Say Ahhh!

Once President Obama signed into law the health care reform bill, we all started to dig a little deeper into what the provisions mean for those in the "real world."  One issue that has risen to the top is untangling the new rules governing when insurance companies have to cover sick children. So, let's break down what the bill does.

Soon children with employer-based insurance no longer can be subject to pre-existing conditions. For example, a child with asthma who is on a parent's employer plan cannot be denied coverage for services during any length of time related to his/her condition. This provision will be applicable in a new health plan year beginning after September 23rd. (Note: this specific change will not apply to children currently in individual market plans.)

The question many are asking is "what about a child that is not currently insured?" While the current legislative language is not clear on this issue, the White House has provided assurances that HHS will issue regulations to address it. HHS spokesman Nick Papas stated:

"... the secretary of HHS is preparing to issue regulations next month making it clear that the term 'pre-existing exclusion' applies to both a child's access to a plan and his or her benefits once he or she is in the plan for all plans newly sold in this country six months from today."

With this clarification, a new health plan would not be able to deny coverage for a child under either an employer or individual plan because of a pre-existing condition. For families with limited or no options to secure coverage right now when their child is sick, this change cannot come soon enough.

While this is all good news for families, how the insurance industry responds to these new protections for children will also be critical. Specifically, since the provision to limit insurers from charging different premiums based on health status doesn't go into effect until 2014, we need to monitor whether insurers will attempt to place the burden on families and raise premiums once these changes go into effect.

By Ann Bacharach, Pennsylvania Health Law Project

I went to Providence last week, just ahead of an historic weekend. No, I'm not talking about Rounds One and Two of the NCAA Men's Basketball Tournament or the upset of Georgetown by Ohio. No, I was there to attend the second of CCF's regional meetings: Transforming Health Care Coverage for Children and Families: A Convening of Northeastern States.

Many thanks to CCF and the New England Alliance for Children's Health for this gathering of experts; the meeting provided an extraordinary boost to my knowledge, my strategies and my morale. It's always helpful to have dedicated time to one topic and to have colleagues from Pennsylvania share the experience.  My longtime colleague and friend from the PA Chapter of the American Academy of Pediatrics, Suzanne Yunghans, came away from the meeting ready to incorporate new ideas into her chapter's work.

Aha! moments included:

• The cost of one ER visit is enough to cover 3 kids for a year and  taking out ads thanking elected officials for"... ensuring the health of generations to come" were two great ideas from the messaging strategies session
• More clarification as to what "counts" as implementing the 5 of 8 CHIPRA simplification options (can require a signature for administrative renewal, 1906 HIPP can be converted to 1906A as Medicaid premium payment) from Vikki Wachino's presentation.
• Start administrative renewal with children in households with a low likelihood of income changes from Tricia's presentation.
• Use the shorter 3-1-1 instead of an 800 number in outreach from Vinnie DeMarco's re-cap of Maryland's efforts.
• RIteSmiles is using a dental benefits manager to improve dental access from Elizabeth Burke Bryant, executive director of Rhode Island KIDS COUNT.

Those in attendance bolstered each other's work. I heard about new resources to reinforce the argument that retention is a critical element in expanding coverage: CCF's 5 Reasons Not to Add Red Tape to Your Child and Family Health Programs, Gerry Fairbrother's report on post-gap-in-coverage hospitalizations, California studies on gaps in coverage, research on the administrative costs to states and on 21st century technology.

And I came back with a list of to-do's: re-energize the Covering Kids and Families Coalition in Pennsylvania by holding a Children's Health Care Summit (find some funding for that), finish my paper on the five reasons retention is important to Pennsylvania's CHIP and Medicaid capitation rates, add CHIPRA outreach and enrollment to the Pennsylvania's Health Access Network's conference in April.

There was cautious optimism that we would see health care reform pass in the House by the end of the weekend. There was significant despair over the dire state budgets facing all of us as advocates and as taxpayers. But quite clearly there is work we can do now: reach the families of children who are eligible for Medicaid and CHIP but not enrolled.

In his remarks to House Democrats on Sunday, President Obama said, "Every once in a while a moment comes where you have a chance to vindicate all those best hopes that you had about yourself, about this country, where you have a chance to make good on those promises that you made ...We are not bound to succeed, but we are bound to let whatever light we have shine."

So if you get a chance to attend one of CCF's remaining convenings, don't pass it up.  Let whatever light we have shine.

Today, health reform is the new law of the land.  In a signing ceremony before an enthusiastic group of supporters, President Obama signed the health reform bill.  (While the House-passed reconciliation measure that makes some improvements to the health reform bill is still pending in the Senate, the key elements of health reform are now law.) 

President Obama said the new law recognizes the fact that "everybody should have some basic security when it comes to their healthcare."  

One of the more touching moments of the signing ceremony was when President Obama paid tribute to an eleven-year-old boy who lost his mother to an illness as she was uninsured and couldn't afford necessary treatment.  It drove home for me the point that the well-being of our nation's children depends not only on whether or not they have coverage but whether or not their whole family has access to affordable, reliable coverage.   If previous efforts to pass health reform had succeeded, Marcellas Owen's mother might still be alive and well today.

While many improvements to our healthcare system will be gradually and thoughtfully put in place, there are some very important changes that will take effect beginning this year such as:

• Young adults will be allowed to stay on their parent's policies until they are 26.
• Insurance companies no longer will be able to impose lifetime limits or restrictive annual limits, nor can they drop coverage when someone becomes sick.
• Children with insurance no longer can be denied coverage for a pre-existing condition.
• Seniors no longer will pay a copay or deductible for preventive care under Medicare (starting in 2011) and will start to see some early relief from the Medicare drug benefit's "doughnut hole."
• Starting today, states will be required to "hold steady" when it comes to providing Medicaid and CHIP coverage -- they must at least maintain the coverage that they have in place now and no longer can add new red-tape barriers that make it harder for families to sign up for coverage.

At CCF, we would add one more:

• Five million more uninsured children could start receiving affordable health coverage right now through state CHIP or Medicaid plans. (These children are already eligible but unenrolled).  With families expecting concrete gains from health reform, it is a wonderful opportunity to educate people about the chance to sign up uninsured children for coverage right away.

At CCF, we view passage of CHIPRA over a year ago, as the beginning of health reform.   Many of the improvements included in CHIPRA will lay the foundation for a successful transition to an era where everyone has access to affordable, reliable health coverage.  The better job states do right now in removing red-tape from the system and reaching out to eligible but unenrolled children, the stronger the foundation will be for them to seize the opportunity to transform our health care system into one that works better for everyone. 

Yesterday, the House of Representatives released a "reconciliation" or "fix it" bill with final changes to the health reform package. With these changes, we can now get a complete picture of what health reform could mean for America's families and children. The $940 billion package would cover 32 million uninsured people through Exchanges and an expansion of Medicaid, adopt broad-reaching reforms in insurance industry practices, make major new investments in public health, close the Medicare doughnut hole, and reduce the federal deficit (according to the nonpartisan Congressional Budget Office).

As everyone has probably heard by now, even those who would prefer to watch March Madness than the news, the House is heading toward a final vote on Sunday on the compromise package (both the underlying Senate bill and the "fix it" bill) and it is going to be very close. If it passes, the Senate will take up the "fix it" package as early as next week. In a sign of the high stakes, President Obama has canceled a trip to Asia to be present for the final stages of congressional action on health reform. 

The final health reform package adheres closely to the structure of the underlying Senate bill and incorporates most of President Obama's ideas for changes.  For funding, it relies less heavily on an excise tax on high cost health plans and more on Medicare savings. From a child and family health perspective, some of the key provisions include:

• Stronger affordability protections. The final package increases the adequacy of tax credits aimed at helping people purchase coverage through new "health insurance exchanges." For example, those up to 133% FPL would pay 2% of income and those up to 300% to 400% FPL would pay 9.5%. Cost-sharing assistance also would be stronger than in the Senate bill. Overall, 24 million people are expected to be covered through Exchange plans, 19 million of whom would receive a tax credit for their coverage.

• Expands Medicaid up to 133% of the FPL. The "fix it" bill eliminates the special deal for Nebraska and instead provides all states with an enhanced federal matching rate for people made newly eligible as a result of the Medicaid expansion. This new "super" matching rate is set at 100% in calendar years 2014, 2015, and 2016; 95% in 2017; 94% in 2018; 93% in 2019; and 90% in 2020 and future years. Overall, the federal government is expected to pick up 95% of the cost of the new Medicaid expansions and fully 98% of the cost of covering 32 million more uninsured people. 

• More equitable Medicaid financing for leading states. Due to a provision in the reconciliation bill, leading states that already cover adults (both parents and childless adults) up to at least 100% FPL will be treated more equitably. By 2019, these states will receive the same "super" matching rate for childless adults up to 133% FPL as states that never covered them prior to reform. Specifically, each of the "leading" states will see 50% of the gap between its regular Medicaid matching rate and the "super" matching rate addressed in 2014, 60% in 2015, 70% in 2016, 80% in 2017, and 90% in 2018. For example, a "leading" state with a regular matching rate of 60% will receive a matching rate for childless adults of 80% in 2014, 84% in 2015, 88% in  2016, 88% in  2017, 90% in  2018, and 93% in FY 2019.  The states that appear to meet the criteria of a "leading" state include AZ, DC, DE, HI, MA, ME, MN, NY, PA, VT, WA, and WI.

• Higher Medicaid reimbursement rates for primary care. As reform is being launched in 2013 and 2014, states will receive 100% federal funding for the cost of increasing their Medicaid reimbursement rates for primary care services up to Medicare levels. CBO estimates this change will cost the federal government $8.3 billion over 10 years and will have a positive effect on Medicaid reimbursement rates even after 2014.  

• Simplified enrollment procedures. Along with maintaining the Senate's provision requiring "no wrong door enrollment," the final package simplifies enrollment and allows for better coordination between Medicaid and the Exchange by adopting a uniform definition of income ("modified adjusted gross income"). In place of Medicaid disregards for various types and kinds of income, the final bill calls for using a uniform 5% income disregard. This provision applies to all Medicaid beneficiaries, except for those who also qualify for Medicare, as well as to CHIP.

• Continuation of CHIP. As expected, the final package continues CHIP through 2019, and provides new federal funding for the program from FY 2013 through FY 2015. States are required to maintain their CHIP and Medicaid coverage for children, and will receive a 23-percentage point increase in their CHIP matching rate beginning October 1, 2015.