Recently in Medicaid Category

Many thanks to the organizations that joined us in submitting a letter to federal officials in opposition of Wisconsin's request to waive maintenance of effort provisions.  These provisions are so valuable to families because they preserve stability in states' Medicaid and CHIP programs.  Groups such as the AARP, American Heart Association, Center on Budget and Policy Priorities, Families USA, First Focus, and the March of Dimes signed on to voice their concerns on this issue.

I won't go into too much detail about the waiver proposal because our friend, Jon Peacock, from the Wisconsin Council on Children and Families blogged about the specifics of the waiver proposal, while cleverly comparing it to a triple feature horror film.  Some of the proposals included:

* Increasing premiums to five percent of family income for families with incomes above 150% of the FPL;

* Excluding eligibility for adults ages 19 to 26 above 100% of FPL if they could be covered on a parent's employer sponsored plan; and

* Excluding adults from Medicaid with incomes above 100% of the FPL and children with family income above 133% of the FPL if they have access to employer coverage that costs less than 9.5% of their family income.

According to Wisconsin's Legislative Fiscal Bureau, just by raising these premiums, 19,000 individuals, including 12,000 children, would lose their Medicaid coverage.  The group letter stated that allowing these individuals to lose coverage would be an inappropriate use of the Section 1115 waiver authority and be unprecedented.  Section 1115 waivers should promote the objectives of Medicaid and test innovative approaches to provide health care to families in Medicaid.  Waiving the maintenance of effort protections would have the opposite effect. 

Just from reading some of what's been proposed, you can see that Jon's analogy of a horror film is pretty accurate.  If these provisions were waived, this would be frightening to families, to say the least. 

We hope that HHS holds their ground on the maintenance of effort waiver in Wisconsin.

It's a really big weekend: the third anniversary of CHIPRA and the Super Bowl rematch between the New England Patriots and New York Giants. What more could a child health policy wonk and Patriots fan, want? There is a connection between these seemingly disparate events. Thousands of kids watching the action will be dreaming of becoming the next Tom Brady or Eli Manning or the first female NFL Commissioner!

But too frequently, you can't get in the game if you aren't covered! How often have we heard parents of uninsured children say their kids aren't allowed to play sports because of a lack of insurance or for fear of an injury they can't afford?

So one thing we can all cheer is the fact that 1 million more children have insurance today than in 2008 when the Patriots and Giants met in the epic Super Bowl that brought an end to the Pats' perfect season in an upset victory.

No doubt that CHIPRA has much to do with this winning story - no, no, not the Pats' loss in 2008 - the fact that 1 million more kids are covered today. Covered despite the fact that the economy and erosion of employer-based insurance keep moving the goalposts.

For a play-by-play description of the impact CHIPRA has had on children's coverage over the past three years, my colleague, Jocelyn Guyer, and I put together this brief that celebrates the victories, both small and large. From eligibility expansions to outreach grants to removing red tape and paperwork barriers, CHIPRA has been gaining yardage and scoring points across the country. In fact, each and every state has gotten in on the action, some more than others benefitting from the options and opportunities provided by CHIPRA.

Whether it's the Patriots or the Giants that take home the Vince Lombardi trophy on Sunday, every state can be a winner when it comes to covering kids. The game plan is easy to follow. Scout out the uninsured, practice streamlining how families apply for and renew coverage and earn performance bonuses when your efforts get you to the playoffs.

And just think about the team we're building for the future. Healthy kids today means lower health care costs tomorrow. With kids, we can spot problems early and block them from interfering with a child's development. We don't have to fumble our children's future health. CHIPRA gave us more tools and resources, but the ball doesn't run itself down the field. Strategic plays and strong fans (including policymakers, state officials and advocates alike) are the winning combination needed to score extra points and get to the end zone!

On Super Bowl Sunday 2012, I'll be rooting for the Patriots. But on Monday, I'll be back cheering on states and advocates to use more of CHIPRA's resources to make sure all of our kids can get in the game and be winners in life.

Undoubtedly you've heard about Super Bowl XLVI , but have you heard of CHIP III which is also taking the field this weekend?

CHIP is short for the Children's Health Insurance Program which was reauthorized three years ago this weekend. To mark the occasion, we're hosting a Super Blog-Off between Patriots fans and Giants fans.  But here's the kicker - they have to compete for kids. That's right, we've taken HHS Secretary Sebelius' "Connecting Kids to Coverage Challenge" quite literally and want the teams to compete based on how much they are doing to help uninsured children.

While we won't likely reach over 110 million people or be able to sell ads for $3.5 million per thirty seconds, our goal is to help reach the 4.3 million uninsured children who are eligible for CHIP or Medicaid coverage but not yet insured.

Last year, the Pittsburgh Steelers won.  That's right.  They might have lost the football game but they won our Super Blog-Off by going to great lengths to reach out to uninsured children.  Pittsburgh fans even swaddled newborn babies in "terrible towels" declaring that no baby should leave the hospital without an insurance card or a terrible towel.

This year, Dayanne Leal of Health Care for All Massachusetts is blogging on behalf of Patriot's fans and a team of health policy experts and advocates from New York are taking the field for Giant's fans. 

So whether you are a Pats' fan, a Giants' fan or wish there were a team from some place west of the Mississippi in the Super Bowl, you can bring home a victory for uninsured kids in your state by supporting efforts to enroll them in Medicaid or CHIP and keeping those programs strong. 

To vote for your favorite team, go to the Patriot's blog or the Giant's blog and post a comment.  Include the words "Go Patriots" or "Go Giants" in the text.

May the best (outreach) team win. 

By Dayanne Leal and the team at Health Care For All Massachusetts

On Sunday, the Patriots are going to win the Super Bowl. 

Really, I don't know why the Giants would even bother to show up. 

And since a 4th banner in Gillette Stadium is inevitable, it's worth asking to what can we credit this success? 

Some point to the offense, led by the great Tom Brady. Others look to the previously unheralded defense or maybe the play of the special teams. And there is a camp that says the culture of class and professionalism that Bob Kraft created should be credited. 

(Editor's note: That's Dayanne next to Tom Brady, his wife Gisele and son Benjamin)

At Health Care For All, we believe a big reason is the genius of Bill Belichick. And the genius of Mr. Belichick is not confined to the football field. To the contrary (and many don't know this), he has been a long-time and outspoken supporter of kid's health.     

For evidence of this, we have picked out eight (in recognition of this eighth trip to the Super Bowl by the Patriots) quotes from Coach Bill, cleverly disguised to make them appear to be pigskin-related and delivered at post-game press conferences.

But we know the truth: he was really talking about making sure that kids have health coverage. 

1. "I don't know what normal is. You can go back and look at the past few years. There are always going to be changes."

The normal in Massachusetts is that all kids through age 18 can qualify for health coverage regardless of family income or immigration status. We are proud that more than 99% of children are covered. 

2.  "This won't be good enough. It wasn't good enough today. It won't be good enough against anybody else, either."

The work goes on. 99% is good. Great even. But what about the few who aren't covered? We're working hard to make sure that they have access to care too. 

3. "The experience level they bring, there's no question there is a value to that... In the end, for me, it's more about having the best players that we can have on the roster. I think you have to look at it that way. You have to be cognizant of the overall makeup of your team, but you try and get the best players you can." 

No one organization can get to the remaining kids who aren't covered. Just like the Patriots, HCFA put together a strong squad as part of its "got coverage? Health Coverage for Kids and Teens campaign". We partnered with faith-based and community organizations, and collaborated with ethnic media to get the word out and reach across the state. 

4. "You can play hard. You can play aggressive. You can give 120%, but if one guy is out of position then someone's running through the line of scrimmage and he's going to gain a bunch of yards."

There are several important players in the game of making sure children access the health coverage they need. Community-based organizations like Health Care For All and many others have been the Most Valuable Players (MVP's) to the success of Massachusetts. Some 66 organizations from across Massachusetts stepped up and accepted the challenge of focusing their efforts on enrolling kids who weren't covered already. 

5. "On a football team, it's not the strength of the individual players, but it is the strength of the unit and how they all function".

The team of 66 was successful beyond our most optimistic goals. We had hoped to enroll 500 uninsured kids - instead, 1,479 children got coverage in only one month! HCFA and its partners carried the ball and pushed it over the goal line, nearly tripling the "score" they set out for.

"Pat" the Patriot loves kids and kids love the Patriots!

6.  "It's hard to win when you give the ball away."

All too often, newly insured individuals will go for a needed doctor visit or to pick up a prescription, only to find that their coverage has disappeared. Coverage is not a one-time thing. After you get it, you need to renew it every year. The work doesn't stop once you get children enrolled - as matter of fact, enrolling people is hard work, keeping them covered is even harder. That's HCFA's next frontier in kids' coverage work: making sure that the kids who have insurance keep their coverage from year to year. This time, the name of the game is coverage retention and we have innovative strategies to make this happen. Check out the got coverage? Campaign website for more details. 

7. "There are certainly areas that you can improve in and develop more consistency (in)."

Things aren't perfect and there are changes to be made that will make things better. We are lucky to have not only a strong advocacy community, but also a Legislature that has prioritized children's health.  Just like the Pats, we are working together to make sure that all kids have coverage and that all kids keep their coverage. 

8. "We'll worry about next week next week."

We're in it for the long haul. Next week, next month, next year - we'll be here working for the kids. HCFA isn't interested in just putting up good numbers for one year. Over 99% coverage of kids is only something to be proud of if we can keep it going. The Patriots have brought home three (about to be four) Lombardi trophies since 2002 - we're in the midst of our own dynasty of kid's coverage here too. 

Massachusetts has made the choice to defend children's health, has made a commitment to do the work and has embraced creativity to make it happen. We couldn't be more fired up if we had our own end zone militia to celebrate our success!

Go Patriots, it's your patriotic duty to jump, play and get covered.

Go Pats! Go kids!

(To vote for the Patriots and New England kids, post a comment on this blog with "Go Pats" in the text.  Tweet out the blog or like it on Facebook to get your friends to help put the Patriots over the top.)

By the Community Service Society of New York, Children's Defense Fund - New York, Schuyler Center for Analysis and Advocacy and Health Care for All New York

As the New York Giants head to the Super Bowl this year, another giant comes to mind, the title character from Roald Dahl's famous book, The Big Friendly Giant (BFG). Just as the BFG spreads good dreams to the children of the land, New York's BFG spreads health insurance to the children in the state.

New York's BFG comes in many forms and is incredibly benevolent. He has made sure all children in the state qualify for public health insurance, regardless of their immigration status and income. New York's CHIP, Child Health Plus, covers children up to 400% of the federal poverty level and a full premium buy-in option beyond that. To assist families with enrollment, the Facilitated Enrollment (FE) program in New York reaches families in their own communities. Community-based facilitated enrollers across the state represent the cultural and linguistic diversity of the communities they serve and are available at times and places convenient for working families. Building upon the FE program, Cycle 2 of the CHIPRA Outreach and Enrollment grants funds the REACH-Out project, with retention specialists working alongside facilitated enrollers to ensure children do not lose coverage. 

Beyond taking giant steps to connect kids to coverage, New York is also a behemoth when it comes to ensuring children have access to quality and affordable healthcare through school-based health centers (SBHC).  There are currently 217 SBHCs operating in New York State enrolling over 160,000 children.  These SBHCs help provide care to thousands of children who may have limited access due to geographical, financial or other barriers.  They make available services such as comprehensive physical health and mental health assessments, diagnosis and treatment of acute illnesses and chronic conditions, screenings, management of chronic diseases, health education, mental health counseling and referral and immunizations.  These services are offered to any student whose school has a SBHC and play a crucial role in the health of children who otherwise may not be able to see a doctor.   New York can and should do more to support SBHCs.

When the BFG in Dahl's book catches a nightmare, he destroys it. In New York, children's advocates work to identify and destroy barriers to enrollment. In 2010, the State eliminated the face-to-face interview and asset test for Medicaid. Online renewal for New York City residents makes it easier for families to renew coverage, and the Statewide Enrollment Center --which started rolling out in some New York counties in June 2011--is intended to facilitate renewal through phone and mail-in renewal. In November 2011, in anticipation of ACA requirements, the State eliminated Medicaid stair-step eligibility for children, bringing the eligibility level for children 6-18 up to 133% FPL from 100%FPL. (Children under the age of 1 are eligible at 200% FPL.)

As might be expected, the BFG is rather large. When he visits the Queen in Dahl's tale, they must make a table, chair, and cutlery big enough to accommodate him. With over 4.3 million children in New York State, and nearly half--2.1 million--of those enrolled in public health insurance, special structures must be in place to support such a large enrollment. The Affordable Care Act has provided the tools to support the building of structures, such as an online application and updating the state's eligibility systems.

We know there are many more big friendly giants across the country who, like New York's BFG, are working hard to spread insurance to the children of the land. (We hope there are no children-eating giants out there!) Just as we're rooting for the BFG to make sure every child has access to quality affordable healthcare, we'll be cheering on the New York Giants to win the Super Bowl! 

(To vote for the Giants and kids in the tri-state area, comment on this blog and use the words "Go Giants" in the text.)

By Gretchen Hammer, Colorado Coalition for the Medically Underserved

This month, All Kids Covered released Crossing the Finish Line: Achieving Meaningful Health Care Coverage and Access for All Children in Colorado.  The report provides an update on the current status of meaningful health care coverage and access for children in Colorado, and describes the significant progress we have made to make sure that all our children can get the health coverage and health care services they need. 

The good news is that roughly 90% of kids in Colorado have health insurance and between 2008 - 2010 over 40,000 children gained coverage.  In addition, the most recent Colorado Health Access survey reports that most of children in Colorado have a usual source of care - a place where they regularly go to get their health care.

Cue the Kool and the Gang music, start the disco ball and break out your best dance moves! Let's take a moment to celebrate these great accomplishments. 

As with any great success, many people have contributed to this progress.  Over the last five years, state policymakers, state and local agencies, community leaders, health care providers, advocates and private foundations have worked together with a common goal and concerted effort to achieve these milestones.

While recognizing and celebrating success is important, there is still more work to be done.  Much of that growth in coverage has come through higher enrollment in Medicaid and CHP+, resulting from policy changes to improve public programs and unfortunately, economic hardships facing many Colorado families which make them eligible for these programs.

Additionally, the most recent estimates suggest that between 112,200 (8.2%) and 124,128 (10.1%) children in Colorado still do not have health insurance.   And, access to care varies across the state.  While fewer than 5% of children in the metro area, the Eastern Plains and Northwest Colorado report they do not have a usual source of care, nearly 1 in 13 children (7.6%) in Southwest Colorado do not have a usual source of care.  And that's too many!

It is not too much to ask that all of Colorado's kids have access to they health care they need, when they need it.  To build on the strong momentum of the last few years we need to focus on five key strategies that we believe will continue the progress in Colorado and would likely be useful in other states, as well:

- Leadership and Accountability

- Coverage and Access for All Children

- Systems and Practices for Maximizing Enrollment and Retention

- Messaging and Communications

- Regional Adaptation

Check out the report for more details on these strategies and examples of how to implement them from Colorado and across the country.

Colorado is 90% of the way there to crossing the finish line and covering all kids.  It is going to take all of us working together to ensure that our children will have the health coverage and health care services they need to have healthy and fulfilling lives.   And, once we get there, we can really get the party started!

To access the full report, visit www.allkidscoveredcolorado.org/report.pdf

This week's national football league conference championship games and the theme my colleague, Jocelyn Guyer, picked for her latest blog  (where she admits to an obsession with Tom Brady) got me was thinking about statistics and scores as it relates to children's coverage. While the uninsured rate is the final score, there are a lot of factors that impact it including the prevalence of private insurance coverage in a state. I'm a fan, not a sports expert, but I know that teams need quarterbacks who can complete passes, runners who can gain yardage rushing, blockers who can get inside to make a sack, kickers who can keep it within the goalposts (sorry Ravens fans!), and the list goes on.

The same is true in children's coverage. Eligibility levels aside, we know that how a state handles enrollment and retention can make a huge difference in how successful they are in covering children (as well as others eligible for coverage). No NFL team manages its players without tracking their results, nor plans for the next game without looking at their competition. Likewise, we need good data that tells us how well our Medicaid and CHIP programs are doing in terms of enrolling and retaining kids. By comparing states, we can identify successes as well as opportunities to make improvements and reach more eligible children.

For far too long, we've heard that state eligibility systems just weren't designed to collect and report data; that state Medicaid agencies are handicapped by the lack of timely data. Hopefully, that's all about to change.

Given the unprecedented 90% federal financial match for states to overhaul or build new Medicaid eligibility systems (known as the 90/10 rule) and 100% federal funding for Exchange Information Technology systems (IT), a large number of states are embarking on major systems development projects. According to the 2012 50-state survey on state Medicaid and CHIP eligibility, enrollment, retention and cost-sharing practices that we released with our friends at the Kaiser Commission on Medicaid and the Uninsured last week, 29 states have received approval or submitted their plans for approval of 90/10 funding to transform their Medicaid eligibility systems. And 19 of the remaining 22 states plan to move in that direction in 2012.

There are a number of reasons why states need to bring their use of technology into the 21st century but a key one for me is building in the capacity for collecting and reporting data that allows us to assess and compare the performance of Medicaid, CHIP and, beginning in 2014, coverage through new state-based Exchanges.

Two new reports provide some useful insight into the kind of reporting that is needed. In December 2011, the Kaiser Commission on Medicaid and the Uninsured released its brief, "Performance Measurement Under Health Reform: Proposed Measures for Eligibility and Enrollment Systems and Key Issues and Trade-offs to Consider." Just a month earlier, the Maximizing Enrollment: Transforming State Health Coverage program, an initiative of the Robert Wood Johnson Foundation administered by the National Academy of State Health Policy also published "Using Data to Drive State Improvement in Enrollment and Performance."

As our policymakers continue to debate the role of government in health care, assessing and disclosing the performance of our public health coverage programs is a critical step in demonstrating their effectiveness. Data also is an unparalleled tool to pinpoint opportunities for improvement and track progress over time. Ask any sports team statistician. Each of the reports I noted earlier, as well as this paper I wrote a couple of years ago, offer states a rich inventory to draw from in designing their systems as they await further direction from CMS.

Some policy makers say we need to run government more like business and major league sports certainly qualifies as "big" business. When it comes to using data to make informed decisions, I agree. Making sure our new systems are built with the capacity to track the right data is step one. But it doesn't end there. We need to make such data publicly available on a routine and timely basis. (For example, I know that Tom Brady tied the record set by Joe Montana for most playoff wins - public information.) Moreover, we need to use the enrollment and retention data to celebrate our successes (just as Jocelyn and I are relishing the Patriots' win yesterday) and make program improvements (yes, the Giants beat the Pats in 2008) to ensure that all eligible children, families and individuals get and stay covered. 

There are people in my family who think I am unduly obsessed with Tom Brady.  They might even accuse me of co-authoring a paper on states at the forefront of covering our nation's children that features Massachusetts just so I could say "Just as Tom Brady is in a league of his own when it comes to quarterbacking, the Commonwealth of Massachusetts is the clear national leader when it comes to covering children." But, the honest-to-goodness truth is that the new paper we issued yesterday with the Kaiser Commission on Medicaid and the Uninsured, "Secrets of Success: An Analysis of Four States at the Forefront of the Nation's Gains in Children's Health Coverage," grew out of a discussion that CCF and Kaiser Commission on Medicaid and the Uninsured staff had together last spring.  It took place long before Tom Brady beat Tim Tebow and the Denver Broncos (soundly, I must add) and resulted in a paper that examined Massachusetts, but also three other states -- Alabama, Iowa and Oregon -- that are at the forefront of covering children.

Here is how it started.  We were discussing the news that Massachusetts had achieved a 99.5 percent coverage rate among children in 2010 and commenting on the extraordinary nature of this achievement.  Tricia Brooks with CCF, Samantha Artiga with the Kaiser Commission on Medicaid and the Uninsured, and I decided to jump in and try to untangle how the state got there.  At the same time, we didn't want to leave it just at Massachusetts.  While it is in a league of its own, states around the country have made enormous strides in covering kids.  Indeed, as we've pointed out repeatedly at CCF, the nation now has the lowest uninsured rate of children on record despite sharp jumps in child poverty and lots of other dire economic news.  So, we selected a diverse group of four states - one state from each region of the country at the forefront of covering kids: Alabama, Iowa, Massachusetts and Oregon - to investigate the "secrets" to their success.

Even though these four states have dramatically different political and policy cultures, we heard a number of common themes when interviewing state officials and advocates from each of the four states: 

* At least one political leader in the state - and, in most instances, a number of political leaders over time - made coverage of children a top priority.

* Expansive eligibility levels for children and adoption of a broad range of simplification strategies have been key elements of achieving progress. All four states have expanded eligibility for children to 300% of the federal poverty level and have taken up many of the opportunities to streamline and simplify enrollment and renewal processes for families.

* Community partners and providers play a vital role in helping families to enroll in coverage. We heard this in each of the four states, but perhaps most strongly in Massachusetts.  Interestingly, Massachusetts lags somewhat in the extent to which it has simplified its application and enrollment process, but makes up for it in no small part by relying heavily on community partners to help people enroll in coverage.  (Hey, even Tom Brady has someone weakness - a poor running game - but he also makes up for it in other areas.)The state and advocates have a robust relationship in which they exchange information on emerging issues and ideas about how to improvement enrollment.  It also has the advantage of a strong culture of coverage, which can be directly linked to its passage of broad health reform in 2006. 

* Strong coordination between Medicaid and CHIP aid in outreach and enrollment efforts and smooth transitions between programs. Each of the four states has taken steps to promote close alignment between Medicaid and CHIP, with Massachusetts and Oregon fully unifying the two programs. 

We also talked to each of the states about where they see their remaining challenges, and what they are working on now.  In a sure sign of why they are at the forefront of covering kids, each of them had a long list of challenges they were actively working to tackle, such as the need to improve retention, to cope with ongoing growth in enrollment amidst diminishing administrative resources; updating decades-old eligibility systems; and improving communications with families and obtaining better enrollment data.  Just like Tom Brady and the New England Patriots, they do not rest on their laurels and, instead, start each week looking ahead and figuring out how to continue to get better and better.

and Tricia Brooks

For those of you who have been anxiously awaiting (and you can count us, too!) the release of the annual survey on Medicaid and CHIP, today is your lucky day.  In partnership with the Kaiser Commission on Medicaid and the Uninsured, we released "Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost Sharing Policies in Medicaid and CHIP" at a briefing today.

Probably not surprising to those who follow such things, but we found that eligibility held steady in nearly all states, with only two states reducing eligibility. And the two that did - they did so for low-income adults relying on limited exceptions to the stability protections (otherwise known as maintenance of effort provisions of the Affordable Care Act). It's very likely that without the stability protections, more states would have made cutbacks and far more children and families would be left without an affordable coverage option during these turbulent economic times.

A far more surprising finding was the fact that 29 states went beyond holding steady and improved coverage through targeted expansions and simplifications. Most of these changes centered around the greater use of technology to boost government efficiency and make it easier for people to enroll in coverage; actions that have a dual benefit of helping eligible children and families while also stretching scarce state administrative resources.

But perhaps the most striking finding is how quickly a large number of diverse states across the country are leaping at the opportunity to make sweeping changes to their decades-old eligibility systems. More than half of the states have already sought the enhanced federal funding to develop the latest technology that will both transform families' experience of applying for health care coverage and make government work better. And, with just three exceptions, the rest of the states are planning to move in that direction in 2012.

And all this in spite of the fact that in 2011, state budgets remained stressed due to dampened revenue growth and the mid-year expiration of the temporary increase in the federal matching rate. So while strained state budgets have taken a toll on administrative resources, states have sharpened their use of technology and streamlined their procedures to create more efficient programs, while also simplifying the steps for families to enroll in and renew coverage. These actions, in addition to the massive systems upgrades they've undertaken, have not only helped states deal with current pressures, but are also laying the groundwork for the coverage expansions and new enrollment requirements that will take effect in 2014.

And let's not forget that amid these ongoing pressures, the stability protections in the Affordable Care Act were central to the preservation of health care coverage last year. So even with a weak economic recovery that has been slow to add new jobs with access to employer-based insurance, Medicaid and CHIP continued to be key sources of coverage for children, and, in some cases, for their uninsured parents. A bit of good news to start the year!

[A parting note to those who like us, want to dig in on the nitty-gritty details - there are several new areas that we report on this year (such as the use of out-stationed state eligibility workers and enhanced functionality with online accounts) all of which can be found in the full report. Enjoy!]