Say Ahhh!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By David Blatt, Director, Oklahoma Policy Institute 

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

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

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

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

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

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

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