Say Ahhh!

In May, HHS' Inspector General released a study that presented some pretty depressing news - almost three-quarters of children on Medicaid in nine states are not receiving all of the medical, vision and hearing examinations (the study did not look at dental) that federal law (through the Medicaid EPSDT benefit) requires. 

It has long been recognized that low-income children are at greater risk of being in ill health, often facing vision, hearing and speech problems, and other developmental obstacles. The importance of providing these children with early and regular screenings to identify and address problems before they become worse is clear. Medicaid EPSDT provides this comprehensive approach to kids' health by requiring that every child receive periodic preventive medical assessments that include physical exams, vision and hearing tests, dental exams, immunizations, lab tests (for example, to assess blood lead levels), and health education. Additionally, EPSDT provides necessary diagnostic and treatment services to address concerns identified in the screenings.

The newly released report shows that the states examined (Arkansas, Florida, Idaho, Illinois, Missouri, North Carolina, Texas, Vermont, and West Virginia) have a ways to go to meet the promise of EPSDT. Among these states, even for children who received a medical screening, 60 percent did not receive all of the services they should have (with lab tests most commonly skipped). States in the study reported efforts to improve these results, including outreach to families, but it is not clear what the scope of those activities were (handing out flyers versus hands-on assistance to families).

The Inspector General's report recommends that states report hearing and vision screenings and that CMS work with states to find incentives to increase doctor participation and improve outreach efforts to families. Experts working on this issue have also recommended providing states with best practices, creating better linkages with groups routinely in contact with children, offering better education to providers, increasing provider reimbursement, and requiring better data collection and reporting.

Efforts in this area may also be helped through health reform. Included in the law is a provision that requires private health plans to offer these types of screenings (through Bright Futures, a compatible set of preventive services recommended by the AAP) at no cost.   With many more children now in the mix, there are increased incentives to make the EPSDT screening component the best it can be for all children. 

While there is much work to be done implementing the many facets of the health reform, creating the exchange marketplace(s) is one of the tasks that receives much of the attention. Not only is it a new concept to most states but, along with the expansion of Medicaid, it is the mechanism for insuring the 32 million Americans who are expected to gain coverage.

People tend to look to Massachusetts for lessons learned because the exchange concept in national reform is based on that state's health reform model. In fact, early this year the State Coverage Initiatives (SCI) hosted a meeting of state officials in Boston to provide the nuts and bolts of how the Massachusetts exchange known as the Health Connector works. This two-day meeting drew more than 100 participants from 42 states, including representatives from state insurance departments, Governor's offices, and the state department responsible for health programs. The SCI program, funded by the Robert Wood Johnson Foundation and administered by AcademyHealth, provides technical assistance to state leaders to help them move health care reform forward at the state level.

It's important to note that other states beyond Massachusetts have made advances in health reform that can inform our efforts moving forward. SCI documented a number of the important issues in its report,"Implementing State Health Reform: Lessons Learned for Policymakers," on the experience of five states: Massachusetts, New Mexico, Tennessee, Vermont and Wisconsin.

The report and its companion webinar focus on key questions and takeaways in a number of areas including enrollment and eligibility, marketing and outreach, staffing and coordination, and reporting and evaluation. It asks critical questions like:

• "Are current state information systems equipped to perform the necessary eligibility and enrollment functions for the health insurance expansion?"

• "To what extent can the state's current CHIP and Medicaid outreach activities be modified to include outreach and marketing for the health insurance expansion?"
  

Some states are already moving beyond forming a key group of state officials charged with beginning the planning process. Wisconsin, one of the early state implementers of health reform, has recently issued a request for proposals (RFP) to add exchange functionality to its current eligibility system. Connecticut and the District of Columbia are early adopters of the new option to cover adults (both parents and adults without dependents) now without waiting for health reform.

And speaking of waiting...let's not forget that with 5 million uninsured children already eligible for Medicaid or CHIP, kids don't also have to wait for health reform.

Yesterday, CMS issued two additional guidance letters related to implementation of the Children's Health Insurance Reauthorization Act (CHIPRA) of 2009. The first of these letters is on new federal support for covering for lawfully residing children and pregnant women who have been in the country less than five years. This long-awaited guidance explains that there is new federal support for states that have previously covered these populations using state-only funds and offers a new opportunity to expand to states that do not cover these populations due to the lack of federal  support for doing so.

Prior to CHIPRA, close to 20 states used state-only dollars to cover these children and/or pregnant women. Now, these states can receive federal matching funds for this coverage -- freeing up state funds during a time when state budgets are tight. It is important to note that since CHIPRA was enacted and this new opportunity for federal support, another six states have taken up the new option to cover this population, resulting in almost half of the states offering coverage to lawfully residing children and pregnant women.

The second guidance letter issued by CMS is about a provision in CHIPRA that gives states the opportunity to receive enhanced federal support to better serve Medicaid and CHIP beneficiaries for whom English is not their primary language.

There is much more to say on both of these topics, but not enough time before the long holiday weekend to do them justice, so please check back on our website next week.

Happy Fourth of July!

Today, HHS launched a web portal designed to provide families with a central place to go for information on health care coverage in their state. The folks at HHS must have been burning the midnight oil to get this done by the July 1st deadline created by Congress.

Healthcare.gov is a remarkable accomplishment in such a short time frame. Not only can you obtain general educational information on health coverage, by answering a few simple questions, individuals can receive a list of state-specific private and public health insurance options available to them and their family. 

This is light years away from what exists today for families shopping for health coverage. But there still is a ways to go -- once families are provided with the list of options, they have to navigate through a number of links, and ultimately, leave the site to find more information and apply for coverage. And let's face it, until the majority of health reform provisions are implemented in 2014, there are not a lot of affordable coverage choices available to uninsured families unless they happen to qualify for Medicaid or CHIP.  (The new pre-existing condition insurance plans -- also officially launching today in selected states -- will offer much-needed relief to some, but were always intended to be a bridge to broader reform.)

In the meantime, healthcare.gov at least gives families a starting place to look - and could serve as a particularly critical resource for the millions of uninsured children (and in some cases their parents) who are eligible now for Medicaid and CHIP. 

The other good news is that HHS also sees this version of the site as a first step and plans are already underway for a second iteration. The young leader of this effort at HHS, Todd Park, is wildly enthusiastic about getting feedback and doing all that he can to lead his team in making it better and better over time.

We've already added a few items to our list of how to make the site work better for families, including paring back the number of steps it takes to get to Medicaid and CHIP information and providing a more prominent and direct link to state Medicaid/CHIP applications (not just the state's web site providing information on those programs.)  Plus, we'd like to see a way for people to report back on their experiences once they leave the safety of healthcare.gov.  After they were sent to a private plan or a Medicaid agency, what happened?  Were they able to get the coverage that they needed?

What would you like to see?  We urge you to take a tour of the web site and share with the Say Ahhh community what you think.

When I served as an aide in the Ohio Legislature, an annual tradition was the Rockin' Fiscal New Year's Eve Party, held on June 30th as a way for staffers to mark the end of the state's fiscal year (and every other year, the end of a grueling budget process).  With or without rockin' parties, 46 states end their fiscal years on June 30 and they will begin fiscal 2011 without the federal Medicaid support most of them counted on.  That extra support has helped states through one of the worst fiscal crises on record and has been vital in stabilizing Medicaid coverage for children and others in families facing job loss.  The U.S. Senate last week failed to advance a bill that would have continued the federal government's commitment to enhanced Medicaid funding through the end of fiscal 2011--instead, under current law, that support will dry up halfway through the year. 

Congress's failure to provide extra funds for Medicaid will potentially have a real impact on many families who are still struggling to stay afloat through the recession, depending on state policymakers' responses.  The health reform law will keep states from cutting back on eligibility levels or procedures for Medicaid and CHIP, but states may react to the decline in federal Medicaid support in other harmful ways.  They might choose to cut payment rates to doctors and hospitals or make it tougher for families to get Medicaid or CHIP coverage by cutting state workers who process applications.  Either of these steps could mean preventing kids from getting the care they need.

While it's still possible that Congress will continue the needed Medicaid support before it expires in December, state lawmakers who thought they had completed their 2011 budgets will likely have some more tough choices to make in coming months.  Advocates for kids and families will be working to show that the smart choice is to protect the health coverage that keeps kids healthy and helps families through the recession.