September 2010 Archives

By Shelby Gonzales Center on Budget and Policy Priorities

In 2008, Linda Nablo was recognized as a Child Health Champion for her relentless work to improve children's health coverage programs in Virginia.  Having known Linda for many years, I couldn't think of anyone more deserving of this honor.  As you can imagine, I was quite thrilled to hear that this champion will now be playing a key role at CMS as the director of the Division of State Children's Health Insurance Programs in the Center for Medicaid, CHIP and Survey & Certification.

Because of her vast experience and accomplishments as a lifelong advocate for children, Linda was tapped to join the "Child Health Dream Team" in Governor Warner's Administration.  As the director of the Division of Maternal and Child Health, she was specifically tasked with streamlining and invigorating Virginia's FAMIS programs (VA's CHIP and Children's Medicaid program).  Accountable to a Governor who was heavily invested in seeing that all eligible children were enrolled and had access to care, it was not unusual for Linda to get surprise and often public inquiries from Gov. Warner wanting to know exactly how many kids had been enrolled in any given month--Linda never disappointed.  Linda strategically made significant changes to state policies, protocols and data systems and her efforts paid off. During her tenure, enrollment in the FAMIS programs grew by 90,000.

Having had the opportunity to witness Linda as she led efforts to simplify, modernize and re-energize children's health coverage programs in Virginia, I'm confident that she will be successful in her new role as she takes on the challenges of enhancing support that CMS provides to states and overseeing the ongoing implementation of CHIPRA and aspects of the Affordable Care Act as they relate to CHIP. 

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

Earlier today, the Census Bureau released health coverage estimates from the American Community Survey (ACS). The results look very similar to what was reported a few weeks ago from the Current Population Survey (CPS). Overall, since 2008, the percentage of the uninsured increased, as did the percentage of those in poverty. The magnitude of the change is different - the ACS finds 15.1% of the population to be uninsured in 2009, while the CPS finds 16.7% (this is likely due to in part to the fact that the CPS captures coverage over the course of the year, while the ACS asks about coverage at the point of the interview). Children, however, were a bright spot, with the percentage of uninsured declining significantly from 2008.

Despite the dire picture that the data paint for coverage as a whole, there is a silver lining - the data source itself.  I've mentioned this before, but it bears repeating. The ACS is similar to the CPS in that it is a national survey, but it has a much larger sample size, which allows you to take a closer look at different areas of interest, whether they are geographic or demographic. This new tool can help state-level folks (especially those in small states) identify where gaps may exist in coverage in their state and learn more about who the uninsured are.

(In case you all were worried, the CPS is still a very important data source, as it is really the only source of historical coverage trends. For further details, the Census Bureau provides recommendations on which data source to use depending upon your research question.)

Some tables of interest to check out (which are all available at American FactFinder 

•  The Data Profiles (the economic version) allow you to look at employment status, income, poverty, and health insurance coverage for 2009.
•  The Comparison Profiles (again, the economic version) allow you to compare the same data points from 2008 and 2009.
•  The Subject Tables allow you to look in more detail at coverage in your state or locality, as well at selected characteristics of the uninsured.
•  The Detailed Tables (scroll down to #27) allow you to look at coverage by very specific pre-set characteristics (for example, coverage by employment status).

This is just a snippet of what the ACS has to offer. The Census has also put out a really handy Quick Guide to the FactFinder tool that walks you through the various table options and what data they can give you.

A special note to those serious data users - there were some logical edits applied to the 2008 data, so when analyzing data year to year, be sure to use the adjusted tables or the pre-set 2008-2009 comparison tables. Comparing the unadjusted 2008 tables to those from 2009 is not an option, as the data just aren't analogous.

We're planning on spending more time digging into this wonderful new data source and promise to share what we've learned. We'd love to know how you all in the states are taking advantage of this.

By Suzanne Wikle of Kansas Action for Children

At a time when I can pay my bills using an Iphone or Blackbery, it seems a no-brainer that states should be pursuing more technological fixes to simplify and streamline processes to ensuring that families are able to access health insurance through Healthwave, Kansas' Medicaid and Children's Health Insurance (CHIP) program  Well, I'm here to report that the Kansas Health Policy Authority is moving forward on some really commonsense initiatives to do just that. 

These changes are happening at a time when program efficiency is more important than ever. The economic downturn has delivered a double blow of dwindling state employees and an increasing number of applicants as more and more families encounter the harsh reality of the economic downturn.  As a result, Kansas is experiencing a backlog of applications and renewals that tops 20,000 - resulting in families and children waiting months for their applications to be processed.

Kansas was faced with making program changes when CMS took notice of the large backlog, but KHPA isn't breaking new ground.  They are making smart policy decisions based on the experience of other states.  For example, Louisiana has many years of success with using the telephone or online technology to remove excess paperwork from the renewal process. Other states have been using technology to verify Social Security numbers and citizenship, instead of requiring paper copies.  Or, enrolling children whose family is enrolled in food assistance programs rather than duplicating another agency's work These are commonsense solutions that will help to cut red tape for families who are seeking health coverage through  HealthWave for the very first time while at the same time, prioritize limited state dollars for coverage rather than administrative paper pushing. 

Anytime there are changes to the application process concerns can rise about efficiency versus accuracy, but KHPA has wisely chosen administrative simplifications that have been tested in other states.  The experiences in other states have shown that when implemented correctly, simplifications don't jeopardize the program's integrity.  In fact, Louisiana, which has been a model for other states in this arena, has one of the lowest error rates in the country. 

Times are tough everywhere and Kansas is no exception.  Now is the time that we need the state programs to be as efficient as possible.  The KHPA has taken a step in the right direction for Kansas families while at the same time improving efficiency.  That's a win for everyone.

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

In honor of the six-month anniversary of the Affordable Care Act, our friends at MomsRising invited moms, dads, grandparents, bloggers, community leaders, government officials, policy experts and others to share their thoughts and feelings about health reform.  They received an overwhelming response to their invitation.  Here are a few of the many interesting blog entries:

Kerri Marrone Sparling, who chronicles her life with diabetes on the very touching Six Until Me blog wrote:

"I don't know enough about the health care reform bill to speak eloquently about the details.  I am only exposed to what the media shows me, and what my research procures, and what pages of the bill I'm actually able to pour through and understand.  And I know that talking politics on the blog (just like talking religion) can be a very tough topic, because PWD (people with diabetes) have so many varying opinions and stances on these issues.  But I'm a person with diabetes.  And I'm hopeful.  I'm hopeful that this could be the beginning of diabetes not dictating my insurability.  I'm hopeful that people with diabetes will have the option to work in fields that inspire them, not just ones that insure them."

Lisa Shapiro of First Focus wrote:  "As we mark the six-month anniversary of the passage of health reform, families have much to celebrate today as several key provisions of the new Patient Protection and Affordable Care Act go into effect for children.  While there are a wide array of opinions on both sides of the aisle on the new law - from those that say health reform goes too far to those who lament that it doesn't go far enough, the impact for children cannot be disputed. Children and families will be better off today and for many years to come because of a long list of new child-focused policies that were included as part of national health reform."

Laura Tellado who lives with spina bifida and created the Holdin' Out for a Hero blog wrote:

"Nearly six months ago, I sat in front of a desktop PC with tears brimming in my eyes. I was watching history unfold before me, when Pres. Barack Obama signed into law the Patient Protection and Affordable Care Act. I had been waiting for this for years, and now it seemed surreal that it would finally come to pass. Maybe it seemed surreal to me because it seemed that it had taken forever to accomplish. Or maybe because it felt like my needs and the needs of millions of other Americans were being heard and understood."

Please check out what others had to say and leave your own thoughts in the comments section.

Finding the right health care professional to provide primary care can be a challenge--we're all looking for the right balance of expertise, compassion, communication skills, and availability.  So no one likes it when an insurance company steps in to limit our choice when it comes to picking an available primary care provider.  One of the new protections added by the Affordable Care Act, and going into effect for new plans this month, aims to ensure choice of providers--and it includes special safeguards for children.

Some health plans require enrollees to choose a primary care provider (PCP) who serves as a gatekeeper for other types of care; to see a specialist or get certain tests, enrollees need to get the approval of the PCP.  Under the new law, new plans (though not grandfathered plans) that have this requirement must allow enrollees to choose any PCP who participates in the plan and who is available to take new patients.  Under the Patients' Bill of Rights regulations, plans must notify enrollees of this right.  This prevents insurance companies from limiting the choice of PCP to a subset of their network providers. 

For children, all participating pediatricians (who are taking new patients) must be available as choices for a child's PCP.  This is an important provision for children as regular pediatric care has been proven to improve child health outcomes, avert preventable health care costs, and limit delays in care.  Moreover, parents want to be able to choose a pediatrician they trust.  A way to take this important advance one step further would be to include pediatric subspecialists in the definition of pediatricians that can be designated as a primary care provider. 

For some children with serious chronic conditions, pediatric subspecialists can provide children with their routine and ongoing care as well as needed specialty treatment. This improves continuity of care for the child and the ease of receiving treatment for the family.  A family with a child who is receiving cancer treatment, for example, could designate their pediatric oncologist as the PCP for their child.   Families should be afforded the ability to designate these kinds of clinicians as the primary care provider if they choose.

The choice of health care professionals helps to shift control over care to consumers and away from insurance companies.  Together with the other provisions that take effect September 23, it adds valuable protections that will benefit millions of Americans immediately and millions more as health care reform is fully phased in over the next four years.    

The wedding date for most provisions of the Affordable Care Act (ACA) may be January 1, 2014 but we're celebrating the engagement tomorrow, September 23, 2010, when a number of insurance market reforms go into effect for new plans. These early wins for children and families include the end of insurance industry discrimination against children with pre-existing medical conditions. But just as we were ready to pop the champagne, the headlines suggest that insurers are reneging on their promise to cover these vulnerable kids. Instead of complying with this provision as they promised back in March, plans across the country are breaking the engagement and leaving sick kids standing at the altar.

The relationship over this particular issue got off to a rocky start. Within days of passage of health reform, insurers indicated they were interpreting the ACA differently than what was being reported by the Administration in the media regarding this provision. Insurers contended that the law did not require them to guarantee coverage for pre-existing conditions for children until 2014 when the provision goes into effect for adults as well.

In a letter to the insurance industry, the Administration pledged to clarify the issue through regulations but stood faithful to the intent of Congress for a timely elimination of pre-existing exclusions for children. The reply from America's Health Plans President Karen Ignagni, was "we await and will fully comply with regulations consistent with the principles described in your letter." In that letter Ignagni said: "Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition." So it seemed that a prenuptial deal was struck!

A good marriage requires give and take. The subsequent regulations gave insurers a way to protect their interests but took away their ability to deny coverage to sick kids outright. The regulations allow insurers to establish open enrollment periods that limit when families can get coverage for their children's pre-existing condition. Additionally, subject to state law or regulations, plans can add premium surcharges for these policies.

It is important to point out that not all uninsured children with pre-existing conditions will be looking to purchase coverage directly. Nearly 60% of uninsured children are eligible for Medicaid or CHIP, and they and their families would be better served in these child-friendly programs. Additionally, children who have been uninsured for six months may qualify for subsidized coverage through the new Pre-Existing Condition Plans established by the ACA.

This is a very fixable issue if insurance companies don't get cold feet, particularly considering that there are very few children who are in these plans. Several states are working on rules to provide clear guidance to insurers including California where legislation (AB 2244) awaits the Governor's signature.

The latest in this stormy relationship with insurers illustrates once again why we need to move forward with full implementation of the Affordable Care Act to provide paths to coverage for children and families.

This is sad -- I was sitting outside my daughter's school waiting for a friend this morning avidly reading Friday's Federal Register. For those of you who missed it, the proposed regulation implementing new transparency and public notice procedures for Section 1115 Medicaid and CHIP waivers was released on September 17th, 2010.  I think my friend thought I was a little kooky, but I was very excited about this because I have given birth to two children (one of whom is now in middle school) since I started advocating for more public participation in these high-stakes and often-secretive processes.  Finally, finally we have a big step forward.

I blogged on the role of waivers in the new world and the particular provisions of ACA that mandated these new rules back in June. The new rules are not everything we would have wished for, but definitely something worth cheering about.

The proposed regulation is available here. 

Comments are due on November 16th, 2010. Georgetown CCF will be developing some analysis of these regulations and public comments with our partners at the Center on Budget and Policy Priorities so stay tuned to Say Ahhh.

By Cathy Kaufman, Oregon Healthy Kids

It was a proud day for Oregon last month when our Healthy Kids Program was hailed as a national model by U.S. Health & Human Services Secretary Kathleen Sebelius.  Secretary Sebelius paid a visit to Cleveland High School in Portland to help launch a new Healthy Kids Sports Campaign, designed to encourage school and community youth coaches to help spread the word about Healthy Kids to families of uninsured children. Oregon Governor Ted Kulongoski, Congressman Earl Blumenauer, student athletes and coaches and families with children already enrolled in Healthy Kids also participated in the event. (A video of the event was featured at the Connecting Kids to Coverage back-to-school event in Washington, D.C. earlier this month.)

Because children who play sports need a physical exam and health coverage to play, Oregon is partnering with the Centers for Medicare and Medicaid Services to implement a statewide campaign aimed at coaches. This campaign is part of our response to the challenge the Secretary issued at the one-year anniversary of the signing of the Children's Health Insurance Reauthorization Act (CHIPRA). Secretary Sebelius challenged states to enroll the five million eligible but uninsured children in Medicaid and CHIP over the next five years, calling on all levels of government, as well as the private sector.

The Governor enthusiastically embraced the challenge, saying "I accept the challenge.  Oregon has already made great strides in reaching out to and enrolling uninsured children into Healthy Kids."

Governor Kulongoski signed the Healthy Kids program into law one year ago, expanding coverage to an estimated 80,000 more uninsured Oregon children in families up to 300% of the Federal Poverty Level, with the ability for families above that income limit to buy into the program at full cost. In the past year, we've enrolled 54,000 children - which puts us two-thirds of the way to our goal.

There are many reasons for our success to date. Healthy Kids created a new office dedicated to rolling out an aggressive outreach and marketing campaign. We have beautiful ads across the state - on billboards, radio, busses and trains, and even in shopping malls. We have a well-funded Application Assistance program, through which certified organizations from local communities will receive $75 for every application they've helped a family fill out that results in at least one child enrolling in Healthy Kids. We've also distributed $3 million in outreach grants to community-based organizations across the state. We've developed a number of targeted campaigns, including a school-based campaign; a campaign for communities of color; a campaign aimed at employers who aren't able to offer health coverage to employees or their dependents; and a faith-based campaign through which we're reaching out to a wide variety of faith communities to help spread the word about Healthy Kids to more families.

In addition to our great outreach and marketing efforts, we're doing everything we can to improve our systems and eliminate red tape. We're in the middle of streamlining our application, the new version of which will be rolling out - both print and an online version-- in October. We've also worked to reduce administrative barriers to enrollment, like reducing the required period of uninsurance from six months down to two months; eliminating the asset test for children; and providing all kids with 12-months of continuous eligibility.

We're helping more children enroll quickly thorugh through "express lane eigibility," where a family who has qualified for other programs can fill out a fast and basic form to qualify for health coverage, without needing to resubmit income documentation. We've already begun using express lane eligibility families receiving Supplemental Nutrition Assistance Program (SNAP) and will start using Free and reduced Lunch applications from select school districts later this year. Lastly, we've implemented "ex-parte" renewal and an improved redetermination process, so that once eligible children are enrolled, we can keep them enrolled.

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

The portrait revealed by the data released today by the U.S. Census Bureau was bleak, underscoring the extraordinary toll the nation's economic downturn took on families in 2009.  A record number of people are now living in poverty and the nation's uninsurance rate is at the highest level since the Census started tracking it in 1987.  In 2009, there were more people living in poverty (43.6 million) than the Census Bureau has ever before recorded in its 51 years of tracking these data.  The number of impoverished children jumped by 1.4 million to 15.4 million.

Many also had to face the harsh reality of becoming uninsured when they lost their jobs or their employers could no longer offer health benefits due to the economic climate. More than 50 million people reported no health insurance coverage in 2009, which translates into an uninsured rate of 16.7 percent.

In the midst of this bleak landscape, Medicare and its companion program, Medicaid, provided some stability to our nation's seniors and children.  The new data show that the uninsured rate among children held steady at 10 percent.  The number ticked up slightly to 7.5 million, but this was not a statistically significant jump. Credit for this good news for children goes to Medicaid and the Children's Health Insurance Program (CHIP), which provided families with affordable coverage options.  This coverage was available because of the hard work of state and federal government leaders and advocates who worked to successfully maintain a lifeline to uninsured children during tough economic times.  

We all know, though, that the health and wellbeing of children depends on whether they have access to quality, affordable health coverage. Children's wellbeing can also be dramatically affected by the health and income of their parents.  Building a more stable source of health coverage for their parents and other adults in their lives, as envisioned in the full implementation of the Affordable Care Act, will fill a critical gap for struggling families. And with so many families yet to find solid footing in the wake of the economic crisis, it will be crucial to maintain access for children to Medicaid and CHIP in the months ahead.

A new opportunity for states to further their efforts in streamlining and coordinating public benefit programs has been announced by the Ford Foundation and its partners, the Urban Institute and the Center on Budget and Policy Priorities. "Work Support Strategies: Streamlining Access, Strengthening Families" aims to provide a select group of states with the opportunity to design, test, and implement more effective, streamlined, and integrated approaches to delivering key supports for low-income working families, including health coverage, nutrition benefits, and child care subsidies.

These activities will not only provide critical resources for states to continue streamlining and improving coordination and efficiency in public benefit programs but will build on the base of knowledge acquired through other multi-state initiatives such as the Covering Kids & Families Initiative and Maximizing Enrollment for Kids. It also sounds like a great opportunity for states to test out Express Lane Eligibility projects.

The initiative will invest $15 million over a five-year period to build on recent state and federal innovations by providing states with expert technical assistance, peer support, and financial backing to take their efforts to the next level.

The call for proposals will be available on Friday, September 17, 2010, at www.urban.org/worksupport. A summary of key dates and additional information about the initiative are available now. For questions regarding the request for proposal, please email worksupport@urban.org.

By Edwin Parks, Center on Budget and Policy Priorities

The Senate will vote tomorrow on an amendment to small business legislation that would seriously weaken an essential element of the new health reform law -- the requirement that individuals obtain health insurance or pay a penalty  -- and eliminate preventive care funding aimed at reducing the onset of chronic diseases and improving overall health.

Sponsored by Senator Mike Johanns (R-NE), the amendment would repeal a provision of the health reform law designed to improve businesses' compliance with the tax laws.  Repeal would cost $17.1 billion over the next ten years, the amount of additional revenue that would have been collected due to improved tax compliance.

To make up for this loss, the amendment would do two things.  First, it would eliminate all $11 billion in Affordable Care Act funding for the Prevention and Public Health Fund for fiscal years 2010-2017 -- taking away critical investments that could help reduce the incidence of chronic illness and infectious disease, improve overall health, and reduce the cost of treating preventable medical problems.

Second, it would weaken health reform's individual mandate, which is designed to lower the overall cost of coverage by encouraging healthy people (who cost less to insure) to enroll in coverage rather than wait until they get sick.  While the Affordable Health Act would allow some people to remain uninsured without incurring a penalty, the Johanns amendment would allow many more to do so, meaning that fewer people would receive federal subsidies to help them buy coverage.

This would reduce federal costs for these subsidies, but at the price of increasing the number of uninsured people by 2 million (relative to what would occur under the health reform law), driving up premiums by as much as 4 percent for people with coverage through the new health insurance exchanges (because the pool of people in the exchanges would be less healthy, on average), and raising the cost to health care providers and state and local governments of providing health care to the uninsured.

While critics have argued that the tax-compliance provision would create excessive paperwork for businesses, senators who want to modify it can do so without undermining health reform.  An alternative amendment from Senator Bill Nelson (D-FL), which the Senate will also consider on September 14, would scale back rather than eliminate the provision to ease the burden for small businesses and make up for the lost revenue by reducing tax subsidies for the largest oil companies.  That's a much more sensible approach.

The blog originally appeared in CBPP's blog "Off the Charts".  Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

By Elizabeth Burke Bryant, Rhode Island KIDS COUNT  

Rhode Island was proud to be one of three states highlighted in a video at Secretary Kathleen Sebelius' Connecting Kids to Coverage Challenge event on September 3, 2010.  Rhode Island's successful RIte Care health insurance program and our Family Resource Counselor program were both featured as models of community-based outreach and enrollment.

RIte Care, Rhode Island's combination Medicaid and CHIP program that provides health insurance coverage to low- and moderate-income children, their parents and pregnant women, is a national model of high-quality, cost-effective, and affordable coverage. RIte Care's two managed care health plans (Neighborhood Health Plan of Rhode Island and United Healthcare of New England) were ranked in the top 11 Medicaid health plans in the U.S. last year. RIte Care has earned broad support among policymakers and Rhode Islanders in general.

Family Resource Counselors (FRCs) are specially trained staff members of community health centers, hospitals, and community organizations who assist families with applying for health coverage through RIte Care. FRCs assist Rhode Island families in completing the application, assembling all of the supporting documentation that is required for applications and help families resolve any problems that may occur during the application process. Many of them are bilingual and are known as trusted helpers for Rhode Island families. In place since 1998, the FRC program has been a long-term public-private partnership that serves as an important outreach mechanism for Rhode Island children and families.

New data released at the event show that 83.5% of children who are eligible for RIte Care are actually enrolled.  We want to turn what is essentially a "B" grade into an A+ by ramping up our collective outreach efforts to enroll eligible children and families in RIte Care coverage.

Rhode Island KIDS COUNT is proud of what Rhode Island has achieved for children. RIte Care has a long history of documented positive health outcomes for children and families enrolled in the program - that means healthier families and lower costs to the state. Using the federal opportunities that are available through CHIP and the Patient Protection and Affordable Care Act (PPACA), Rhode Island can once again lead the nation in making sure that all of our children have health coverage.

We're almost there - 93% of children in Rhode Island have health insurance coverage.  We are determined to step up to the Secretary's Challenge to finish the job and cover all eligible children.  It can be done!

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

September 23rd will mark the six-month milestone for the Affordable Care Act and several provisions impacting children and families will go into effect on that date including provisions in the "Patient's Bill of Rights" which:

o Prohibit employer or new individual health plans from excluding coverage of specific benefits associated with a pre-existing condition for any period of time and from denying coverage to a child based on a pre-existing condition.

o Eliminate lifetime dollar limits and establish restricted annual limits (until fully eliminated in 2014) for essential health benefits in employer and new individual health plans.

o Allow a parent/guardian to designate a participating pediatrician as their child's primary care provider and require plans providing emergency services to eliminate the need to prior authorizations, even when the services are out-of-network.

At the end of June, the Obama Administration issued an interim rule addressing how these provisions will provide important safeguards for families in obtaining and utilizing health insurance for themselves and their children.  CCF joined with American Academy of Pediatrics, Children's Defense Fund, Family Voices, First Focus, March of Dimes, National Association of Children's Hospitals and Related Institutions, and Voices for America's Children to recommend ways to make the protections even stronger for families. 

Specifically, the comments asked that revisions to the interim rule ensure that:

o Families with sick children can truly obtain coverage when they most need it, as envisioned by the pre-existing provision on the health reform bill. This includes prohibiting insurers from establishing unreasonable premium increases and/or excessive premiums for families with children with pre-existing conditions. In addition, it is important that guidelines be established for child-only plans establishing open enrollment periods (as allowed under an advisory  released following in interim rule). Without rules on when and how these periods can be applied, it will be difficult for families to access coverage when they most need it; and

o Children can receive the services they need during the phase in of the annual dollar benefit limits. Families with children, especially those with special health care needs, may quickly hit the limits proposed under the interim rule. It is important that the limits more accurately reflect the experiences of these families and that the dollar limits be raised. In addition, it is important that health plans be prohibited from establishing non-dollar limits of families (e.g., restrictions on the number of doctor visits).

In the coming weeks, we will post additional information on the "September 23" reforms so check back in! 

By Ann Bacharach, Pennsylvania Law Project and National Covering Kids and Families Network

I took a break from my stay-cation this week to get motivated for the fall. On behalf of the National Covering Kids and Families Network, I took the early morning train from Philadelphia to Washington on Friday to attend the re-launch of Secretary Sebilius' Connecting Kids to Coverage Challenge (CK2C).

It was inspiring:

• Education Secretary Arne Duncan pledged to work with HHS to reach and enroll eligible children through a variety of school-based outreach strategies.
• A mother courageously recounted her path to Maryland's M-CHIP program.
• Sixteen national organizations, including National Covering Kids and Families Network, pledged to step up to the Secretary's Challenge.
• Pastor Wiggins from Camden reiterated the challenge of reaching and enrolling families just trying to survive day to day.

According to the recently released report from the Urban Institute, there are 129,000 children in Pennsylvania who are eligible for Medicaid or CHIP but not enrolled. That means Pennsylvania is missing about 15% of those who could be covered.

That data prompted me to remember the number of proven strategies and tactics that agencies, organizations and even individuals in Pennsylvania have utilized: stationing enrollment assistors in Philadelphia's Health Centers as well as FQHC's in Greene, Fayette and Washington Counties, providing application assistance through Children's Hospital of Philadelphia, offering over-the-phone enrollment through the State's Helpline 800-986-KIDS, using Pennsylvania's web-based application, and reaching out through community-based organizations in unlikely places such as volunteer firehouses.

Why not spread these ideas to other parts of the state? And share them with others trying to help connect kids with coverage across the country?  And learn from other such as members of the National Covering Kids and Families Network?

And while we're at it, what about heading to barbershops and hair salons, laundromats, food banks? Friday night football games? Fishing and hunting license distributors? Sunday School, Hebrew School and other religious education classes?

And how do we promote retention? The number of very low-income children estimated to be eligible but not enrolled is disconcerting at best. This is, most likely, an outcome of losing eligibility at renewal. While we work to make renewal easier, how can we keep eligible families enrolled: reminders from their doctor's office, from their managed care plans or from their pharmacies? Renewal assistors working in health care settings?

And finally, the estimated 129,000 children who are eligible but not enrolled are not a finite group; children move in and out of health coverage all the time based on their family's status. If a parent loses or changes a job, if a parent divorces or remarries, if a parent gets sick, if a sibling ages out of the household, a child's health coverage can be interrupted or lost completely.

So, we need to keep up the drumbeat on available health care coverage and how to enroll using the tried and true methods and by exploring new and creative ways.

Let's get busy!

And if you have outreach and retention ideas, please share them with all of us avid readers and bloggers on Say Ahhh! and the National Covering Kids and Families Network.

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

Having spent much of the summer in South America and without much access to American media, I was curious to see how things had changed when I returned to work this week.  Hmmm.  Not so good. Controversy over the health reform bill seems as rhetoric laden and inflammatory as ever as the election approaches.

That is why I was interested to see in my inbox a note about a new analysis done by the Congressional Budget Office on August 24th which estimates that if the health reform law (PPACA) was repealed, the deficit would actually rise. CBO found that PPACA will reduce the deficit by $28 billion in 2020. Sen. Crapo (R-ID) had requested the estimate. 

I guess the good news here is that should Congress flip, it will be hard to repeal PPACA because it will cost money. Real money. But the likelihood of this kind of information breaking through the current heated debate seems slim. Say Ahhh! likes to share these little factoids with you though!

I had a chance to go to a fantastic event this morning sponsored by Secretary Sebelius on the Connecting Kids to Coverage Challenge, which aims to reach the nation's 4.7 million uninsured children who already are eligible for Medicaid or CHIP.  She made a compelling pitch that nothing is more important to our future than the health of America's children and that is why Medicaid and CHIP were created.  Thanks to these programs, tens of millions of Americans have the peace of mind that comes from knowing that their child is safe.

In recognition that millions of our children are heading back to school this week, the event also featured Education Secretary Arne Duncan who tackled the issue from an education perspective.  He argued that some foundational things have to be in place for students to be able to excel.  If they can't see the blackboard, or if they are coping with untreated asthma, it is pretty tough to expect them to do well.  He pledged to work with some of the major school districts in the states that have the furthest to go in covering uninsured children.  (California, Florida, and Texas account for 40% of all uninsured kids, according to powerful new data released today by the Urban Institute.  See my colleague Martha Heberlein's blog for more on the report).

The star of the morning, though, was probably Bonnie, a mom from Maryland.  "I speak to you as a mother and as an American," she began before going on to explain that her husband is an auto-mechanic who doesn't have any affordable employer-based coverage.   So, when she lost her job, she found her family uninsured.  Luckily, she hooked up with a community-based organization that helped her file an application for child health coverage.  It took only 15 minutes from start to finish, and within 24 hours she got a call that her son qualified.  Since her son has asthma, it was an enormous source of peace of mind in a time of need.  As she concluded, "No mother, no parents should have to choose their mortgage and utilities over health care" for their child. 

I left encouraged about the level of commitment shown by two key leaders in the Obama Administration, as well as impressed by the broad array of national organizations they've already signed up to work on the Connecting Kids to Coverage Challenge.

Most of you know the CPS - the annual social and economic supplement (ASEC) has been our go to source for health insurance coverage on a national and state-by-state basis for years. However, given the nature of the sample, analysis has been somewhat limited, especially for those smaller states and for those interested in data on a sub-state level. 

Now there's a new kid on the block. In 2008, a question on health insurance coverage was added to the American Community Survey. Like the CPS, the ACS is a national survey, but it has a much larger sample size (the CPS looks at about 78,000 households annually, whereas the ACS surveys 250,000 per month). It may seem somewhat counterintuitive, but the bigger the sample size, the smaller the area (geographic or demographic) that you can examine. We may just be able to get answers to some of those long-standing research questions.

One such question that has long plagued those of us looking to enroll eligible children in Medicaid and CHIP is: who are those kids and where can we find them? Thanks to the ACS (and some very talented folks over at the Urban Institute) we now have a much better idea, as today in Health Affairs, Dr. Genevieve Kenney and her colleagues released a paper that looks at that very question. (The report will also be highlighted at a media event today where HHS Secretary Sebelius will relaunch her Connecting Kids to Coverage Campaign.  You can watch it live here).

They found that of the 7.2 million uninsured children in the U.S., 4.7 million or 65% were eligible for Medicaid or CHIP. Of those, about a third are concentrated in just three large states (California, Texas, and Florida), a piece of data that certainly highlights the need for outreach and enrollment efforts in those states.

But I think an equally appropriate (and far more upbeat) view of the data is the success states have had enrolling children in their Medicaid and CHIP programs. Nationwide, the participation rate in Medicaid and CHIP is 82% (high compared to other means-tested programs). And 11 states were shown to have participation rates that were close to or above 90%. Those are amazing numbers and states should celebrate their well-deserved accomplishments.

For those of you doubters who say, "well, that could never happen in my state," I beg to differ. To quote the authors: "since these states constitute a diverse group in terms of their size, income distribution, racial and ethnic composition, and region, it suggests that high participation rates can be achieved across a range of different circumstances." In other words, while it is certainly not easy to get all the eligible kids in your state covered, there are plenty of places to look to as role models, and ones that may be very much like your own.

By Mike Odeh (Children Now) and Kristen Golden Testa (The Children's Partnership) with the 100% Campaign 

And we're off! Implementation of the Affordable Care Act (ACA) is officially underway! Less than six months after Congress passed the ACA, California has blazed the trail as the first state in the nation to create a statewide Health Insurance Exchange under the Act. Two complementary pieces of legislation create the California Health Benefit Exchange and are headed to Governor Schwarzenegger's desk for an expected signature - (AB 1602 creates the Exchange and SB 900 creates a decision-making board).

By creating the Exchange, the State has built a framework that will dramatically improve the way many Californians, particularly the uninsured, get health coverage and will set the right trajectory for health reform implementation by providing new affordable coverage opportunities for millions of children and their families!

Make no mistake - creating the Exchange was no easy task. The legislation that created the California Health Benefit Exchange only came about (on party-line votes) through strong legislative and gubernatorial leadership, thoughtful and dedicated staff, and the efforts of a broad coalition of health and consumer advocates. Certain insurers (ones that are apparently afraid of transparency and a little competition) worked throughout the process to water down the legislation and tried desperately to kill the bill in the final hours. Thankfully, other insurers were supportive and engaged earnestly in negotiating amendments.

CCF's recent blog and issue brief on Health Insurance Exchanges lays out some of the primary responsibilities of an Exchange and identifies some opportunities within the broader federal framework to coordinate among the Exchange and existing programs, like Medicaid and CHIP.

So, as many of you probably know, the ACA allows states to make some important choices, not least of which is the decision whether or not to create a state Exchange in the first place. Given that California is home to nearly 1.5 million uninsured children,  the infamous 39% premium increase proposal and a seemingly infinite state budget stalemate, we really need a custom-designed Exchange that will work for California. Alan Weil and Jon Kingsdale cautioned the California Legislature that making an Exchange work by 2014 would require a lot of strategic planning, thoughtful coordination and time. It's a good thing the Legislature was listening and has been able to take the first step forward for California.

Although the authorizing Exchange legislation creates a governance structure and outlines a framework for the core responsibilities of the Exchange in California, some of the details of coverage in the Exchange, such as the benefit design for the child-only insurance products, will be determined by the governing Exchange Board along with future federal guidance. That's why we believed it was very important that the Exchange be run by a qualified Board with expertise and the authority to negotiate health plan contracts based on price and value while not having conflicting financial interests.  The board also needs representation from those that recognize the importance of coordinating with existing health care programs, systems, agencies, and regulators, so that children are protected and don't fall through the cracks and lose health coverage unnecessarily. Along with minimum benefit standards and cost-sharing limits in the federal law, we believe these factors are critical to ensuring that the coverage offered in the California Exchange is much more meaningful and more affordable than coverage today.

In fact, one of the key features is that the five-member appointed Board is authorized to be an "active purchaser" and will select health plans to participate in the Exchange through a competitive bidding process. Because Exchange board members will be required to have experience with health coverage, administration, and financing, they will be qualified and savvy in negotiating contracts with health plans based on price and value for an estimated 8.3 million lives (including 3.8 million small-business owners and employees and their dependents). 

The legislation also lays out the overall duties and responsibilities of the Exchange, many of which are explicitly required in the federal law (e.g., operating a toll-free telephone hotline and website with comparative plan information) and some of which just make good sense (e.g., authorizing the Exchange board to maximally collaborate with existing health agencies and applying the same standards for insurers and health plans inside and outside the Exchange). It also will allow California to be one of the first states to apply for the federal planning grants that can be used to establish the Board, promulgate strong consumer protections regulations, and develop a process to coordinate effectively with existing state health insurance programs like Medi-Cal (Medicaid) and Healthy Families (California's CHIP).

Since the federal law builds upon (and protects) Medi-Cal and Healthy Families, it is critically important that the Exchange coordinate with existing state and local programs as much as possible. The Children's Partnership and the Kaiser Commission on Medicaid and the Uninsured point out in a recent issue brief that the ACA requires enrollment systems that are consumer-friendly, coordinated, simplified, and technology-enabled. But getting into the "nuts and bolts" of creating enrollment systems that will effectively talk to one another and be easy for families to use requires thoughtful planning and sufficient lead time. That is why we continue to recommend that, as the Board develops the enrollment system for the Exchange and its subsidies, the State buckle down now and start planning for the streamlining and coordination of the other enrollment systems, like Medi-Cal and Healthy Families.

The hard work is just beginning! The 100% Campaign and our partners will continue to advocate (administratively) for better and more program coordination among the Exchange and other programs - not just at enrollment but also during renewal (something we didn't get in the final bill) and at transitions (included in the bill but could still be strengthened). Coordination is especially important when families will be split across programs, for example, when a parent is covered through the Exchange while their child is enrolled in Healthy Families. We will be laying out detailed recommendations for the Board on seamless enrollment, renewal and transition coordination and protections to ensure that only the minimum necessary information is collected from families to determine eligibility for coverage.

While we pushed to get the state Exchange law as strong as possible, we recognize that many detailed decisions of the Board will be determined by federal guidance. That's why we are sharing our thoughts and concerns with the Office of Consumer Information and Insurance Oversight about how the Exchange should coordinate with other programs, and urge them to provide helpful regulatory guidance on the issue. Like stakeholders in other states, we are weighing-in as the federal government develops these guidelines, rules, and regulations, but here in California we are in the unique position of simultaneously sailing ahead into uncharted waters.

So we can't wait passively for guidance to be issued and instead need to focus like a laser on ensuring that we get clear federal guidance that will address such critical issues such as children's benefit design, access to databases for existing eligibility information, and assurances of a coordinated and streamlined enrollment system.

Furthermore, as part of our effort to ensure that families know about and actually enroll in available coverage, we continue to recommend a preferential role for experienced community-based organizations as navigators. Based on our experience here, health care advocates in other states should be prepared for attempts to narrow the navigator role to licensed brokers/agents.

In the end, our State did not develop a perfect bill - the 100% Campaign and our partners had hoped for greater public/consumer representation on the Exchange board, stronger conflict-of-interest prohibitions, more comprehensive coordination requirements, and a preferential navigator role for experienced local community-based organizations. Yet, we are pleased to have a strong starting point and hope to make improvements in the months and years ahead. The new legislation helps structure the incredible amount of work that will be needed to turn the concept of an "Exchange" into an actual gateway to affordable coverage for millions of Californian kids and their families when 2014 rolls around.

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