Recently in Connecting Kids to Coverage Category

When CHIP was reauthorized in 2009, the Performance Bonus was designed to reward states for enrolling more Medicaid-eligible children. As my colleague, Jocelyn Guyer, pointed out on Tuesday, the House Energy and Commerce Committee voted last week to eliminate these bonuses.

While this raises questions of whether the Committee supports the intention of connecting the poorest of children to affordable health coverage (as the bonuses were designed to do) perhaps the larger question is where would those newly-covered kids be if states didn't have the incentive to streamline and simplify their programs to enroll more eligible, uninsured kids?

Data on the bonuses show that in the 23 states that received bonuses in FY 2011, an additional 1.1 million kids were enrolled above expected levels. The most (123,000) can be found in the state of Ohio. While we can't say that the bonuses fully explain this jump in enrollment, it would certainly be fair to say that they get some of the credit for supporting states in reaching these kids.

As we've seen over the years, Medicaid and CHIP have been responsible for driving the uninsured rate of children down to record lows. These bonuses have been an important incentive in making this progress and dismantling them threatens to undercut the great success we've seen in Medicaid and CHIP.

By George Hoover, Pennsylvania Partnerships for Children

Having dedicated my career to making health care coverage accessible to all Pennsylvanians, I am dismayed over recent actions by the state that are jeopardizing health care access for children.

The number of Pennsylvania children covered through Medicaid has plummeted by about 89,000 in recent months, including many kids with life-threatening medical needs who were hastily -- and wrongly -- cut from Medicaid despite meeting the eligibility requirements.

Those wrongly dropped from Medicaid included a 5-year-old undergoing treatments for leukemia and an infant with congenital heart deformities. They also include a severely disabled 12-year-old who requires home health care and a pair of 9-year-old twins -- one diagnosed with autism, the other with a hearing impairment -- who rely on Medicaid to provide supports and services critical to their development and learning.

Many of these children rely on Medicaid not only for physical health services, but also critical behavioral health services that help them get by day to day. To understand how this happened and how we can fix it requires a quick history of the health care coverage crisis that has been quietly unfolding in Pennsylvania since last summer.

Last August, the Department of Public Welfare began sending out hundreds of thousands of renewal notices to Pennsylvania families receiving Medicaid, allowing these families 10 to 15 days to provide documentation to keep their children enrolled in Medicaid. If DPW did not receive and process all requested paperwork within this 10 to 15-day deadline, the child was dropped from Medicaid, even if the deadline was missed due to DPW's own bureaucratic backlogs.

Locally, this poorly planned process cut off Medicaid to more than 2,000 children in Dauphin County, nearly 1,600 in York County and more than 2,500 in Lancaster County. There's another troubling aspect to this story: Families whose children are no longer income eligible for Medicaid are referred to the Children's Health Insurance Program, or CHIP, yet we have not seen an increase in CHIP enrollment that corresponds to the drastic Medicaid enrollment decline.

In a state with near universal coverage for children, where have these children gone? ?And what can be done to ensure these children, and others, are not put at risk due to lack of access to health care?

Part of the solution lies in the Affordable Care Act. Look beyond the heated political rhetoric and it's easy to see how the ACA is helping to keep young Pennsylvanians healthy at a time when our state policies are putting children's health care at risk.

More than 1.1 million Pennsylvania children are benefiting from the ACA's prohibition on lifetime limits on health care. Insurance companies can no longer deny coverage for children in Pennsylvania with pre-existing conditions, and nearly 65,000 young adults can now remain on a parent's health insurance coverage up to age 26.

Why should any of this matter to Pennsylvanians who don't have kids? Because we all benefit, financially and otherwise, when children are healthy. Healthy kids grow up to be healthy adults. Families are less likely to put off medical care for their children and run the risk of needing more costly and complicated medical treatments later.

Fortunately, Governor Tom Corbett has embraced a critical aspect of the ACA that state lawmakers should support, too. The state is moving ahead with plans to create a health insurance exchange, a user-friendly, online insurance marketplace that will enable all families with children to obtain and maintain high-quality health insurance in a streamlined way.

If we do it right, Pennsylvania's exchange will allow children to have access to the behavioral and physical health benefits they need to be healthy. The governor and General Assembly should enact necessary legislation this spring to get the exchange up and running. The commonwealth has been a national leader in providing affordable, accessible, quality health care coverage for children through Medicaid, CHIP and Cover All Kids -- efforts that have been supported by governors and lawmakers of both parties for over two decades.

The ACA helps us build on those efforts, and it does so at a critical time when we have seen children's access to health care jeopardized through shortsighted policies at the state level.

By Anna Strong, Arkansas Advocates for Children and Families

Arkansas Advocates for Children and Families recently published an update on our state's efforts to ensure that all children have health coverage.  The best news in "Crossing the Finish Line:  Cutting the Red Tape in 2011" is that, despite a recession and an increasing child poverty rate (currently over 26 percent in Arkansas), our rate of uninsured children fell to just 7.3 percent in 2010. ARKids First, our CHIP program, has kept children covered through families' job losses or dropped coverage.  New and better data from the American Community Survey allows us take a closer look at our state's 54,000 uninsured children and will guide further efforts to help Arkansas cross the finish line. 

We know children in families just above the income threshold for ARKids First have the hardest time getting coverage. Over 10 percent of children from 200-250 percent FPL are uninsured.  Arkansas lawmakers passed a bill in 2009 to extend ARKids First to this group, but budget constraints during the recession postponed implementation. 

             Percent of Arkansas Children Under 19 Who are Uninsured, by Income

Source:  Unpublished runs from the Annie E. Casey foundation for Children Under Age 19

The data has also shown us that the northwest corner of the state, typically regarded as a wealthier area, actually has the highest rate of uninsured children in Arkansas.  Up to 11 percent of children in some counties in that region are uninsured. 

We are doing a great job of covering young children. Only 4 percent of children under 6 are uninsured.  But our school-age youth, especially 18-year-olds, don't seem to stay covered as they age out of early childhood programs that require physical exams that can be covered by ARKids First.  A child's race matters, too.  For children eligible for ARKids First based on income, Hispanic children are disproportionately uninsured at 14.3 percent.  The following graph shows, however, that we do a much better job of covering African-American and White children. 

Percent of Uninsured Children under 200% of FPL within Racial/Ethnic Groups

Source:  Unpublished runs from the Annie E. Casey foundation for Children Under Age 19

Data from state agencies tells us that access to care is extremely important.  In many counties in Arkansas, some children on ARKids First and Medicaid do not have the required primary care physician on record, evidencing the struggle to find regular, consistent access to a provider.  We also know that thousands of children - 28,000 in 2010 - fall off ARKids First each year for reasons other than eligibility.  Act 771 was passed in 2011 to help reduce the red tape in ARKids First through Express Lane enrollment through other programs, paperless renewals, and 12-month continuous coverage.  This legislation, as well, has yet to be implemented. 

As the third anniversary of CHIPRA has come and gone, and more of health reform's promises emerge on the horizon, we've reflected on how we can do a better job of crossing the finish line here in Arkansas. Of course we want to do the obvious - implement existing legislation that will help families get covered and protect Medicaid funding in tough economic times.  But this data gives us direction for delving into policy issues to cover our uninsured children. 

For example, Arkansas could take advantage of the ICHIA option in CHIPRA, which allows states to cover lawfully-residing immigrant children before the current five-year wait.  This will help cover the growing Hispanic population as well as Arkansas's sizable Marshallese community that resides in the northwest part of the state.  Under a special compact, people born in the Marshall Islands are technically "non-immigrants" who can live and work in our country but have no option to become U.S. citizens.  The ICHIA option would allow their children coverage for the first time. 

Using the state's Coordinated School Health program and school-based health centers to reach the 9% of school-age children who are uninsured is another sensible way to cover more kids.  And with health reform, it's key that AR's federally-facilitated "partnership" exchange works for families in complex coverage situations and that outreach programs reach uninsured Arkansans. 

We have the data and the tools at our fingertips.  It's time we take the final steps to cover all children and families in Arkansas.

Gene Lewit,  The David and Lucile Packard Foundation

Living in Silicon Valley, I am used to reading about new tech wonders every day. In fact, today, we use the internet to do many things we used to do in person, by snailmail or on the telephone. This trend is encouraged by new technology, but has gained popularity because it is often less expensive and more convenient than traditional methods. So, it's not surprising that states are increasingly using the internet to enroll, and sometimes re-enroll, children and families in their Medicaid and Children's Health Insurance Programs (CHIP).  A recent survey  by the Kaiser Family Foundation and Georgetown University's Center for Children and Families found that as of January 2012, 34 Medicaid programs and 30 separate CHIP programs allow for electronically- submitted applications for children and sometimes their parents as well.

California, the home of Silicon Valley, started providing a public access online application option, known as Healthy-e-Application Public Access (HeA PA), for its Medicaid (MediCal) and CHIP (Healthy Families) programs for children and pregnant women in December 2010. Previously, families could only apply for these programs using a paper application or with the help of application assistors and county employees who had exclusive access to HeA and/or One-e-App, an electronic application for a variety of public benefit programs. The positive change HeA PA has made in families' ability to enroll their eligible children in MediCal and Healthy Families is reported in Healthy-E-Application Public Access:  A New Online Path to Children's Health Care Coverage in California, An Overview of the First Year, released on March 5th by Mathematica Policy Research.  This report is the first in a series of reports that will examine the impact, functionality and user experience associated with the new online enrollment route.  The work is supported by the David and Lucile Packard Foundation and the California HealthCare Foundation in partnership with California's Managed Risk Medical Insurance Board.

The current report provides some encouraging information about the potential impact of HeA PA and other online application tools. One piece of good news is that the use of HeA PA was associated with a 14% increase in total applications submitted to the state processing center from 2010 to 2011.  About a quarter of HeA PA applications were submitted outside of regular business hours, which suggests convenience is important in the application process and the use of HeA PA. HeA PA applications were also more likely to be complete, including required documentation, than paper applications but less likely to be complete than assisted online applications.

But the report also raises a number of questions and caveats to be considered as we look for technological solutions to the challenges we face enrolling children and their families in these programs. For example, more than 4,000 HeA PA applications were submitted in the first full month it was available, but before there was an active outreach campaign. This is especially surprising since HeA PA was released at the end of 2010 during the holidays, with very little fanfare. However, the number of HeA PA applications remained at around the same level for the rest of the year, despite an outreach campaign launched in July. These findings suggest that while there may be a demand for online public access applications, that demand may be limited. 

Another interesting finding is the large variation in the use of HeA PA by county. The share of applications accounted for by HeA PA by county ranged from 0 to 48 percent and both heavily-populated urban and sparsely populated rural counties were present at both ends of the range. We need more research to better understand this variation and what it means for the impact HeA PA and other online application systems might have.

The Patient Protection and Affordable Care Act (ACA) calls for states to have enrollment portal systems that provide a high-quality customer experience, reach a high degree of online use, and maximize self service for people applying for health insurance coverage through Medicaid, CHIP or a health insurance exchange. We can learn a lot from the experience of the first year of HeA PA as California, along with other states, strive to implement the consumer-friendly online experience the ACA envisions.  The HeA PA data, and common sense, caution however that we will continue to need to accommodate people who prefer paper applications and/or personal assistance.

We have long been fans of the enormous success that Louisiana has had in improving retention among children in Medicaid and CHIP through administrative renewals and ex parte. I mean, really, who wouldn't be wowed by the fact that just 1% of children lose coverage at renewal for procedural reasons! Not to mention the low, low error rate of 1.5% -- far below the national average of 6.7%. A sought-after combo if there ever was one.

Well, a new study from our friends at the Urban Institute highlights another combo that shows just why Louisiana continues to be a shining star in the Medicaid and CHIP world. This time, because of its success deploying Express Lane Eligibility (ELE), the state is enrolling more kids and saving administrative dollars.

While I'm a big enthusiast for digging into the process behind such things, I'm going to skip that part (it is in the report for folks who are interested) to cut to the chase and talk about outcomes.

More than 10,000 children had Medicaid cases activated in February 2010 and by December of that year, more than 20,000 children had been sent Medicaid cards through ELE. More than half of these kids (54%) formally enrolled in coverage by using their cards to access care. By November 2010, the state was also renewing coverage through ELE - accounting for about 38% of renewals over the next year.

While some of these children may have enrolled in coverage anyways (such as when they needed health care), some of their characteristics certainly suggest that others may not have. For example, 74% of the kids enrolled through ELE were over the age of 7, compared to 57% of the non-ELE enrolled population. ELE also seemed reached kids in corners of the state where there were the greatest number of uninsured.

I'm sure a question going through your mind is how much did this fancy new endeavor cost? It took about $600,000 to get the project off the ground, with more than 90% covered by a grant from RWJF through the MaxEnroll project. But the return on investment was pretty substantial.

Compared to a typical application process costing $116, ELE-processed apps cost between $12 and $16. If all the kids who were enrolled through ELE had applied through the regular process, it would have cost at least $1 million to sign them up for coverage.

The savings at renewal were even greater. A manual renewal would set the program back $76 and one capitalizing on the state's well-known use of data matches would cost about $51 per child. Under ELE, Louisiana would automatically deem SNAP recipients income-eligible for Medicaid at really no cost. Just in the first year alone, this streamlining approach saved between $8 and $12 million.

Importantly those in the state have been happy with the results - outreach workers believe that ELE has made a difference in enrolling eligible, but uninsured children who hadn't been reached through other means and families received coverage they valued.

Other states have followed suit, with 8 additional states having taking advantage of ELE to enroll or renew coverage for tens of thousands of eligible, low-income children. Will your state be next?

Our Say Ahhh! audience is certainly aware of the benefits of implementing continuous coverage, namely, how it can improve health outcomes for beneficiaries while also decreasing administrative and utilization costs.  As of January 1, 2012, 28 states offer 12-month continuous eligibility in their CHIP programs (23 in Medicaid).  Alabama is one of those states, and is the subject of a study that recently appeared in "Clinical Pediatricians".  This study focuses on children with chronic asthma in Alabama's CHIP program, "ALL Kids," and furthers the case for the states that haven't yet chosen to take up the continuous coverage option.

      In order to examine the utilization of asthma-related care and its associated costs, the researchers identified CHIP enrollees with persistent asthma who were continuously enrolled in ALL Kids for at least three years between 1998 and 2009.  Matching billing codes for treatment or prescriptions that met the definition of asthma used by the Healthcare Effectiveness Data and Information Set (HEDIS), 1,954 children with persistent asthma were identified for the study.

      Controlling for age, gender and calendar year of enrollment, the findings show an overall decline in utilization of asthma related care in subsequent years of enrollment, when compared to the first year of enrollment. In addition, costs - which were adjusted for inflation and included any required CHIP payments - also decreased when compared between the first and subsequent years. 

      The particular areas where utilization of services and medication subsided were hospitalizations, emergency visits, outpatient visits, and both quick relief and long-term control prescriptions. The decline in asthma related emergency visits experienced the most marked improvement, declining seven percentage points between the first (10%) and second year (3%) and continued to decline to 2% in the third year. Asthma related hospitalizations also decreased from 6% in the first year to 2% in the second year, where they remained constant in the third year. Outpatient visits also diminished from an average of 1.46 visits a year, to 1.12 in the second year and less than one in the third (0.94). In terms of medication, those prescribed for long-term control dwindled from an average of 5.8 in the first year to 4.4 in the third year.  Quick relief prescriptions experienced a smaller decline in utilization from an average of 2.6 prescriptions in the first year to 2.1 in the third year. 

      So what kind of savings do these decreases in care utilization amount to?  Total costs for all asthma related care dropped from an average of $1,395 in the first year, to $1,281 in the second year, and $1,134 in the third year, an average savings of $261 dollars. Inpatient services experienced the biggest dollar decline in services, saving $207 over three years. In regard to medications, average costs for long-term control prescriptions had bigger savings than average costs for quick-relief medications, $115 vs. $14.

      Researchers suggest that the decrease in care utilization, and consequently costs, may be due to families having regular access to outpatient services which allow them to be better educated about their asthma, and allow for better self-management of the disease.

      This study illustrates the impact that having access to a usual source of care can have on treating chronic asthma, which according to the study is one of the most prevalent chronic diseases experienced by children in the U.S. In addition, it has implications for how children with other chronic health conditions stand to benefit from access to continuous care.

NPR reporter Nina Totenberg tells the story of how Supreme Court Justice William J. Brennan briefly met her sister the day she learned she was pregnant.  He got caught up in the excitement and eight months later, remembered the news and asked Nina about her sister's due date.  When he learned that Nina's new niece, Clara, was already two weeks old, he quickly sent off a letter enthusiastically welcoming the newborn to the world adding:  "It's a wonderful world if you will just make it so."

In sending baby gifts to friends and relatives, I have often paraphrased Justice Brennan's quote as it so aptly captures my feelings about all the hope and promise a newborn brings to the world.  We need to welcome children to the world with open arms and help them thrive so they will have every opportunity to reach their full potential and help make the world a better place. 

One very important way we can welcome newborns to the world is to make sure they have the health care they need.  In fact, we should start the welcome wagon even before the "little bundles of joy" arrive through good prenatal care for their mothers to ensure they have the healthiest start in life possible.

That's why I'm so excited about the partnership announced today by the Centers for Medicare and Medicaid Services (CMS) and "Text4Baby".  The goal is to reach out to uninsured mothers-to-be and new mothers to connect them and their children with affordable health care coverage and free texts on important health care topics.  When about two-thirds of uninsured children are eligible but unenrolled in Medicaid or the Children's Health Insurance Plan, it's a strong signal that we need to do more to help connect kids with affordable coverage and this  partnership will help achieve that goal. Mom's Rising is doing it's part by hosting a blog carnival today to help spread the word about affordable coverage options for pregnant women and children.  What a warm welcome to the world for all the babies who will get the healthy start they need because of this initiative. 

In the spirit of Justice Brennan, let's make sure every mother has what she needs to help her children thrive and make the world a better place.

In the last year, we've examined the potential impact of proposed premium changes in Florida  and Wisconsin, but a new study in Health Affairs provides some real-world data on what actually happens when premiums rise (not that we in any way condone experiments in children's coverage of this sort).

Healthy Kids in Los Angeles County is one of a number of county-run programs in California that were designed to expand coverage to children who are not eligible for Medicaid or CHIP. While successful in improving access to care for kids, securing dedicated funding has been a challenge. As a result, in 2008, the program closed to new enrollees between the ages of 6 and 18 and in July of 2010, premiums were increased to $15/child for the older kids that remained in the program.

Before the premium increases, retention rates among these older kids were high, averaging 98%. However, after the increase, the retention rate dropped 5 percentage points, mostly in the first two months. At the end of the study, 59% of those enrolled in June of 2010 were still enrolled, as opposed to the 80% expected without the premium increase. Meaning, that 4,441 (or 20%) fewer children were enrolled in the program as a result of the increase. 

These data confirm what our prior research suggested - that for many low-income families, even modest increases to premium amounts can lead them to drop coverage as they struggle to meet other, often competing, demands on their limited resources.

Say Ahhh! readers should know about an important new data source on Children with Special Health Care Needs (CSHCN); the 2009/10 National Survey of Children with Special Health Care Needs. This is the third survey in this series, which is funded by the Maternal and Child Health Bureau (MCHB) and conducted by the National Center for Health Statistics. Using the Browse the Data section, one can easily access national and state level data.

The new estimates reveal a rise in the number of children aged 0-17 in the U.S. who are considered to have special health care needs, from 14% or 11.2 million in 2005/2006, to 15.1 percent or 11.2 million children in 2009/2010.  You can also compare data within subgroups, such as age or sex. The 2009/10 findings show that boys are more likely to be classified as girls (17.4 vs. 12.7 percent) as are children aged 12-17 over those aged 0-5 (18.4 v 9.3 percent).

There are some great statistics on health insurance coverage and program participation, which can be of great use to our Say Ahh readers!  It includes three indicators: CSHCN without insurance at some point during the year, CSHCN without insurance at the time of the survey, and currently insured CSHCN whose insurance is inadequate. In addition, you can filter health insurance coverage by type, and find the percentage of CSHCN that have access to necessary services. 

The insurance data underscores the integral role of public health insurance coverage for CSHCN, which CCF has highlighted in the past.  On average, 36 percent of CSHCN are covered only by public insurance; however, estimates range from a high of 49 percent in the District of Columbia to a low of 38 percent in Montana. Moreover, CSHCN with public insurance are more likely to have adequate insurance coverage (69.4 percent), than those with private only (64.3 percent), or a combination of public and private (64.1 percent).

In addition to health insurance figures, this source provides a wealth of other information pertinent to advocates of CSHCN.  The survey questions, which were asked of parents with CSHCN, are based on six core outcome that are essential to promoting the development of CSHCN: 1) Families are partners in decision making; 2) Coordinated, ongoing, comprehensive care within a medical home, 3) Adequate insurance to cover needed services; 4) Early and continuous screening for special health care needs; 5) Community-based service systems are organized for ease of use 6) CSHCN youth receive services needed for transition to adulthood. You can either browse data on each of these outcomes, or access data briefs here.

If you aren't sure how you can use the data, take a peak at reports and issues briefs that other states have published, using the data.

Find some fast facts on the survey background and methodology here.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.