The District is #1!!! – Say Ahhh! A Children’s Health Policy Blog


By Julie Hudman, PhD,  Director, Department of Health Care Finance, District of Columbia

And no, it isn’t #1 in murders, infant mortality, or a
high concentration of policy wonks. It is #1 in enrolling and keeping children
enrolled in Medicaid and CHIP.  A Health Affairs article by Dr, Jenny Kenney and others found that the District’s
Medicaid/CHIP participation rate for children is 95.4% compared to the national
average of 81.8%. The District’s high participation rate for children is the
main factor in the District being #2 (right behind Massachusetts) in uninsured
kids – only 3.2% of the District’s children lack coverage.

There are many good research reports (some I’ve read
about right here on Say Ahhh!) on what states need to do to help kids get into
coverage for which they are eligible. 
The District has implemented many of those proposed policies (no asset
tests, no procedural differences between Medicaid and CHIP, and 12-month
continuous eligibility) but some key ones we have not (on-line enrollment and
eliminating unnecessary documentation). 
We are working towards further simplification but are not quite there

So, why is the District the best in the county in
enrolling eligible children into public programs? Dr. Kenney and her colleagues at the Urban Institute list possible reasons why they found wide variation among states including population
density, per capita income, political culture as well as policy decisions such
as eligibility thresholds for families and retention efforts.  I think there is a lot of truth in the
possible reasons they lay out for differences in participation.  Here are the three key reasons for the
District’s success in getting kids covered:

  1. Policy and Program Choices Are Paramount – While we
    still have some simplification changes to make, the District has managed to put
    many policies in place that facilitate enrollment. I believe the two most
    important policies are expansive eligibility and no financial barriers.

  • Eligibility.
    Due in part to the high cost of living, the District covers children (and
    pregnant women) up to 300% FPL through a Medicaid expansion using its CHIP
    program. And, maybe more importantly, everyone under 200% is eligible for
    public coverage including parents, childless adults, and undocumented
    residents.   We utilize
    Medicaid wherever we can – and just became the 2nd “state” in the country to take
    advantage of the ACA provision to allow us to cover everyone under 133%.
    Anyone, including those unable to prove citizenship status, are in our
    look-alike locally-funded Alliance program. Heck – we even put undocumented
    kids into our Medicaid program (with local dollars of course) so they can have
    a chance to grow and thrive with access to need care provided by
    Medicaid’s  EPSDT and benefit
    package. Providing access to such crucial coverage and covering parents and
    undocumented residents allows for us to help whole families at a time.  We also have a “no wrong door” approach
    – come in for food stamps, housing, cash assistance or whatever benefit you
    need, and you will be screened for Medicaid or the Alliance program.
  • No Financial Barriers. In our Medicaid/CHIP and Alliance
    programs, we have no premiums, no enrollment fees, and no cost-sharing.  Families have no reason NOT to enroll
    the entire family into coverage – and the whole family can be together in the same
    health plan.  Research shows that
    financial barriers cause folks to delay or not enroll in coverage – that’s why
    we got rid of those barriers here in the District.

2. Political Culture Does Matter. I hate to use the six letter word “stigma” but research and my personal experience suggests that it is alive and well in some parts of the country.  I grew up in Oklahoma, but have lived and worked in DC, Baltimore, Boston and upstate New York.  How Oklahoma residents feel/think about government services is fundamentally different than these other places (and the OK participation rates for kids are lower than these other places). I don’t blame the people – I blame many of the leaders who set up and talk about the programs in a way that discourages people from participating in public programs..  Here in the District , leaders try to make people feel welcome and encourage them to come in and get the coverage that they need and qualify for.

3.  Location, location, location – Ok this isn’t the same as when you are buying a house, but location and geography matters. The District of Columbia is 61 square miles of an urban-concentrated area with more than 600,000 residents – over a third of whom rely upon our public programs.  Families, providers and eligibility offices are within close proximity to each other and near a good public transportation system.  The District also has an amazing network of community health centers. They are the main place folks go to get care – and they are very efficient in enrolling children into our programs (financial incentives work – they want to get paid!).  They really operate as our main outreach network –families trust them, visit them and they in turn help connect children with coverage. 

While we would all like to focus on how to get kids into coverage, this is a tremendously challenging time for state health programs and the leaders that run them.  States are facing tough budget times — going on at least three years now. According to the Kaiser Commission, Medicaid grew 8.8% in FY10 (mainly from caseload increases), and over two-thirds of states anticipate Medicaid budget shortfalls for FY11.  At the same time, states are faced with the huge, but exciting, challenge of implementing the Patient Protection and Affordable Care Act. Many state Medicaid agencies, including mine, are taking the lead on health care reform by expanding Medicaid coverage and developing the health insurance exchange.

The leadership in many states will change due to next Tuesday’s elections. Thirty-seven states are having governors’ races – and in 25 of them, the incumbent is term-limited and not running.  Here in the District, my boss, Mayor Adrian Fenty, lost his primary race and both Fenty and I will be leaving District government by January.  And on top of it, elected leaders in many states are spending their time throwing roadblocks in the way of health reform rather than rolling up their sleeves and making sure their constituents are able to fully benefit from the new law. 

But as things settle down, the economy improves and new leadership takes the helm, states should re-focus on the important business of implementing health reform – and if we can’t figure out how to get people into public programs that they are eligible for (the individual responsibility requirement and exchange will help), health care reform won’t achieve its full potential. But most importantly, millions of children won’t have access to the crucial coverage  that Medicaid and CHIP offer – enabling them to live healthy lives.  That is why we care and why we must succeed.

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