July 2010 Archives

Is this a scene from the latest Mad Men episode?  While it's from the same era, it's fairly apparent from the attire that the photo was not taken on Madison Avenue.  The photo was taken 45 years ago today at the signing ceremony of the Social Security Act of 1965, the law that created Medicare and Medicaid to provide care to the most vulnerable in our society.

As he watched President Johnson sign the new law, I like to think Vice President Hubert Humphrey was thinking something along the lines of his famous quote: 

"It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."

I think Medicaid represents an appropriate moral test for our government and the American people as it was created to serve those in the dawn of life, twilight of life and shadows of life.  Medicaid is there for families facing poverty, the elderly who cannot afford long-term care, people with disabilities and for children with severe and chronic health conditions.

The White issued a proclamation today celebrating the 45th anniversary of Medicare and Medicaid.  Here's an excerpt:

"Medicaid created an essential partnership between the Federal Government and the States to provide a basic health care safety net for some of the most vulnerable Americans: low-income children, parents, seniors, and people with disabilities.  Forty-five years later, we must ensure this invioable trust between America and its citizens remains stronger than ever." 

This might seem like an old-fashioned idea to some, but I think compassion for the most vulnerable among us is always in style.  How well we treat Medicaid is a good indicator of who we are as a nation. (And for you Mad Men fans who watched Draper fumble the reporter's question  "Who is Don Draper?", Humphrey could have easily handled that question by pivoting to the more important question of who we are as a nation.)

So happy birthday Medicaid & Medicare!  Here's to hoping that you get even better with age.

HHS announced today that up to $1 million per state will be available in grants to begin establishing health insurance exchanges. This first round of grants is designed to help cash-strapped states conduct the research and planning necessary to build the new marketplaces. Grant applications are available at: http://www.healthcare.gov/center/grants and are due by September 1, 2010 (there is a pre-application call scheduled for August 5th). Only states are eligible to apply for the grants and no matching funds are required. 

In describing their planning activities in the grant application, states must include information on how they will involve stakeholders in the decision making process, as well as how they plan to build on and integrate the exchange with existing public programs such as Medicaid and CHIP. And in a nod to transparency, states must post information about the planning grants on their websites.  

The administration also released a request for comments on the standards and rules that Exchanges will be required to meet. The administration is encouraging states, consumer advocates, employers, insurers, and other interested stakeholders to provide input. To add your two-cents, go to: http://www.healthcare.gov/center/regulations. Comments are due by October 4, 2010.

By Christine Barber, Community Catalyst

We've all heard the recently-passed Affordable Care Act (ACA) provides a lot of new opportunities for improving health care coverage and access - but we also hear most Americans don't understand what the law actually means for them. At Community Catalyst, we think a major opportunity created by national health reform is improving consumers' access to clear information about their health care options from trusted sources. Consumer assistance programs (CAPs) are a critical way to make this happen.

The ACA included $30 million in grants for 2010 to fund state CAPs and ombudsman offices (Section 1002) to help real people understand their health care options. And the Department of Health and Human Services Office of Consumer Information and Insurance Oversight (OCIIO) just released the grant guidelines for the program late last week. Overall, we at Community Catalyst applaud the guidelines.

A few highlights:

• The grant criteria take steps to ensure that the selected programs are independent. In particular, we are happy to see that the guidelines clearly welcome states to contract with non-profit organizations to provide consumer assistance.
• CAPs must assist people with all types of coverage and provide assistance that is culturally appropriate. In addition, programs must collect data about any problems and questions, which we hope will provide real-time, on-the-ground information about what's working and what's not. Regular feedback to state and local policymakers can help improve health reform implementation.
•  Each state is eligible for one grant award. Therefore, it is important that states know about this grant program, so consumers can get help, no matter their zip code.

Examples like Health Care for All Massachusetts's Helpline, New York's Community Health Advocates, and Health Assist Tennessee have shown us that strong consumer assistance programs can mean the difference between a failed attempt and successful reforms. The Helpline in Massachusetts saw their call volume increase by 400 percent after Massachusetts's health reform law passed. People still call with questions, from enrollment assistance to help with paperwork to navigating the health system.

We hope that states will partner with community-based non-profits wherever possible to help provide consumer assistance. We have seen these models work, and know that they are trusted sources of health care information for communities and for families looking for help in understanding a system that's about to get bigger and more complex.

The CAPs grants are an important step in making sure the public understands and can navigate the health system as it changes. Grant applications are due September 10, and year-long grants will be awarded to states this October.

By Sabrina Corlette, Georgetown Health Policy Institute

In the last couple of weeks there have been reports that some insurance companies have decided they will no longer market "kids-only" policies, in response to the new requirement under the Patient Protection and Affordable Care Act (ACA) that they issue coverage to all children, even those with pre-existing health conditions.  What are these "kids-only" policies, and how many families will be affected if plans drop out of the market?  

Only a small percentage of families buy kids-only commercial coverage - by some estimates these plans constitute 8% of all policies offered on the individual market (in fact, AHIP  found that its surveyed members only cover about 150,000 children through kids-only policies).  In some cases, the parents who buy these policies can't obtain coverage themselves, because it's simply unaffordable or they have health conditions that cause insurance companies to deny their applications.  In other cases, a parent has access to insurance through their job, but it's much cheaper to buy a kids-only plan than to purchase family coverage. 

Currently, companies that sell kids-only policies engage in underwriting, which allows them to deny policies to children who have health conditions.  And if they do issue policies to these children, they often refuse to pay for the very treatment that would help them get better.

The ACA includes an important new reform for families with children that have pre-existing health conditions - as of September 23, 2010, plans are no longer allowed to deny these kids coverage, or to exclude from policies the benefits they need.  This provision is estimated to help 162,000 kids get coverage they otherwise wouldn't have.

This is a reform that should be embraced by everyone - how can anyone justify denying a child access to health care?  And early on, most health insurance companies said they would willingly comply with the new rules.

But lately, that commitment has started to crumble as the companies look at their bottom line and realize that covering kids who need health care will drive up their costs.  In a move that demonstrates how dysfunctional our health system has become - and why the broader insurance reforms, slated to go into effect in 2014, are so vital - many are now saying they want to get out of the kids' market.

What does this mean for families?

First of all, families with children currently enrolled in a kids-only policy don't need to panic.  Under another federal law - the Health Insurance Portability and Accountability Act (HIPAA) - these policies are "guaranteed renewable," which means that they can keep their children enrolled in the policy if they wish.  Most plans won't completely exit the market - they are simply no longer selling the policy to new customers.  Families should be aware, though, that they could face higher premiums over time.

For families whose kids don't currently have coverage, they may find that fewer plans are offering kids-only policies.  But that doesn't mean they won't be able to access coverage. Many families will want to explore whether their child is eligible for Medicaid or CHIP, both government-sponsored programs for low- and moderate-income families available in every state. Most uninsured children in the country - two out of three - are eligible for these programs, which offer affordable coverage without imposing any pre-existing condition exclusions.

If parents are looking for insurance on the individual market, they should check out the new HHS website, www.healthcare.gov.  The site has easy-to-use comparative information on health plans' family coverage options in every zip code. And under the ACA, even if their child has a pre-existing health condition, plans will no longer be able to deny them coverage or limit benefits, although it is possible that they could charge them more if their child has such a condition.

Based on regulations released by the Administration earlier this week, families shopping for plans may also face "open enrollment" periods. (See Administration's fact sheet addressing "open enrollments.)  Insurers want to curb the practice of people signing up for coverage only when they become sick.  But the effect could result in children having greater difficulties obtaining coverage when they most need it. Federal officials need to ensure that "open enrollment" policies include strong protections for kids, including making sure that children cannot be improperly dropped from coverage and that a child can bypass the enrollment period at critical junctures, such as when a child loses employer, Medicaid/CHIP or other coverage.

The website also has information on the new high risk pools, which are established in every state to provide affordable coverage to people who've been uninsured because of a pre-existing health condition.  For some families, if they can show their child was either denied coverage or charged an excessive amount for a policy, and has been uninsured for at least 6 months, these new high risk pools could be a viable option.  Federal officials could also revisit the pools' eligibility requirements to ensure that sick children facing a loss of coverage can access care without having to wait 6 months. Additionally, state and federal officials running the pools need make sure the application and enrollment process for these kids is simple and accessible, and that the benefits effectively meet children's unique health care needs.

Over the coming weeks and months, it will be critical for state and federal officials, as well as advocates for children and families, to closely monitor health insurance companies and cry "foul" against any business decisions that could negatively impact kids.

Of course, in 2014, when the full range of health insurance reforms are implemented, many more options will become available.  And the dysfunctional insurance industry model that denies millions of families access to coverage when they need it the most will hopefully be a thing of the past.

For more information, see answers to some frequently asked questions, available here. 

Summer vacation is not even half over and I'm already thinking about getting my kids ready to go back-to school.  It's not that I don't enjoy their company; I just want to get a jump-start on my to-do list so that I deliver them to school ready to learn.  Along with back-to-school shopping, they need their annual physicals and 6-month dental check-ups.  Child health advocates around the country have another major item on their back-to-school checklists - reaching out to the five million children who are eligible for Medicaid or CHIP but are unenrolled. 

This is an ideal time of year as the media and huge segments of our population are focused on children's needs as they prepare to head back to school. The National Covering Kids and Families Network (NCKFN) is helping groups leverage the increased attention to children's issues during the back-to-school period to help reach enroll eligible children in state Medicaid and Children's Health Insurance Program plans. They recently hosted a webinar to discuss messaging and strategies that work. (Georgetown CCF is providing technical assistance to NCKFN). 

Many of the NCKFN participants and other groups have been working on back-to-school efforts for many years and had a wealth of experience to share with each other. Some excellent messages have been developed for groups working on this initiative by GMMB with the support of the Robert Wood Johnson Foundation.  The trick is getting the right messengers to use the messages to reach families of uninsured children. Many of the NCKFN groups have had a lot of success working with school nurses, school administrators, social workers, community outreach workers and teachers. Two participants on the webinar focused on more non-traditional messengers - school board members and youth sport leaders. 

First, Donna Cohen Ross, senior advisor to the Office of External Affairs at CMS (and an expert on outreach), announced HHS's plan to launch a coaches campaign "Get Covered: Get in the Game" which will enlist youth sports leaders to help find uninsured children and get them enrolled (more details on the campaign to come in August). Coaches are great messengers.  (Just compare the sports section to the health section of your local newspaper if you doubt the ability of sports leaders to get a message across in your community.)  Coaches can pitch a different message to families by linking the importance of coverage with the ability to compete in team sports. As Donna pointed out, there is a strong link between good health care and sports as kids frequently are excluded from school sports participation if they don't have a physical.  Parents are also understandably reluctant to allow children to participate in sports if they aren't insured for fear of an injury that they can't afford to treat. 

As the mother of three boys, I'm involved with my fair share of youth sports teams and recall one heart-breaking incident when one of my son's soccer teammates suffered a concussion during a tournament.  I offered to drive him and his mother to the hospital but she said she didn't have insurance so she would just wait to see if he really needed care.  No mother should be faced with that choice and coaches could help make sure they are not.  Good coaches teach children more than just about sports, they teach them about the importance of teamwork, perseverance, and hard work and they make sure kids are doing as well off the field as they are doing on the field.   Youth sports participation helps children learn many valuable life lessons and it is tragic that some children are unable to fully participate in this aspect of childhood due to the lack of insurance coverage - especially for those who are eligible but unenrolled in CHIP or Medicaid. 

Second, April Griffin, a school board member from Hillsborough School District in Florida, spoke about the importance of getting buy-in at the top. (In other words - cultivating the grass tops as well as the grass-roots).   She pointed out that school district staff and teachers are stretched thin and are under pressure to raise test scores.  According to Ms. Griffin, the more groups are able to link children's health coverage with school performance, the more successful they should be in getting the buy-in of school system personnel. 

Her message also hit home.  A friend of mine tried to get our school district to include information about our state's Medicaid and CHIP programs in back-to-school packets.  The school district staff refused and said it was against school district policy.  My friend appealed to a school board member by pointing out that the school district included promotional materials of for-profit insurance companies in the packets.   The school board member was able to look at the "big picture" rather than reading a policy manual and gave the staff person the go-ahead to include the CHIP & Medicaid information in this fall's packets. 

There were a lot more great ideas shared on the NCKFN webinar and I encourage readers to check them out here.  In collaboration with the network, Donna Cohen Ross of CMS has scheduled a second webinar on school-based outreach efforts on July 29th. (All those of you who have read Donna's posts on this blog or have worked with her over the years know that Donna cares deeply about this topic and you won't want to miss this opportunity.)   

Last week, the National Association of Insurance Commissioners held a first of many planned meetings on health care reform.  In many ways, state insurance commissioners, have become the front lines of health reform implementation as they are responsible for ensuring that health plans are compliant with the insurance reforms in the Affordable Care Act and they will play a key role in the establishment of the exchanges.

For this meeting, at the top of the agenda was the exchanges and the discussion ran the gamut, from basic questions about exchange responsibilities to detailed analysis of how to limit adverse selection. The consumer perspective was well represented with our colleague at the Georgetown Health Policy Institute, Sabrina Corlette, who testified along with Tim Jost of Washington and Lee University. Tim shared his view that the success of an exchange will depend greatly on its ability to establish a streamlined enrollment and eligibility system that is seamlessly linked to Medicaid and CHIP.

Interestingly, the issue of coordination between the exchanges and Medicaid and CHIP brought forth many questions from the represented commissioners. More than once we heard reference to the fact that public programs, and the populations they serve, are a new world for insurance commissioners and that they are eager for more information. Key issues on their minds were how to maintain continuity of care between those moving back and forth between exchange and Medicaid/CHIP coverage, what IT funding and/or technical assistance will be available to assist Medicaid/CHIP agencies, and how to align the more "prescriptive" eligibility rules of Medicaid/CHIP with the tax credits so that enrollment in exchanges is consumer friendly.

The conversation was a good start - but also a good opening for ongoing dialogue with and education to state insurance commissioners on the central role that exchanges will play in helping people to secure subsidies for coverage and in facilitating their enrollment into Medicaid and CHIP. Georgetown CCF submitted comments to the NAIC on these critical issues.

For the meeting agenda and other materials, visit the NAIC site. 

By Jon Peacock, Wisconsin Council on Children and Families

It isn't often that state policymakers have to make program changes and policy choices because of a law passed in another state or territory of the U.S.  Thus, it came as a big surprise to learn that a law enacted in Puerto Rico forces states to make a choice about how they administer public benefit programs, including Medicaid and CHIP.    

The Puerto Rico law invalidates all certified copies of birth certificates issued by the Puerto Rico Health Department before July 1, 2010. The law was adopted by the commonwealth last year after it was informed that stolen birth certificates were being used fraudulently. Beginning on October 1, 2010, states may no longer use those birth certificates to document citizenship to identity those eligible for public benefit programs.  The new law was initially scheduled to take effect on July 1, but states and program applicants have been given three additional months to prepare for the change.

The older certified copies will not be valid for new applications starting October 1, but states have the option of not requiring Puerto Ricans who are already enrolled to obtain a new birth certificate when they come up for their annual review of eligibility.  Additional information on the new law, as well as application forms for new copies of birth certificates, can be found here. 

Wisconsin recently became one of the first states to tackle this issue:  the state decided not to make current program participants obtain new copies of their birth certificates. (See Operations Memos # 10-39.) The WI Department of Health Services (DHS) decided that requiring all enrolled Puerto Ricans to obtain new birth certificates would be a burden for those individuals and wouldn't be a cost-effective use of time for caseworkers.  

Wisconsin's BadgerCare Plus program has been extremely effective in giving nearly all Wisconsin children access to quality affordable health insurance, and in making enrollment and renewals easier for eligible families.  However, Wisconsin still has room for improvement in streamlining renewals, and DHS is working toward that goal.  The department's choice not to require new birth certificates for already-enrolled Puerto Ricans prevents what could have been a setback to Wisconsin's efforts to reduce churning among program participants.

For new Puerto Rican applicants, states can mitigate the potential burden of the law by taking advantage of the CHIPRA option to use Social Security numbers for automated verification of citizenship and identity.  Although Wisconsin does not currently employ that option, DHS is preparing to put it in place this fall--and many states are already up and running with it.    

There is no avoiding the fact that the Puerto Rico law will affect Medicaid and CHIP programs across the U.S and is likely to delay some applications.  However, the choices made in Wisconsin illustrate that states can minimize the additional burdens for program applicants, participants and caseworkers.  Especially when budgets are tight, smart decisions that avoid additional red tape can pay off for both state budgets and uninsured kids.

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

By Eugene Lewit and Liane Wong

The David and Lucile Packard Foundation

The percent of uninsured children has consistently declined, despite deterioration of coverage for adults and the economy. This is one of the significant but frequently overlooked good news stories of recent years.

The gains in children's coverage have been due in large part to actions taken by states to simplify enrollment and retention processes for their Medicaid and CHIP programs while expanding eligibility for those programs. In many states, policy advocacy groups have played important roles in spurring and supporting progress in their states. These organizations are likely to continue to be important players in the implementation of CHIPRA and broader health care reform. Yet, there has been little rigorous, systematic research on how advocacy groups do their work and the strategies they employ to achieve their objectives.

Two recently released issue briefs based on findings from an on-going evaluation of the David and Lucile Packard Foundation's Insuring America's Children: States Leading the Way (IAC) grantmaking strategy attempt to fill some of this knowledge void. The briefs examine some of the state-based advocacy work supported through IAC and identify the lessons that have been learned regarding how to effectively support and promote growth of children's health coverage.

In the first brief, State-Based Advocacy as a Tool for Expanding Children's Coverage: Lessons from Site Visits to Six IAC Grantee States. Evaluation Brief 1, the authors summarize key findings gleaned from in-depth site visits to states where IAC has made its most substantial investment in advocacy through multiyear "Finish Line" grants. These findings describe how persistence, flexibility, creativity and commitment to conducting effective states-based advocacy, especially in a changing environment, can benefit coverage expansion to all children. They also describe the importance of building strong and broad-based coalitions that include both grassroots and state-level stakeholders, an often key step toward maintaining a unified voice among a sometimes crowded community of advocates working to improve children's well being. While acknowledging that much work remains, the brief pinpoints a number of important gains in children's coverage since the IAC efforts began -- gains that have resulted despite a severe and ongoing economic downturn.

The second brief, Strategic Engagement of Policymakers is Key to Advancing a Children's Health Care Policy Agenda. Evaluation Brief 2, examines the benefit that positive engagement of policymakers can have for advocates to move the children's health care coverage agenda forward in states, as well as the strategies for making this engagement happen. Understanding states' unique political environments is one important first step toward this engagement. Further strategies include identifying, nurturing, and supporting political champions; creating strategic links between grassroots organizations and policy advocacy groups; creating effective, appealing messages for policymakers; establishing advocacy groups as the "go-to" resource for reliable data and information; and sharing ownership of agendas and successes with champions and key policymakers.

These briefs provide objective validation of the advocacy strategies and tactical innovations employed by veteran advocates throughout the country. They also offer practical and field-tested ideas for advocates looking for new ways to accelerate the pace of change. Most importantly, they remind us that tough, smart advocates can guide and support leaders in continuing the children's coverage success story.   

As we've noted previously Congress has yet to reach agreement on extending the increased Medicaid funding it originally granted in the 2009 economic recovery legislation.  The increased payments are scheduled to end in December 2010, but most state budgets are looking no better than they were a year and a half ago.  It seems like federal lawmakers would like to help states maintain Medicaid for the children and families who need it--Medicaid fiscal relief has passed both houses of Congress separately, but never in the same piece of legislation, so it is not law.

About half the states responded to this demonstrated interest by Congress--they included a six month extension of the increased Medicaid funds in their fiscal year 2011 budgets (see the map that employs data from the National Conference of State Legislatures) .  Since fiscal 2011 is already underway, states will be forced to make jarring budget adjustments if the extension does not come through.  

(Click to enlarge graphic)

In its absence, states will face budget holes of tens of millions in smaller states to more than a billion dollars in states like New York and California.  That means cuts to services state residents depend on or tax increases at a time when the economy remains fragile.  And because federal law protects eligibility standards and procedures in Medicaid, only limited parts of the program can be cut by state policymakers.  That makes the Medicaid funding extension an issue for all parts of the state budget--from education to economic development to the support for local governments that funds police and fire services.  Failure to extend Medicaid funding will have a ripple effect through the budgets and economies of many cash-strapped states.

The U.S. Senate moved yesterday toward extending unemployment benefits for those who have lost their jobs, recognizing that the recovery has not yet reached many workers.  It hasn't reached state budgets either, so an extension of Medicaid fiscal relief would help states maintain the services that families are counting on now more than ever.        

Since the last time we talked about state estimates of the cost of health reform, several more have put them out.

A few, in particular, struck me - Maine, Maryland, and Wisconsin. Why, you might ask? Because these three states found that health reform would save them money.

John Holahan of the Urban Institute suggested just this when he put out some estimates of state spending back in May, saying that "the states will come out ahead."(My colleague Jocelyn Guyer blogged about his findings.) But much of what we've heard from the states themselves has been "it's going to cost us $(fill in the blank)."

Let's start with Maine. An estimate put out by the state back in mid-June, found that the state is projecting to save $31.8 million in 2014. Wisconsin takes a longer view, estimating  savings of at least $745 million between 2014 and 2019. Maryland looks even more long term, projecting  savings of $1 billion over ten years.

As is always the case with state-by-state data, it's important to remember that each one is different (as are the assumptions the states are using to come up with their estimates in the first place). Maine, Wisconsin, and Maryland, have all been leaders in coverage and, as a result, will now reap some of the financial benefits of health reform. Other states may have to spend some money in order to see the coverage gains expected as the Affordable Care Act is implemented (which given their current budgets can understandably be seen as a daunting task).

But, the most important number to remember, whether your state saves or spends, is 32. As a result of health reform, 32 million more people will have coverage. How much is it worth to you to have a healthier America?

By Judith S. Palfrey, MD, FAAP

President, American Academy of Pediatrics

On Wednesday, I was honored to attend an event in DC unveiling the US Department of Health and Human Services' (HHS) Interim Final Rule on preventive services under health reform. To so many of us in the business of taking care of children, the achievement of passing the law last March was a time of historic celebration, and now, as one of the most significant pieces of the law takes shape, we realize just how much better off our children will be under health reform.

One of the earliest provisions of the Patient Protection and Affordable Care Act to take effect is Section 2713, which requires health plans to cover, at absolutely no out-of-pocket cost to families, preventive care services outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Supported by the Health Resources and Services Administration, Bright Futures is the definitive standard of pediatric well-child and preventive care developed by an evidence-informed, active collaboration led by the American Academy of Pediatrics (AAP).

Perhaps the best-known aspect of Bright Futures is the schedule of "well-baby and well-child visits" it establishes--31 visits between birth and age 21 years (to pediatricians and other clinicians, it is also known as the "periodicity schedule"). The interim rule clearly states that all components of pediatric well-child visits--including physical exams, immunizations, hearing and vision screening, developmental and behavioral screening, and anticipatory guidance--in accordance with the Bright Futures periodicity schedule must be free of financial barriers, including co-pays and deductibles. Insurers may not exclude any of these services from coverage, and cost-sharing cannot be imposed on families.

This landmark investment in preventive services will eventually allow all families, regardless of income, the opportunity to visit their pediatrician regularly during their children's most critical years of development. Having coverage for the clinically appropriate well-child visits will allow pediatricians to identify and treat health problems in children before they start. This, in turn, should help bring down the prevalence of chronic conditions that place significant financial and physical strain on children and families.

The Academy will continue to work with HHS on the development of a Final Rule, and in the process, will continue to advocate for the following: all plans--including those retaining "grandfather status"--to cover Bright Futures services; Bright Futures to be appropriately integrated into other initiatives and standards, such as meaningful use and quality measures; and for insurance companies to eliminate cost-sharing while making up those dollars for pediatricians and other health care providers.

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

Editor's Note:  CCF's Dawn Horner also blogged about the preventive health services rule. 

"An ounce of prevention is worth a pound of cure."

It is not often that I find myself quoting Benjamin Franklin, but it seems particularly apropos this week with the release of the latest Affordable Care Act regulation. On Wednesday, the Obama administration issued new rules requiring that health plans provide a series of expert-recommended preventive services without co-payments or deductibles.  This is particularly good news for children since included in the mix of required services are those recommended by Bright Futures, the American Academy of Pediatric's "gold standard" of care for children, and immunizations recommended by the CDC. This includes: 

• Well-baby and well-child doctor visits covering an array of services including physical exams, vision and hearing screenings, oral health risk assessments, and developmental assessments.
• Screenings and counseling to prevent, detect, and treat common childhood problems like obesity, depression, dental cavities, and anemia.
• Immunizations like an annual flu vaccines, and many other childhood vaccinations and boosters.

Research continues to show that significant long-term health benefits (in addition to decreased health costs and increased worker productivity) can be derived from the utilization of preventive services. Unfortunately, even with the long ago wisdom of Benjamin Franklin, Americans continue to fall behind in receiving this care. For example, according to research conducted by the Commonwealth Fund, about one-third of young children do not receive an adequate level of basic preventive and developmental services. 

The new rules are meant to change this dynamic by making preventive services more readily available and affordable. The Administration estimates that 31 million people in employer-sponsored plans and 10 million people in individual plans will receive these new benefits in the next year. However, it is important to note that the rules apply only to new health plans (that begin coverage after Sept. 23, 2010), not to those that have grandfather status.  

In addition to children's services, all non-grandfathered health plans will be required to provide with no cost sharing (the full lists are available at healthcare.gov):  

• Tests and screening recommended by the United States Preventive Services Task Force. This includes blood pressure, prenatal care, diabetes and cholesterol tests, screenings for cancer, HIV, obesity, and depression, and smoking cessation counseling.
•  Immunizations for adults recommended by the CDC.
•  Preventive care and screenings for women (not otherwise addressed) recommended by HRSA. (These guidelines are currently being developed and will be released next year.)

The rules also provide some clarification on what charges can be applied when doctors combine billing for a preventive service with an office visit: short answer, insurers cannot apply cost-sharing for the doctor visit if the recommended-preventive service was the sole purpose of that visit. Plans also are not obligated to cover services or waive cost sharing if provided out of network. The Administration estimates that premiums will increase on average about 1.5 percent as a result of these changes. 

The new requirements provide significant new benefits for consumers, and now the work begins to ensure that individuals and families can (through monitoring and enforcement of the rules) and do (through public education) access the preventive services that Ben so wanted us to have.

Doctor Donald M. Berwick, a respected Harvard professor and pediatrician who has built a reputation for improving quality and reducing health care costs, was sworn in this week as administrator of the Centers for Medicare & Medicaid Services.  The agency had been without a permanent administrator since 2006. 

Dr. Berwick was installed in the CMS position through a recess appointment, allowing him to serve without Senate confirmation through the end of 2011.  While he's coming into office under less than ideal circumstances due to the controversy surrounding the recess appointment, a prolonged confirmation process would have delayed filling a crucial job vacancy. CMS has been without a leader for four years and it's important to have someone of his stature at the helm while CMS navigates its way forward toward full implementation of the Affordable Care Act. 

At CCF, we're happy to see the first pediatrician be appointed to head the agency.  With his strong background in children's health care issues, we are hopeful that he'll be influential in recognizing the unique developmental and health needs of children and that his grasp of these issues will be reflected in the policy decisions the agency makes.  

This last weekend, the nation's Governors came together for their annual meeting in Boston where the main topic of conversation was the economic crisis that continues to cripple state budgets.  One of the key policies many of the Governors made a pitch for was an extension of fiscal relief for strapped states through the extension of increased federal support for Medicaid (aka FMAP) .  As my colleague Joe Touschner pointed out in a blog last month: "That extra support has helped states through one of the worst fiscal crises on record and has been vital in stabilizing Medicaid coverage for children and others in families facing job loss."

My colleague Jocelyn Guyer also blogged about this topic earlier this week and I wanted to follow-up her comments with another look at why the Governors (and many others) think it is so critical for Congress to act sooner rather than later on an FMAP extension.  To do that, I pulled out a brief that Jocelyn and I, along with our colleague here at CCF, Martha Heberlein, did back in 2008 when the economic crisis we are currently in, began.

In this brief, we noted the astonishing progress that states had made over the last decade in covering uninsured children and explained that that progress was at risk due to the worsening economic climate facing states and a dramatic increase in the number of uninsured seeking coverage through Medicaid and CHIP.  We cited research from the Urban Institute that found that a one percentage point rise in the national unemployment rate can be expected to cause the number of uninsured people to grow by 1.1 million and to increase Medicaid and CHIP enrollment by one million (including 600,000 children and 400,000 non-elderly adults).

At the time, we considered the implications of this study if the unemployment rate reached 7.5 percent. Today, we face an unemployment rate of around 9.5 percent- and the model employed two years ago would suggest that as a result, the number of people that have lost employer-based coverage is 11.2 million; 4.7 million have likely enrolled in Medicaid or CHIP and about 5.1 million more people have become uninsured.

In the 2008 brief, we outlined key policies that lawmakers were considering to assist families through this crisis- reauthorizing CHIP and temporarily increasing the federal funding for Medicaid through increasing the FMAP.  CHIP has been reauthorized, the FMAP was increased until the end of this fiscal year and health care reform was been signed into law. However, the economic crisis continues and has likely resulted in millions of more people seeking coverage through Medicaid and CHIP just when the federal commitment to help states weather this economic storm appears to be eroding. While help is on the horizon in 2014 when states will receive new federal support through health reform, states need help now to meet the unprecedented demand for publicly-funded health care coverage.  It would be a mistake for the federal government to turn its back on the states before our nation has clearly pulled itself out of the recession. 

Community Catalyst and Georgetown's CCF have just finished up a piece that explores in detail the way that the new individual responsibility requirement will work.  With all of the controversy and rhetoric surrounding the requirement, it seemed a good time to take an objective, detailed look at how it will actually work. 

Plus, even though it doesn't go into effect until 2104, we wanted to write about the individual responsibility requirement because it is the foundation on which much of health reform rests.  It allows the country to move forward with popular insurance reforms, such as the ban on excluding people from coverage if they are sick, and plays a major role in expanding coverage.

In working on this Q & A, a few particularly interesting themes emerged, including:

• Nearly everyone is expected to secure coverage, but they won't necessarily face a penalty if they don't do so.  Very, very few people are exempt from the individual responsibility requirement.  Just people in prison, with strong, documented religious objections, and undocumented immigrants (who are left out because they are denied help in securing coverage through Medicaid, CHIP and the Exchange.)  But, lots more people are exempt from a penalty if they end up not complying with the requirement, including those who can't afford coverage, experience shorts gaps in coverage, fall below the tax filing threshold (which hovers around the poverty line, but can be somewhat below or above based on family size), or are native Americans.
• When it comes to children, IRS rules determine who is responsible for getting them coverage.  Parents (or caretakers) are obligated to secure coverage for their children; if they don't, they may be subject to a financial penalty when they file their taxes.  Interestingly, it is the parent(s) who claims a child as a dependent on the tax form who is responsible for securing her coverage, not necessarily the parent who is living with the child and taking care of her on a daily basis.  While not a big deal for many families, this policy could be a bit complicated in some divorced or never-married families where a non-custodial parent is claiming a child as a dependent for tax reasons.
• The Massachusetts experience with a coverage requirement went surprisingly smoothly. One of the more interesting Q & As in the document is about the Massachusetts experience with a coverage requirement.  Advocates in Massachusetts have dubbed it the "dog that didn't bark," reflecting that it has generated relatively little controversy and 98.6 percent of taxpayers properly reported their insurance status on their tax forms. Not everyone is like the residents of the Bay State, and so it may be a different story when 2014 arrives.  But, a very interesting reminder that a coverage requirement that is implemented well and backed up by strong initiatives to make insurance affordable can go surprisingly smoothly.

Dr. Fairbrother and her colleagues at Cincinnati Children's hospital have just come out with an excellent new study that takes a clear-eyed look at how often children end up losing health coverage after a parent loses a job.  The results are powerful, but not pretty -- between 2000 and 2004, almost one in three kids lost coverage when their parents lost a job (311 out of every 1,000).  And, the rate is much higher for low-income children (456 low-income children out of every 1,000 lost their coverage when a parent lost a job).   With the latest government data indicating that in 2009, there were 9.4 million families with at least one unemployed member, these are alarming findings. 

As bad as this news seems, one bright spot is that this is a problem we can fix by helping these children secure affordable coverage options through Medicaid and CHIP as their parents get back on their feet.  And, I'm willing to bet that we've actually already made some significant progress since 2004, the latest year for which data were available for the new study.  Thanks to the hard work of Governors, state-based advocates, and political leaders in Washington who have made a strong commitment to covering children, many of the children in families losing jobs now are eligible for Medicaid or CHIP and, increasingly, they are facing easier, more family-friendly enrollment procedures.  Especially before their budget situations deteriorated, states across the country were getting rid of red-tape barriers to coverage and extending Medicaid and CHIP eligibility to additional children. 

Since the downturn, states have largely held onto the gains in coverage (although concerns are increasing about cuts to provider reimbursement rates) and some are continuing to push forward.  This ability to "weather the storm" has been due in large part to a short-term, temporary increase in the help that the federal government provides states in financing Medicaid.

Now, however, we are coming up on a critical moment that brings the importance of Dr. Fairbrother's research into sharp focus. At the end of this year, the extra help the federal government has given states is slated to expire even though state budgets continue to be battered by rising demand for services. Without a short-term continuation of the extra help, states will be under enormous pressure to scale back Medicaid and CHIP, including children's coverage.  (They can't do it directly because the new health law requires a maintenance-of-effort when it comes to Medicaid and CHIP eligibility rules and procedures but there are indirect ways to cut back on coverage that states may be forced to consider such as slashing the number of state workers who can process applications or cutting reimbursement rates so deeply that children cannot secure needed care.)  If this happens, the reality documented by Dr. Fairbrother that children often lose their private coverage when their parents lose a job will translate into more and more uninsured children.  We will have a much harder time "catching" them in Medicaid and CHIP, and offering their families the peace of mind that comes with knowing that at least their children can still get health care.  On a more global scale, we could end up with a deeply disturbing result - more children becoming uninsured even as the country moves forward on implementation of broader health reform in 2014.

At Georgetown, we work closely with state officials and advocates who are addressing these issues in the states, and the sense of urgency is palpable.   If leaders in Washington don't come through quickly with an extension of federal fiscal relief, it may threaten a lifeline that can help millions of families stay afloat in the midst of unprecedented job loss. 

In May, HHS' Inspector General released a study that presented some pretty depressing news - almost three-quarters of children on Medicaid in nine states are not receiving all of the medical, vision and hearing examinations (the study did not look at dental) that federal law (through the Medicaid EPSDT benefit) requires. 

It has long been recognized that low-income children are at greater risk of being in ill health, often facing vision, hearing and speech problems, and other developmental obstacles. The importance of providing these children with early and regular screenings to identify and address problems before they become worse is clear. Medicaid EPSDT provides this comprehensive approach to kids' health by requiring that every child receive periodic preventive medical assessments that include physical exams, vision and hearing tests, dental exams, immunizations, lab tests (for example, to assess blood lead levels), and health education. Additionally, EPSDT provides necessary diagnostic and treatment services to address concerns identified in the screenings.

The newly released report shows that the states examined (Arkansas, Florida, Idaho, Illinois, Missouri, North Carolina, Texas, Vermont, and West Virginia) have a ways to go to meet the promise of EPSDT. Among these states, even for children who received a medical screening, 60 percent did not receive all of the services they should have (with lab tests most commonly skipped). States in the study reported efforts to improve these results, including outreach to families, but it is not clear what the scope of those activities were (handing out flyers versus hands-on assistance to families).

The Inspector General's report recommends that states report hearing and vision screenings and that CMS work with states to find incentives to increase doctor participation and improve outreach efforts to families. Experts working on this issue have also recommended providing states with best practices, creating better linkages with groups routinely in contact with children, offering better education to providers, increasing provider reimbursement, and requiring better data collection and reporting.

Efforts in this area may also be helped through health reform. Included in the law is a provision that requires private health plans to offer these types of screenings (through Bright Futures, a compatible set of preventive services recommended by the AAP) at no cost.   With many more children now in the mix, there are increased incentives to make the EPSDT screening component the best it can be for all children. 

While there is much work to be done implementing the many facets of the health reform, creating the exchange marketplace(s) is one of the tasks that receives much of the attention. Not only is it a new concept to most states but, along with the expansion of Medicaid, it is the mechanism for insuring the 32 million Americans who are expected to gain coverage.

People tend to look to Massachusetts for lessons learned because the exchange concept in national reform is based on that state's health reform model. In fact, early this year the State Coverage Initiatives (SCI) hosted a meeting of state officials in Boston to provide the nuts and bolts of how the Massachusetts exchange known as the Health Connector works. This two-day meeting drew more than 100 participants from 42 states, including representatives from state insurance departments, Governor's offices, and the state department responsible for health programs. The SCI program, funded by the Robert Wood Johnson Foundation and administered by AcademyHealth, provides technical assistance to state leaders to help them move health care reform forward at the state level.

It's important to note that other states beyond Massachusetts have made advances in health reform that can inform our efforts moving forward. SCI documented a number of the important issues in its report,"Implementing State Health Reform: Lessons Learned for Policymakers," on the experience of five states: Massachusetts, New Mexico, Tennessee, Vermont and Wisconsin.

The report and its companion webinar focus on key questions and takeaways in a number of areas including enrollment and eligibility, marketing and outreach, staffing and coordination, and reporting and evaluation. It asks critical questions like:

• "Are current state information systems equipped to perform the necessary eligibility and enrollment functions for the health insurance expansion?"

• "To what extent can the state's current CHIP and Medicaid outreach activities be modified to include outreach and marketing for the health insurance expansion?"
  

Some states are already moving beyond forming a key group of state officials charged with beginning the planning process. Wisconsin, one of the early state implementers of health reform, has recently issued a request for proposals (RFP) to add exchange functionality to its current eligibility system. Connecticut and the District of Columbia are early adopters of the new option to cover adults (both parents and adults without dependents) now without waiting for health reform.

And speaking of waiting...let's not forget that with 5 million uninsured children already eligible for Medicaid or CHIP, kids don't also have to wait for health reform.

Yesterday, CMS issued two additional guidance letters related to implementation of the Children's Health Insurance Reauthorization Act (CHIPRA) of 2009. The first of these letters is on new federal support for covering for lawfully residing children and pregnant women who have been in the country less than five years. This long-awaited guidance explains that there is new federal support for states that have previously covered these populations using state-only funds and offers a new opportunity to expand to states that do not cover these populations due to the lack of federal  support for doing so.

Prior to CHIPRA, close to 20 states used state-only dollars to cover these children and/or pregnant women. Now, these states can receive federal matching funds for this coverage -- freeing up state funds during a time when state budgets are tight. It is important to note that since CHIPRA was enacted and this new opportunity for federal support, another six states have taken up the new option to cover this population, resulting in almost half of the states offering coverage to lawfully residing children and pregnant women.

The second guidance letter issued by CMS is about a provision in CHIPRA that gives states the opportunity to receive enhanced federal support to better serve Medicaid and CHIP beneficiaries for whom English is not their primary language.

There is much more to say on both of these topics, but not enough time before the long holiday weekend to do them justice, so please check back on our website next week.

Happy Fourth of July!

Today, HHS launched a web portal designed to provide families with a central place to go for information on health care coverage in their state. The folks at HHS must have been burning the midnight oil to get this done by the July 1st deadline created by Congress.

Healthcare.gov is a remarkable accomplishment in such a short time frame. Not only can you obtain general educational information on health coverage, by answering a few simple questions, individuals can receive a list of state-specific private and public health insurance options available to them and their family. 

This is light years away from what exists today for families shopping for health coverage. But there still is a ways to go -- once families are provided with the list of options, they have to navigate through a number of links, and ultimately, leave the site to find more information and apply for coverage. And let's face it, until the majority of health reform provisions are implemented in 2014, there are not a lot of affordable coverage choices available to uninsured families unless they happen to qualify for Medicaid or CHIP.  (The new pre-existing condition insurance plans -- also officially launching today in selected states -- will offer much-needed relief to some, but were always intended to be a bridge to broader reform.)

In the meantime, healthcare.gov at least gives families a starting place to look - and could serve as a particularly critical resource for the millions of uninsured children (and in some cases their parents) who are eligible now for Medicaid and CHIP. 

The other good news is that HHS also sees this version of the site as a first step and plans are already underway for a second iteration. The young leader of this effort at HHS, Todd Park, is wildly enthusiastic about getting feedback and doing all that he can to lead his team in making it better and better over time.

We've already added a few items to our list of how to make the site work better for families, including paring back the number of steps it takes to get to Medicaid and CHIP information and providing a more prominent and direct link to state Medicaid/CHIP applications (not just the state's web site providing information on those programs.)  Plus, we'd like to see a way for people to report back on their experiences once they leave the safety of healthcare.gov.  After they were sent to a private plan or a Medicaid agency, what happened?  Were they able to get the coverage that they needed?

What would you like to see?  We urge you to take a tour of the web site and share with the Say Ahhh community what you think.