Say Ahhh!

Most of us were glued to the TV set last night waiting to see what President Obama was going to say about the future of the health care reform bill given its now uncertain fate in Congress. As I settled in to watch with my husband and one of my girls (the other one sadly could not be pried away from reading New Moon), I found myself getting antsy.

Why do we find ourselves in this situation? Why isn't he announcing that he signed the bill today?

Passing comprehensive health care reform legislation is extraordinarily difficult. Passing any comprehensive bill is difficult these days. But I have very little patience at this point for the political pundits and everybody else assessing the political calculations of whether passing the bill is the right political choice. Personally I think it is. And I thought the President did a nice job in his speech last night in making clear that he wants to see a bill. But the public wants to see results -- results that will improve the lives of families.

Having worked on public policy issues affecting low-income families for the last twenty years in Washington it's easy to become cynical. It's almost embarrassing to let your compassion for people show through in public without citing research and data and carefully crafted messages. Here goes, I'm going to let the policy wonk take a backseat and talk about people because that's what this is really all about -- people who need results from our leaders.

Children need health care reform to ensure that they have access to affordable comprehensive coverage. Yes kids have done relatively well with our current assortment of public programs, but not everywhere. Some states are leaders, but other states will never catch up. And the current state fiscal crisis reminds us that until we have a universal, federal guarantee of comprehensive coverage for children we will be selling our kids short.

Parents need access to affordable coverage options that don't disappear when they lose a job or become sick. Coverage of low-income parents through Medicaid is inadequate at best and almost non-existent in some states. Children do better when their parents have health coverage. Expanding Medicaid coverage to all parents below a specified income level regardless of where they live, as both bills do, would be an enormous victory for the most vulnerable families in our nation.

So-called "childless adults" need access to affordable coverage options. OK the first two are kind of no-brainers for childrens' advocates. So why do I keep finding myself thinking about two "childless adults" that I met in 1991 when I was writing a report on homeless veterans? Childless adults are not politically popular. But I can't get the stories of these two men out of my head.

Both of these men were Vietnam veterans and had seen combat duty in Vietnam. One was white and one was black. One was a Member of Congress who was the primary sponsor of a bill to help homeless veterans (I'll call him Al) and one was a homeless veteran (I'll call him Bill) who was an eloquent spokesperson. At the time that I did the report, I met Bill who was living in his truck. He had, ironically, been working in the Senate as a maintenance worker who moved furniture around. But one night a woman got shot outside his apartment. A shotgun ripped off half of her face. Bill went out to help her (he had served as a combat medic in Vietnam), and she died in his arms. This tragedy triggered PTSD and his blood pressure soared. He lost his job and his health insurance and got little help from the VA. He ended up living in his truck. He was a "childless adult" with no insurance.

Now let's turn to the former Congressman. Surely he doesn't need any help from the pending bills?? Well it turns out that because this public servant was an extraordinarily dedicated guy, he turned down all of the perks of his job (the pension and the health insurance). Then, at an early age, he developed Parkinson's disease. And because he had the audacity to live longer than expected, Al has hit the lifetime cap on his insurance policy. Now people have to have fundraisers to pay his medical costs. Pending bills would remove lifetime caps.

So let's all redouble our efforts to pass health reform. For the kids, their parents and for Al and Bill.

The image of sweet little Sarah McIntyre immediately came to mind as I read the Pediatrics Journal's study that showed that children with special health care needs were 57% less likely to be uninsured in 2005 than those in 2001.  The Pediatrics report is great news but it should be taken with a dose of caution.  CHIP and Medicaid have helped improved access to affordable health coverage for children with special health care needs but those gains can be as precarious as their health so without continued vigilance, this trend could rapidly deteriorate. 

The precarious nature of health coverage for children with special health care needs is what brought Sarah to mind.  Sarah is a 3rd Grade girl from Yakima, Washington who was born with a hole in her heart and cysts on her lungs.  Her life depended on consistent, quality health care that she received through Apple Health for Kids, Washington State's Medicaid and CHIP program.  She lost her health coverage when her parents received modest raises that put their income slightly above the eligibility cap.  The McIntyre family went through a difficult period in which Sarah was uninsured.  Fortunately, Washington state expanded coverage to families earning up to 300% of FPL with the help of increased federal funding included in CHIPRA and Sarah was able to enroll in Apple Health for Kids once again.

There are many more Sarah McIntyre's out there.   According to another report in last month's Pediatrics, approximately 1 of every 7 children in the United States has special health care needs. Children with special health care needs are those who are at increased risk for a "chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally". They are at greater risk for unmet health care needs and, on average, expenditures for their care are about 3 times higher than for other children. Their families oftentimes must rely on Medicaid or CHIP programs to find coverage.  (Medicaid coverage is a better fit because it is more comprehensive than CHIP and provides an important lifeline to children whose health care needs are often greater than the norm and whose families' limited incomes make it difficult for them to afford uncovered health expenses.) There are also many children with special health needs who remain uninsured because insurance providers will not accept them with a pre-existing condition or because their families can't afford the high private health insurance premiums to get the coverage their children need.

Sarah's story and the Pediatrics reports remind us of what's at stake in the health reform debate for families of children with special health care needs. 

 

 

 

 

Like everyone else in D.C. health policy circles, I've spent much of the last few days obsessively checking for updates on whether there is a coherent plan emerging from the White House and Congress for moving forward on health reform. Not yet, which means that instead of rolling up my sleeves and thinking about how CCF might best help to implement health care reform, I have some time to contemplate all that would be lost if policymakers fail to move forward on reform or decide to scale it back.

The worst thought is giving up on the opportunity to create a more compassionate and fair health care system.If reform passes, we can expect millions of children to gain coverage as their parents come forward to apply for insurance. These children no longer will go untreated for medical conditions that could affect their trajectory in life.As importantly, if reform passes, children no longer would have to see their parents and other adults in their lives struggling with the untreated medical conditions or the medical debt that can come with being uninsured.  As my colleague, Martha Heberlein, has pointed out, the research is unequivocal on the point that children fare better when their parents also have insurance, presumably due to both the financial stability it confers and because it is tough to be an effective parent when coping with an untreated medical condition.

More immediately, the failure to pass reform would mean that children could still be denied coverage because they have a pre-existing coverage, such as asthma, diabetes, or autism. And, we wouldn't get the benefit of improvements to benefits for children contained in both reform bills, which means millions of children could miss out on hearing tests, eye tests, dental care, and, in more serious cases, developmental assessments that could dramatically affect their ability to grow and develop.
 
Finally, reform holds out the tantalizing prospect of stabilizing and strengthening the successful Medicaid and Children's Health Insurance Program, which together cover close to one in three of America's children. Medicaid is slated to receive a major investment of federal funds for extending coverage to more people, and, also, possibly, for increasing access by improving Medicaid reimbursement rates. If reform fails, we not only lose a valuable chance to stabilize and strengthen these programs, but face the prospect of states cutting back on Medicaid when fiscal relief runs out at the end of this year. We could see more states try to solve their state fiscal problems, in part, by putting uninsured children on waiting lists for coverage, as already has occurred in Tennessee and Arizona.

There has been a lot of rumbling about a scaled-back version taking on the necessary insurance reforms such as prohibiting insurance companies from denying coverage due to pre-existing conditions, but this isn't a viable option. Many have pointed out that those reforms will actually increase insurance policy costs if we don't also expand those who are insured by making insurance coverage more affordable. If it were possible to ban pre-existing conditions without having the harder debate about broader health reform, it likely would have happened long ago.

I'm still optimistic that the nation's policymakers will find a way to move forward on health reform that offers pathways to affordable coverage for everyone. The cost of failing to do so is simply too high.

The election of Scott Brown to the U.S. Senate changes many things, but it doesn't change one simple fact:  children and families still need better access to quality, affordable health coverage.  

While figuring a way out of this sticky situation is above my pay grade, there are a lot of savvy legislative strategists working on the next step for health reform legislation.   It's very likely that the reconciliation process will be part of the solution.  As we all anxiously wait to see what's next, we might want to channel our nervous energy into refreshing our understanding of the reconciliation process by re-reading last Fall's entry by CBPP's Edwin Park.  

Here's a condensed version of Edwin's earlier post:

 What is Reconciliation?

First, the basics.  A reconciliation bill is a single piece of legislation that typically includes multiple provisions (generally developed by several committees) all of which affect the federal budget -- whether on the mandatory (or entitlement) spending side, the tax side, or both.  Under House and Senate rules implemented when the Democrats took control of Congress in 2007, reconciliation cannot be used for legislation that would increase the deficit so any reconciliation bill must be fully offset, that is it must include mandatory savings and/or revenue increases that pay for any higher spending and/or tax cuts in the bill.  Reconciliation, of course, can also be used, as it was originally, to reduce the deficit.  Reconciliation is generally used to speed passage of legislation through the Senate by providing special procedures that make it easier for a bill to pass.

 

 

There has been much discussion about states' ability (and willingness) to help finance health reform, especially as it concerns an expansion of Medicaid. A little background data may help to illuminate the debate.

While significant, Medicaid's role in state budgets is far more modest than the headlines often suggest. Medicaid constitutes 16.2% of state general fund spending, leaving it well behind elementary and secondary education (in fact, as shown below, states spend nearly twice as much of their own money on elementary and secondary education (35.1%) as on Medicaid).

It is often, misleadingly, suggested that Medicaid consumes a larger share of state budgets than any other item. Misleadingly because the numbers cited to make this point include federal Medicaid matching funds states receive. So while this may be true for total state spending (if you include federal funds), it is not the case if you consider Medicaid spending as a share of a state's own general fund (basically just the state's money). In fiscal year 2009, state funds spent on Medicaid actually decreased by 2.2% from fiscal year 2008 due to the increased federal Medicaid support made available by ARRA - the federal stimulus legislation.

As the health reform debate continues, it is important to acknowledge state concerns regarding their dismal fiscal conditions and realize that there are certainly options to adjust the formula in order to make it more equitable across states.

However, it is also vital not to lose sight of the larger point - states are getting a pretty good deal out of health reform: near universal coverage with marginal costs. Yes, their budgets are in disarray and yes the federal government (not to mention their citizens) are expecting a bit more of them. But these requirements are years away, as states would not be expected to contribute to the cost of the newly eligible until 2015 in the House bill and 2017 in the Senate bill.

There's a risk of exaggerating claims without a full understanding of the fiscal implications of health reform (or current Medicaid spending). Everybody would be better served by having an honest debate about the true costs of reform and how best they can be shared.