP programs from eligibility and benefit cuts until the ACA's coverage expansions begin in 2014. 

Yet, although a significant reduction was averted in 2010, challenges still remain.  Virginia's Attorney General and Governor are pursuing questionable lawsuits and challenges to the ACA, and a new law was enacted that seeks to prevent any federal mandates to purchase health insurance.  Certainly, attempts to circumvent the maintenance-of-effort are possible in our state.  So, while our modest FAMIS and Medicaid coverage for kids and families remain protected for now, we will still need to stay vigilant against efforts to weaken them in the coming years.    

(* Jill Hanken with the Virginia Poverty Law Center contributed to this post.)

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

By Donna Cohen Ross, Center on Budget and Policy Priorities 

All in one night -- February 11 -- 10,484 eligible children were enrolled into Louisiana's Medicaid program. 

Are you trying to imagine this? If so, you're probably picturing mile-long lines of children winding through Baton Rouge, parents in tow, clutching packets of forms and documents.  A winter storm warning is in effect -- so said the Baton Rouge newspaper that day -- and freezing rain is already pelting the city, with an accumulation of 1 to 2 inches of snow expected overnight. The crowd of babies and toddlers, tweens and teens, and thousands of others are just waiting, waiting, waiting.  You're thinking this is an ill-advised stunt.  Can't be done.  Not even with every eligibility worker plugging away, all night, nonstop. Not even with every family equipped with every bit of paperwork in hand, exactly in order. No way. Your anxiety level is out of control just thinking about it.

If this is where your imagination has taken you, relax.  What really happened in Baton Rouge that night took place calmly and efficiently while those thousands of children, families and eligibility workers were fast asleep.  What really happened was that 10,484 children got enrolled in one fell swoop through a new CHIPRA option called Express Lane Eligibility. 

All together, in one night ... done!  And they did it using findings from the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, to determine Medicaid eligibility.  Make no mistake, however.  Louisiana officials didn't just snap their fingers. It took many months of careful planning and preparation -- and coordination with the separate agency that administers SNAP in Louisiana -- to be sure the process would substantially ease enrollment and at the same time preserve program integrity. 

Here's how it worked: State officials started with the knowledge that children who qualify for SNAP are in families with income that meets the test for Medicaid, and a significant proportion are likely to be uninsured.  A file containing all children receiving SNAP benefits was transferred electronically from the computer system at the Department of Social Services to the computer system at the Department of Health and Hospitals, where Medicaid resides. Children already on Medicaid were removed.  The remaining file of children receiving SNAP but not Medicaid provided income findings, as determined based on food stamp rules, as well as the children's Social Security numbers, residency and age.

Under Express Lane there is no need to recalculate income using Medicaid rules. So, these "borrowed" findings are used, along with other necessary information obtained from available data bases (such as U.S. citizenship from the Social Security data base) to determine Medicaid eligibility and enroll the children.

Next, Medicaid cards and decision notices were mailed to the families.  At that point, they were  informed that the last step in this process -- affirming they want to enroll their child in Medicaid -- would happen the first time they use the card to see a doctor or fill a prescription. 

Ruth Kennedy, Louisiana's Medicaid Deputy Director, explains the significance of the February 11th feat:  "Express Lane Eligibility is a huge administrative efficiency and takes advantage of 21st century technology. It demonstrates that we can reduce duplication of effort when government agencies work together."  Ruth says that the state will be monitoring the system to refine the process and make sure that children enrolled through Express Lane are using their health care benefits -- a sign that the new system really works.  Going forward, she anticipates that SNAP findings will be used to automatically enroll children in Medicaid when they are determined eligible for food assistance.  Isn't this just the kind of coordination Secretary Sebelius and Secretary Vilsack were talking about when they joined together to celebrate the first anniversary of CHIPRA last month?  

So, are you still visualizing those 10,484 children standing in line with their families to gain access to health benefits?  Erase that image and instead picture them avoiding unnecessary ER visits, getting critical preventive care, medical treatment and the prescription medications they need.  Nice picture, huh?  Not bad for a night's work!