May 2010 Archives

I'm all for light meals but the smorgasbord offered by the health reform law is something we need to make reform meaningful and to ensure that all Americans have access to affordable health care. Whether you go straight to the entrees (the Medicaid expansion or subsidized coverage through exchanges) or nibble on the appetizers (no more pre-existing exclusions or lifetime caps), there is something for everyone.

One such tidbit will allow certain dependents of state employees to enroll in the Children's Health Insurance Program (CHIP). For the past thirteen years, children of state employees who are eligible for health benefits from the State employee health plan have been explicitly excluded from the definition of "targeted low-income" children who are eligible for CHIP. The new health reform law has eased those restrictions effective immediately.

State CHIP programs may enroll children of state employees (who are otherwise eligible) if one of these conditions is met:

• Maintenance of Effort - the amount the State contributes to health benefits on behalf of employees including dependent coverage for the most recent State fiscal year cannot be less than the amount it expended in SFY 97 increased for inflation. (If you want the nitty-gritty, the most recent contribution cannot be less than the 1997 contribution increased by the percentage increase in the medical care expenditure category of the Consumer Price Index for All-Urban Consumers for each preceding fiscal year.)

• Hardship waiver - The annual aggregate amount of premiums and cost-sharing for coverage of the family of the child in the state employee plan exceeds 5 percent of the family income.

If the state meets the first condition, any eligible state employee child can be enrolled in CHIP. The second condition is applicable on a family-by-family basis. 

Interest is high among advocates and state officials in this change but federal guidance is needed to answer certain questions. In particular, given crowd-out rules is this option only available to new employees or to employees whose children have been uninsured long enough to meet CHIP waiting periods? How will states estimate a family's total cost-sharing to determine if a family meets the hardship waiver?

Whether you like savory or sweet, there's something to please everyone's palate in health reform. While we wait for the meat and potatoes to be served in 2014, there are lots of tasty treats to satisfy our hunger in the meantime. And we'll keep serving them up for you to sample at Say Ahhhh!

Yesterday the Kaiser Commission on Medicaid and the Uninsured and the Urban Institute released some long-awaited state-by-state estimates of the impact on adult coverage of the Medicaid expansion included in health reform, along with estimates of the state and federal cost of the expansion. The new report provides some valuable new estimates that highlight that states will get a huge bang for their buck out of the Medicaid expansion and see major gains in coverage.

Let's start with the big picture - the Medicaid expansion will significantly reduce the number of uninsured. In fact, by 2019, the number of uninsured adults under 133% of the FPL will decline by 11.2 million (a 45% reduction). Nationally, enrollment in Medicaid is expected to increase by 27.4%. The impact of the expansion will vary by state, as states with more limited coverage pre-reform will see larger declines in the number of uninsured.  And, it could be even greater if states step forward and actively pursue maximizing the enrollment of eligible people.

The study's lead author, John Holahan, put it starkly in an interview with the Washington Post, saying that the states "will come out ahead" and that "it is just crazy" for states to issue gloom and doom predictions about the fiscal impact of health reform. In the study itself, he estimates that the federal government will pay $443.5 billion for the Medicaid expansion (or about 95% of the cost) through 2019, an increase of about 22% in federal Medicaid spending. Increases in state spending are very small in comparison - only about $21 billion or 1.4% more than they would have spent on Medicaid if health reform had not been enacted.  While the federal share of spending varies modestly by state, it is important to note that the study concludes that the federal government will pick up at least 93% of the new spending through 2019 in each and every state. (Note - the study looked at two scenarios - a standard scenario using participation rates for new enrollment that approximate current participation rates and an enhanced scenario that assumes more robust participation due to the individual mandate and increased federal and state outreach efforts. The numbers cited in this blog refer to the standard scenario.) 

Moreover, the study identifies a number of sources of potential savings to states that if taken into account in future state-by-state estimates could be expected to show states saving money.  Most notably, the current state-by-state estimates do not factor in any of the savings in uncompensated care spending that states will experience as more people gain coverage through Medicaid and the new subsidized Exchanges (e.g., state spending on public hospitals, community clinics, mental health programs, etc. that can be reduced when more people have coverage). During the briefing, Dr. Holahan gave a rough estimate that states' uncompensated care savings could easily reach $80 billion through 2019, an amount that is far more than the $21 billion they are expected to spend on Medicaid expansion.

The estimates released yesterday are an important confirmation that significant coverage gains will be made through reform and that states will come out ahead in spending.  Yes, there is still some uncertainty around the Medicaid expansion in health reform - it's hard to predict how many people will enroll in the program and how aggressively states will pursue new and existing enrollees. But while some questions remain unanswered, the numbers released today are a much-needed "first look" grounded in data on the gains states can expect to experience under health reform.

By Matt Jewett, Children's Action Alliance of Arizona

Not a lot of good news has come out of Arizona this year.  Amidst leading the country in job losses, selling our state Capitol to raise money (we're leasing it back), and a divisive immigration debate gaining national attention, we also became the first state ever to eliminate our highly successful Children's Health Insurance Program (CHIP).  Fortunately, federal health reform passed just days after Governor Brewer signed the bill eliminating KidsCare, but before the elimination had taken effect.  Since federal health reform requires states to maintain their CHIP programs, Arizona would have been out of compliance, and stood to lose the entire $7 billion a year we receive in federal Medicaid money.  As a result, the legislature and Governor restored KidsCare before the legislature adjourned.  This reversal is a lifeline for the nearly 34,000 children currently enrolled in KidsCare, who will not be dumped from their health insurance on June 15 as previously scheduled.

Children's Action Alliance was active with our Bring Back KidsCare, taking to the radio and internet to convince Arizona's voters and elected officials that KidsCare is a smart investment that helps children grow up strong and thrive.  This campaign showed that bringing back KidsCare was not only smart in light of health reform, but also the right thing to do.  Unfortunately, a KidsCare enrollment freeze has been in place since January 1, 2010.  Enrollment has already fallen by more than a quarter since the beginning of the year, and over 40,000 applications have been submitted for KidsCare that have not been processed due to the enrollment cap.  It is estimated that the majority of those children would be eligible for KidsCare if the enrollment freeze was lifted (read our press release or see the Arizona Republic story).  Should the freeze continue, enrollment will fall by more than half over the next year, and within five years, just 194 children would remain enrolled in KidsCare.  And while national health reform will provide additional help to families in 2014, four years is a lifetime for a child to wait.

The cost to open up KidsCare enrollment to all eligible children is $11 million, or less than $2 a year for every resident of the state.  In a budget 800 times that size, finding the money should not be difficult if our elected officials make children's health the same priority that voters do.  Re-hiring laid off employees at the Arizona Department of Revenue could lead to the collection of money already owed to the state, more than paying for KidsCare.

Children's Action Alliance will keep up the pressure to Bring Back KidsCare fully - so all children in our state can grow up healthy and ready to succeed.

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

In 1997, just months before Congress enacted the Children's Health Insurance Program (CHIP), the Robert Wood Johnson Foundation (RWJF) announced a national grant program called "Covering Kids." The concept was to overcome hurdles to Medicaid enrollment and retention through outreach, policy and procedural simplifications and coordination of coverage between programs. With the creation of CHIP, RWJF recognized the significant potential to enroll eligible children and eventually awarded Covering Kids grants in all states.

Three years later, RWJF broadened the initiative by launching "Covering Kids & Families." Altogether the foundation invested $150 million dollars in technical assistance and direct financial support of coalitions in the states and hundreds of community-based projects. Today, many CKF coalitions continue this work; conducting outreach, working with state program administrators to remove barriers to coverage and providing a real life perspective on how well public coverage programs are meeting the needs of children and families.

CCF is pleased to serve as a technical and policy resource center to these coalitions as they continue their collaboration through the National Covering Kids & Families Network (NCKFN). With support from RWJF, CCF will provide federal policy research and analysis and facilitate information-sharing, networking, communications, collaboration and peer-to-peer learning among member organizations within the network.

A critical aspect of this new partnership is to identify, capture and promote key lessons learned, promising strategies and best practices in enrolling all eligible children and families in Medicaid, CHIP and other public health coverage programs. This insight will be invaluable as we design a consumer-friendly system of health coverage that includes expanded Medicaid coverage, maintenance of CHIP and new affordable options for individuals and small businesses to purchase subsidized insurance through insurance exchanges.

While creating an insurance exchange is new to nearly all states, the experience of Covering Kids & Families coalitions provide valuable lessons learned. Making information accessible, overcoming language and cultural barriers, providing community-based application assistance, streamlining policy and procedures, reducing paperwork and monitoring enrollment and retention through data collection, analysis and reporting are essential building blocks to the success of health reform.

For more information about the NCKF network, visit http://ccf.georgetown.edu/index/covering-kids-and-families

By Amanda Jezek, March of Dimes

Health reform is giving pregnant women throughout the U.S. a far more valuable package than anything they could ever unwrap at a baby shower -- access to maternity coverage.

Coverage for maternity care is crucial because, without it, women face much more difficulty in obtaining needed health services.  Women who have insurance coverage for maternity care are more likely to receive screening and diagnostic tests that can help to identify problems; services to manage developing and existing problems; and education, counseling, and referral to reduce risky behaviors like substance abuse and poor nutrition.

Prenatal care can help reduce infant mortality and improve birth outcomes; postpartum care can help women appropriately space pregnancies, which can reduce the risk of preterm birth.

According to U.S. Census data prepared for the March of Dimes, a whopping one in five women of childbearing age is uninsured. Now consider that 50 percent of pregnancies are unplanned. Those who tried to get coverage on the open market were in for a rude awakening: insurers considered pregnancy to be a pre-existing condition and would therefore often deny coverage.  Needless to say, many women found themselves facing this dilemma.

Consider a March of Dimes family in Virginia who signed up for private insurance because their COBRA coverage from a previous job was about to end. They took the precautionary step of adding a maternity rider, which had a six-month waiting period before covering pregnancies. They didn't think there would be any issue as they used fertility treatments to conceive their first child. Despite being told by doctors that they had only a five percent chance of getting pregnant naturally, four months into the six-month waiting period, they discovered they were expecting. At that point, no other insurance company would pick-up coverage determining that the pregnancy was "a pre-existing condition." It cost the family $20,000 out-of-pocket.

Thanks to health reform, the practice of pre-existing condition exclusions will be prohibited in 2014 (earlier for children).  But the pre-existing condition exclusion was only one of many hurdles that pregnant women faced to obtaining coverage -- and that health reform will fix. 

In 2006, a Georgetown University study commissioned by the March of Dimes found that 19 states had adopted laws to require coverage of maternity care. However, these laws varied in scope, and only five of the states (MA, MT, NJ, OR and WA) required all insurers in the individual market to cover maternity care. In states without such requirements, maternity coverage is typically available only through an expensive rider to the underlying policy -- and then with a waiting period or outright denial if the woman is already pregnant.

Health reform will require insurers to cover an essential benefits package that includes maternity care.  Insurers will no longer be able to exclude this critical benefit from policies.

While these private insurance reforms are a tremendous step forward, over 40 percent of pregnant women rely on Medicaid for their coverage.  Health reform makes improvements for these pregnant women too.  Beginning in 2011, all state Medicaid programs will be required to cover tobacco cessation counseling and pharmaceuticals for pregnant women. Given that pregnant women in Medicaid are 2.5 times more likely than other pregnant women to smoke and that smoking dramatically increases the risk for numerous poor birth outcomes (such as preterm birth and low birth weight), this policy will provide much needed assistance to millions of pregnant women.  The U.S. Preventive Services Task Force has found that tobacco cessation interventions are very successful in helping pregnant women quit, and these services have even been found to save money.

Health reform also gives states the option to start covering more low-income women before they get pregnant using Medicaid family planning expansions.  States previously needed a waiver to extend this coverage, but now they may use a simple state plan amendment.  In addition to appropriately spacing pregnancies, women whose pregnancies are planned are more likely to begin prenatal care early, increasing the likelihood of a healthy birth.  And Medicaid family planning expansions have been found to save money at both the state and federal levels.

The daunting task of implementation awaits, but women throughout the country can at least be assured that when they become pregnant, they will have coverage for maternity care to help provide their children with the healthy start they deserve.

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families. The photo of the mother and baby was provided by the March of Dimes Foundation and may not be reprinted without that organization's permission.

Coverage of young adults up to 26 years of age on a parent's insurance plan is one of the most popular provisions of the new health reform law and an early win for children and families. This week, three federal agencies released joint interim final regulations on this provision. The rules confirm that all individual and group health plans, including self-insured plans, must allow young adults to be enrolled as dependents on their parent's plan starting with new or renewing policies commencing after September 23, 2010.

Under the new law, insurers cannot impose restrictions that have existed previously in determining dependent status, including student status, marital status, residency or financial support by the parent. One short-term exception does apply. Until January 1, 2014, "grandfathered" health plans may reject young adults who are eligible to enroll in their own employer sponsored insurance plan.

The term "grandfathered" health plan generally describes plans in existence on the date of enactment of the health reform law. What is not clear until additional federal guidance is issued is when or how a plan might lose its "grandfather" standing and be considered a new plan for the purpose of this and other provisions of health reform.

Plans must notify subscribers of the new provision and parents will have 30 days to enroll their adult children. The law explicitly allows a parent to enroll if not currently insured or switch coverage options for all family members. However, there is no requirement for a plan that does not provide dependent coverage at all to start doing so.

Insurers must offer all the benefit packages available to other "similarly situated" dependents. For example, if an insurer offers a choice of an HMO product and an indemnity plan to a group, it cannot limit enrollment of young adults to the HMO plan. Insurers can charge more on an individual family basis if they already do so for each new dependent enrolled or they can raise rates across the board to cover the cost of including young adults in the risk pool.

The guidance also clarifies that if a state dependent coverage law imposes stricter requirements on insurers state law is not superseded by federal law. For example, if a state allows a young adult to remain on their parent's plan until age 28, the higher age limit continues to apply to state regulated health plans. Federal law would supersede state law that has less stringent provisions such as excluding young adults who are married or not claimed as a dependent on the parent's tax return.

The administration projects that 1.2 million young adults could be covered under this new provision. As widely reported, some 65 insurers have indicated they will implement the provision early by at least allowing dependents who would lose coverage as they age out or graduate to remain on their parent's plan. This is good news as we chip away at the 47 million uninsured Americans.

Medicaid will continue to be a cornerstone of coverage under health reform, with an additional 16 million people joining the program. A key question that many are asking (especially state officials facing tight budgets) is how the cost of this Medicaid expansion will be financed.

Let's start with the big picture - overall, CBO estimates the federal government will finance the vast majority of the increase in Medicaid coverage attributable to health reform. In fact, over the next ten years, approximately 96% of the cost will be picked up by the feds.

But as many know, Medicaid financing is not completely straightforward. Matching rates vary by state and program (CHIP vs. Medicaid), and under health reform they'll also vary by population (newly-eligible vs. already-eligible). In the hopes of providing a bit of clarity, CCF and the Kaiser Commission on Medicaid and the Uninsured put together a brief on the issue.

For those of you who want the Cliff Notes version, here you go:

•    Regular Medicaid Matching Rate: The regular Medicaid matching rate will continue for those "already-eligible" individuals (people who qualify for Medicaid under the rules in effect on December 1, 2009).  

•    CHIP Matching Rate: The CHIP matching rate will remain available to states through the end of fiscal year 2015, and then assuming Congress extends funding for CHIP past this date, it will increase by an additional 23 percentage points.  

•    "Newly-Eligible" Matching Rate: The newly-eligible matching rate is set at 100% in 2014-2016, 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and beyond. (This is the match rate designed to assure that the federal government finances much of the cost of the Medicaid expansion). It will be available for adults with income up to 133% of the FPL who are not eligible for Medicaid under the rules that a state had in place on December 1, 2009.

•    "Transition" Matching Rate:  The transition-matching rate is designed to provide some additional federal help to expansion states (states that expanded coverage for adults to at least 100% of the FPL). These states can receive a phased-in increase in their federal matching rate for adults without children starting January 1, 2014, so that by 2019 it will equal the enhanced matching rate available for newly-eligible adults.

It was a great victory for children and families when Congress included a maintenance of effort (MOE) requirement in health reform so states wouldn't cutback on Medicaid and CHIP coverage before affordable coverage was available through the state Exchanges.  Now, as with so many issues in health care reform, the way it works out for children and their families will depend on how these provisions are interpreted by policymakers in Washington, D.C. and implemented by states. 

Fortunately, the House and Senate leadership and key health reform negotiators are keeping a close eye on the situation.  This week, they stepped forward to urge Secretary Sebelius to issue MOE guidance that will make it clear to states that they cannot set up new enrollment caps or freezes in their Children's Health Insurance program (CHIP), making it harder for eligible uninsured children to secure coverage.  Specifically, they point out in a new letter to the Secretary that the law prohibits "the implementation of enrollment caps and freezes or other restrictive eligibility procedures that were not already in place and operational as of March 23, 2010". 

The letter was signed by Speaker Pelosi, Senate Majority Leader Reid, Senate Finance Chairman Baucus, House Energy and Commerce Chairman Waxman, Senate Health Care Subcommittee Chairman Rockefeller and House Health Subcommittee Chairman Pallone.  They wrote:  "Working together, we are confident that we can continue the nation's successful track record of covering low-income children even as we move forward on a parallel track to implement broader reform that covers millions of Americans for the first time." 

I agree with that sentiment, don't you?

Mark your calendars - on July 1, 2010, HHS plans on launching the new health reform web portal to provide state-level information about affordable health coverage options. In anticipation of the launch, regulations were released today detailing what information the portal will include and how the data will be collected.

The portal will be designed to help individuals and small businesses learn about coverage options in their state. It will include information on:

• Medicaid and CHIP,
•  Health coverage options offered on the individual market,
•  Existing state high risk pools, as well as the new high risk pools established by the PPACA, and
•  Coverage within the small group market for small businesses and their employees.

In order to promote the ability of consumers to understand the information, it will be provided in a standardized format designed to "minimize the use of technical language, jargon, or excessive complexity." 

As July 1st is a pretty tight timeline, the initial release of the web portal will only contain basic information on issuers and their products. Consumers will be able to learn about issuers that sell individual and small group products in their area and follow links to benefit information for those products, as well as access some educational information on the individual market. The portal also will include information for small businesses and coverage available through the high-risk pools.

A more comprehensive version of the portal will be launched in October. This version will have benefit and pricing information, including premiums, cost sharing options, types of services covered, coverage limitations, and exclusions. 

Importantly (and beginning with the initial launch in July), the portal will also provide information on eligibility and services for Medicaid and CHIP, including contact information and websites for the state programs. (Think of it as an upgrade on insurekidsnow.gov with coverage options for parents and adults, too!)

Having all this information in one place will help families learn about and connect with Medicaid and CHIP, as well as other sources of coverage, and provide the tools that enable more people to obtain health insurance between now and 2014.

Last week my son turned in his final paper and defended his senior thesis, his last acts as a college senior. In a few short weeks, he'll join the 3 million young adults graduating from college this year. Fortunately, this year's crop of grads (and their parents) will have one less thing to worry about as they transition to work or further education: health insurance. Thanks to health reform and advocacy efforts by the White House and HHS, many major insurers have announced they will voluntarily allow adult children to stay on their parents' health plan earlier than is required by the new health reform law.

Continuing access to their family's health plan for young adults - the age group with the highest uninsured rates - is one of the significant early wins in health reform for children and families. As of September 23, 2010, all new or renewing plans will be required to cover young adults up to the age of 26 as dependents regardless of their student status (unless they are eligible for employer-sponsored health insurance). About two-thirds of the states had previously taken similar action but the individual state laws did not apply to large group and self-insured plans governed by federal regulations. These states often excluded young adults who were married or did not live at home.

Until March 30, 2010, those continuing dependent benefits provided through state laws had also been subject to federal tax causing additional administrative work on the part of employers and incurring tax liability on the part of families who were able to continue coverage for their young adult children. Health reform has taken care of this problem as well by making these benefits tax-exempt. The tax exemption also applies to qualified medical expenditures under flexible spending accounts for adult children.

Luckily, my son has a job that will provide health insurance. But I am relieved he has something to fall back on should he experience a gap in employment or decide to tackle graduate school. And I'm thrilled to see tangible and early results from the new health reform law in improving access to health coverage for children and families.

Where we left off: I was musing that the new CHIPRA options to do premium assistance may not prove to be all that much more attractive than the existing ones. Some states may reconfigure their programs (if they can) to qualify for the performance bonus.  So far there hasn't been a rush to pick up these options.  But as we know from the GAO report, a majority of states are already doing some form of premium assistance today.

Yet what about in 2014 when the Medicaid expansion in PPACA kicks in?? On the Medicaid side, states will have two options - the existing Section1906 option and the CHIPRA 1906a option that will be extended to new populations as of January 1, 2014 by PPACA. When states move to an across-the-board eligibility of 133% of FPL, what will this mean for the success or failure of premium assistance programs in Medicaid?

In some ways, premium assistance may be more attractive to states that currently have low parent eligibility levels because the whole family will now be covered through Medicaid. This will make the cost-effectiveness equation more favorable, and eliminate the problem I described in Part III of this blog about states having to provide a wraparound for parents in the new Section 1906a option. But enrollees in most premium assistance programs that I have looked at tend to cluster at the higher end of the income eligibility scale - which is usually above 133% of FPL - because access to employer-sponsored insurance is so scarce at these low income levels. And we are talking really low -- recent data from the Urban Institute suggests that only 14% of people below 133% have employer-sponsored insurance.

For families above 133% of FPL, the question is more complicated - especially in states with more generous income eligibility today. The maintenance of effort requirements for kids in Medicaid and CHIP are in effect until 2019 while their parents are most likely going to be in the new Exchanges receiving a premium subsidy or receiving coverage through their employer. This might make premium assistance an attractive option from the perspective of keeping the family together - assuming kids don't lose benefits or cost-sharing protections in the process. The impact of reform on costs in the private markets may prove a factor in states' thinking about whether to pursue premium assistance options. So, a lot to mull through there and food for future blogging thoughts. That will have to wait for the Appendices.