Say Ahhh!

Facing a $2.6 billion budget shortfall in fiscal year 2011, Arizona has resorted to $1.1 billion in cuts. In doing so, the state made the unprecedented move of repealing the state's Children's Health Insurance program, KidsCare. Estimates are that 47,000 low-income children will lose coverage as a result and another 13,000 children will be impacted by cuts to the state's Medicaid program. No state has ever eliminated its CHIP program. In fact, only one state has ever rolled back CHIP eligibility. (In 2004, Alaska reduced eligibility from 200% to 175% of the FPL.)

There have been instances where states have capped enrollment due to budget constraints, but they have always re-opened the programs once additional funding was secured (this recently happened in both Tennessee and California). However, by voting, not only to defund the program, but to repeal the statutory language authorizing its existence, reopening the program when the budget improves will be a much, much heavier lift.

Also in the state's budget are cuts to its Medicaid program (AHCCCS) - specifically, the state did not fund its Prop 204 expansion population, limiting spending to what the state has in tobacco settlement funds. (Prop 204, passed by a voter referendum in 2000, expanded Medicaid to all uninsured residents below 100% of the FPL.) It is not yet clear how the state will scale back AHCCCS to meet these funding restrictions. Estimates suggest that more than 300,000 people could lose coverage.

These cuts are likely to leave many uninsured, driving them to seek care in the emergency room or to simply go without necessary treatment.

There may be some hope for the low-income children and families who rely on the coverage they get through KidsCare and AHCCCS. Congress is working on extending the enhanced FMAP to states through the end of the fiscal year 2011 and this influx of federal dollars could be tapped to restore the devastating cuts in the state budget.

Arizona is the only state to ever make such a drastic and shortsighted cut to its CHIP program and it will be dealing with the fallout from this decision long after the state's budget situation improves.

The new game in DC these days seems to be naming every other bill coming out of Congress a "jobs bill."  While the provisions in each of these bills may indeed focus on job creation, it has become nearly impossible to keep the different bills straight. It becomes particularly perplexing when tracking an issue many of us have been watching: the six-month extension of increased Medicaid reimbursements that were initially part of the economic stimulus package.

Here is a Q&A to help you decipher where it stands.

Has the Senate passed an extension of Medicaid fiscal relief?
Yes. Last week, March 10th, the Senate passed HR 4213. The bill provides $26.7 billion in additional Medicaid fiscal relief funds through June 30, 2011 (the original provision was slated to expire at the end of this year). The extension would still require states accessing the funding to maintain their Medicaid eligibility and enrollment rules. The bill also extends unemployment benefits and COBRA subsidies through the end of the year.

Is this the same bill that President Obama signed today?
No. The bill that President Obama signed today does not include Medicaid fiscal relief but instead provides tax breaks to businesses hiring unemployed workers and extends infrastructure and transportation projects.

Has the House passed an extension of Medicaid fiscal relief?
Yes. In December 2009, the House passed a similar six-month extension of federal assistance for state Medicaid programs, and the "maintenance of effort requirement, as part of another "jobs bill," HR 2847.

Are there any differences between the House and Senate versions?
There is one difference between the House and Senate Medicaid fiscal relief provisions. The Senate bill includes a provision that would require Governors to affirmatively request the additional help from the federal government. There is some discussion on ways to ensure that this language does not unduly harm residents if a Governor does not want make such a declarative statement.

When will we see a final bill with the Medicaid fiscal relief provision?
The House and Senate need to reconcile their bills (which include many other provisions beyond state fiscal relief) before a final package can be sent to President Obama to be signed into law. The House could either pass the Senate bill or convene a conference committee. There is some urgency to moving this forward quickly since unemployment benefits and COBRA subsidies (included in both bills) are set to expire at the end of March. However, if Congress cannot reach agreement on a final bill before the two-week Easter recess they can pass a temporary extension of these benefits (which it has done twice before).  
 

For additional information, read CCF's analysis of the implications of the Medicaid fiscal relief on children and families.

Mom: "Did you brush your teeth?"

Child: "Yep."

Mom: "How come your toothbrush isn't wet?"

This is an excerpt from the script of the bedtime drama performed live nightly in the comfort of my own home.  Just between you, me and the tooth fairy ... after battling on the nutrition, hygiene and homework fronts, I don't have a lot of energy left to wage the toothbrush wars.  That's why I'm always a bit nervous about dragging my children to their 6-month dental check-ups.  Luckily, we have good dental benefits and an understanding dentist.  With the help of the dentist and dental hygienists, we've managed to get through with only a couple of cavities between all three kids.  (The nightly drama slacks off a bit after a good "education session" from the dentist.)

Other parents are facing the same obstacles to ensuring their kids have healthy teeth and gums but not all of them are able to rely on a dentist.   Even children with excellent brushing and flossing habits need to see a dentist because untreated dental disease and tooth decay can have devastating health consequences.  However, about one in five children in the U.S. do not receive dental care each year according to a new report The Cost of Delay: State Dental Policies Fail One in Five Children, by the Pew Center on the States.  The report points out that states play a key role in ensuring that low-income children have access to basic, preventive dental care and that more than two-thirds of the states are doing a poor job in this area.

The good news is that the Children's Health Insurance Program Reauthorization Act  provided states with new tools to help improve the oral health of children.  All CHIP programs are now required to cover comprehensive dental benefits. CHIPRA also allows states with separate CHIP programs to offer a dental-only plan for children who have other health insurance, but lack adequate dental benefits. Other oral health improvements include education for new parents, better access to benefit and provider information, and enhanced reporting on the quality of dental health services in Medicaid and CHIP.  CCF, the Kaiser Commission on Medicaid and the Uninsured, and the Children's Dental Health Project just released a "CHIP Tip" on CHIPRA's oral health provisions which is a good resource for those who want to see children receive better oral healthcare coverage.

 

Brace yourselves for a hectic few weeks leading up to the Congressional recess.  According to CQ, House leadership is preparing for a possible final vote on health reform as soon as next week.  It is still unclear whether or not they have the votes to pass the measure, which would actually be the Senate bill along with a reconciliation bill that includes agreed-upon "fixes" to the Senate bill.

The process of moving the legislation through the House is expected to begin Monday in the House Budget Committee. The next stop would be the Rules Committee then the floor.  We are expecting to see the actual legislative language of the final bill on Tuesday after which members (and the rest of us) would have at least 72 hours to review it before a vote is taken.

There are a number of procedural questions that remain to be answered but if all goes well, the bill could be on the House floor for a final vote around March 19th or 20th. Members have been told to prepare for a vote at the end of the week, staying through the weekend if necessary.  Then, of course, the Senate still would need to pass the "fixes" included in the reconciliation package.

Right about now, you probably have to "pinch" yourselves to make sure you're not dreaming this.  Believe me, I had to pinch myself while writing it.  In a sign that health reform really is moving forward again, President Obama postponed his March 18th trip to Indonesia so that he would be around for the final push for passage in the House. 

Now, back down to earth ... In other developments impacting health coverage, the Senate moved forward as expected on fiscal relief to states through an extension of the Federal Medical Assistance Percentage (FMAP) increase as part of the American Workers, State, and Business Relief Act (aka "jobs bill").  The House already has passed the FMAP provisions. The jobs bill is now moving through the final stages of the legislative process and, as always, it's not cut and dry.  However, the outlook for enactment of the FMAP provision still looks positive, which is good news for the country's children.  As we noted in a new analysis, when families lose their jobs, they often lose employer-based coverage and turn to Medicaid and CHIP, especially for their kids.  In fact, children represent more than 60 percent of those who have gained Medicaid coverage over the past year.  If the Medicaid program doesn't remain strong in the months ahead in the face of persistently high unemployment and ongoing state budget problems, we can expect that children will be particularly hard hit.

March 10, 2010 was a memorable day for children's health advocates in Ohio. Ohio became the first state to join HHS Secretary Kathleen Sebelius' quest to enroll all children eligible for Medicaid and CHIP. In accepting the challenge Secretary Sebelius issued to states in November at the National Children's Health Insurance Summit to enroll all eligible children, Governor Strickland announced that Ohio will take immediate steps to adopt key policies to advance coverage. 

In a symbolic gesture, Governor Strickland and our dear friend, Cindy Mann, CMS Deputy Administrator for Medicaid and CHIP, cut a red ribbon signifying the state's commitment to remove red tape that too often hampers families from accessing public insurance programs.

The Governor revealed that Ohio will implement three specific policies: 12-month continuous eligibility, presumptive eligibility and express lane eligibility.  These policies are among the eight program features that will help states qualify for the

CHIPRA performance bonus. Implementation of these policies will position Ohio to earn a bonus given that the state's enrollment in Medicaid has increased by 20% over the past three years, which exceeds the target enrollment established in CHIPRA performance bonus provision.

The Governor's announcement came on the eve of the Ohio Covering Kids and Families (OCKF) Annual Conference during which more than 200 attendees met to learn about best practices for enrolling and retaining all children in Medicaid and CHIP. Voices for Ohio's Children, which convenes and facilitates the OCKF Coalition, hosted a legislative reception during which Cindy Mann praised Ohio's commitment to reach all eligible but unenrolled children.

The events in Ohio this week remind us that strong leadership at the state level can make a difference even in challenging economic times. We commend Governor Strickland for accepting the Secretary's challenge and hope it inspires other Governors to do the same.