Say Ahhh! A Children's Health Policy Blog

CCF Coming to a City Near You

2010-03-10T15:51:18Z

CCF is hitting the road! We've scheduled four meetings around the country to bring together child and family health advocates to discuss opportunities and challenges for moving forward on coverage.

Our first meeting, for the Southern region, took place last week in Tampa, Florida and despite how difficult it is to hold a health conference with the uncertainty surrounding health reform, it went very well. But you don't have to take my word for it -- Michele Johnson of the Tennessee Justice Center blogged about her experience at the meeting. You can also find the presentations and materials from the meeting on our website.

Next week, we'll be in Providence, Rhode Island for the Northeast region conference and April will find us in Salt Lake City, Utah, for the West and Cleveland, Ohio, for the Midwest meetings. It's a great opportunity to meet with your neighbors to discuss what's working in their states. If you can't make it when we visit a state near you, check the CCF website for materials and related resources.

CCF's Regional Meeting - Just What the Dr. Ordered

2010-03-10T11:42:32Z

By Michele Johnson

Managing Attorney and Co-Founder, Tennessee Justice Center

The Southern Regional Meeting of Transforming Health Care Coverage for Children and Families was just what the doctor ordered. For anyone feeling down about health reform or frustrated with the status quo, you need to attend this meeting! The technical information about the health care bill, the messaging workshop and success stories from other southern states were so valuable and hopeful.

The messaging workshop put on by Ed Walz from Spitfire Strategies was full of practical tips about how to be heard by policymakers and the public. Ed, always entertaining and compelling, gave us the recipe for communicating effectively. Among other things, he taught us how to write effective blog articles (like this one, I hope!), letters-to-the-editor, and blast emails. By day's end, I not only felt like I could do it, but we had actually done it in hands-on activities.

The presentations about both the nitty-gritty of the health reform bill and the opportunities of CHIPRA were extraordinary. They contained crucial data about the demographics of the eligible but uninsured children who are waiting for us to reach them now. They laid out who will be helped by reform and how. What useful tools to have at our fingertips as we try to raise resources to reach these children! The health reform waiting game has seemed paralyzing in so many ways, but these presentations gave me a "to do list" of practical and immediate steps to enroll children and keep them enrolled.

My favorite part of the conference was seeing and hearing about the experiences of my southern sister states. I heard from friends, old and new, about the challenges they are facing and overcoming. Sometimes working for health care for children in the South can be isolating and demoralizing, so hearing from others facing similar hurdles was moving. Amazing work is going on in our region! I left the conference reminded of Anne Frank's quote "How wonderful that nobody need wait a single moment before starting to improve"...healthcare for children in the South!

Thanks, Georgetown Center for Children and Families and partner organizations for using your extraordinary talents to improve policies every single day for children in Tennessee and all over America.

Editor's Note: Say Ahhh! readers aren't fooled by Michele's modesty as we've seen some great blogs out of her before. With all the nice things she's saying about CCF and our friends, we just might have to make her a regular.

Should we be adding people to Medicaid?

2010-03-09T21:01:11Z

A recent subtext in the debate on health care reform has been about Medicaid's alleged failure to provide its enrollees with access to care - the argument goes that the parents and childless adults who would be added to Medicaid as a result of leading proposals would mean that 15-18 million people would be dumped into coverage where they wouldn't be able to see a doctor. As often is the case in Washington, the facts are considerably more nuanced than the talking points.

First, research is very clear that Medicaid has increased access to care and reduced unmet health needs for both children and adults. In fact, in terms of primary and preventive care, access to care in Medicaid is approximately equivalent to that in private insurance. Access to care issues in Medicaid are more likely to arise in certain specialties (most notably such as access to dentist care) and in certain geographic areas and they most certainly exist. But having Medicaid has been critical in improving low-income children's access to needed care.

We're all aware (perhaps from our own experience of trying to find a doctor who will take our insurance) that having an insurance card does not necessarily ensure access to care. I have virtually given up finding an internist that will take my Georgetown University Blue Cross plan. Doctors and hospitals pick and choose which insurance plans they'll take. A recent Center for Studying Health System Change survey asked physicians whether or not they were accepting new patients. Their answers varied by patient insurance type:

Yes, there are more doctors who are not accepting any new Medicaid patients, compared with those accepting new patients covered by Medicare or private insurance. But overall, more than 70% of doctors are accepting at least some new patients covered by Medicaid.

Part of the issue with the slightly lower physician participation in Medicaid could have to do with lower reimbursement rates, which are about 72% of those paid in Medicare (and these rates are supposedly lower than private rates, but a true comparison is tough since that information is deemed "proprietary").

Now, people may legitimately say that adding an additional 15-18 million people to the program is likely to exacerbate access problems. It is true that adding that many people into the system requires consideration of the program's capacity to provide the care people will need. The most obvious solution -- an increase in reimbursement rates.

And there may be hope on the horizon for just such a solution. Following the health reform summit, the President has appeared to embrace this idea. The House included a provision in its health reform bill for a phased-in increase in Medicaid reimbursement rates and it also seems to have bipartisan support (Sen. Grassley (R-IA) raised it as an issue at the summit).

Medicaid has been instrumental in meeting the health needs of millions of children and families, and through health reform, the program would be expanded to meet the needs of millions more. So let's think about how to do that most effectively, but let's not use the access challenges, which happen in private and public coverage alike, to become an excuse not to do meaningful reform.

Thanks to Martha Heberlein for helping with the research for this entry.

Monday Morning.... Where Are We?

2010-03-08T16:53:33Z

Having just survived a truly impressive tantrum this morning from one of my sons who was deeply committed to going to school this morning without shoes, I'm feeling primed for what promises to be a raucous final stage of the health reform debate.

As far as we know, Congress is still proceeding with the plan of the House passing the Senate health reform bill (with many members kicking and screaming as vigorously as my son this morning), then the House and the Senate passing a smaller reconciliation package designed to improve the Senate bill and make it more palatable to House members. I just hope we get through the week without anyone throwing shoes at an authority figure (at home or in Congress).

This week, RollCall reports that by the end of the week we may see the actual legislative language of the reconciliation bill and a CBO score, allowing us to fill in final details of what health reform might look like. The White House continues to press for a final vote in mid-to-late March.

In the meantime, everyone is digging deeper on the arcane rules of budget reconciliation. Our friends at CBPP have shared the gory details before, but the question of the day seems to be whether using reconciliation actually allows health reform proponents to proceed with a straight up-or-down vote. The issue has flared up because there is a 20-hour limit on debate over a reconciliation bill, but the rules may allow opponents of health reform to offer an endless series of amendments OUTSIDE of the 20 hours of debate. If they take this route, Senate leaders will need to decide whether to call in Vice President Biden to declare the string of amendments "dilatory" and to dismiss them.

Also, this week we'll be tracking where things are heading with a 6-month extension of Medicaid fiscal relief, which has enormous implications for the capacity of states to continue to sustain and strengthen their gains for kids and families. The Medicaid fiscal relief is included in a jobs bill making its way through the Senate right now. To make things confusing, the term "jobs bill" has been used to describe three separate bills currently in motion: 1) a $17.6 billion package that mostly creates a tax credit for companies that hire unemployed people; 2) a short-term extension of unemployment insurance, COBRA and a few other items through end of March/early April (this is the one that Senator Bunning single-handedly held up on the Senate floor last week); and 3) a much bigger extension through December 31, 2010 of unemployment insurance, COBRA, and a few other items.

It is this THIRD so-called "jobs bill" that includes a 6-month extension of Medicaid fiscal relief from December 31, 2010 through June 30, 2011. Congress Daily reports that the jobs bill (the third one) will be up on the Senate floor this week, and then it will need to go to the House for action. The House already has twice passed an extension of Medicaid fiscal relief in other bills and President Obama supports it, which means the prospects for passage are bright if it makes it through the Senate.

An Update on State Fiscal Relief: Momentum is Building

2010-03-04T16:44:37Z

The pressure to extend the temporary increase in the federal medical assistance percentage (FMAP) for Medicaid included in last year's stimulus bill is building. Widely credited with helping states through one of the worst fiscal crises on record, the provision also has been vital in stabilizing Medicaid coverage for children and others in families facing job loss. Currently, the provision is slated to expire December 31, 2010, right in the middle of most states' fiscal year. With most state legislatures in session right now trying to craft next year's budgets, they are looking for some assurances that the federal government will continue the extra help with Medicaid.

It looks increasingly likely that the nation's lawmakers may adopt an extension. In December of 2009, the House of Representatives passed a six-month extension that would provide states with fiscal relief through June 2011, which coincides with the end of most states' fiscal years. President Obama included the same proposal in his budget in February.

Now the Senate, which has been the most skittish on the issue, is planning to take the extension up as part of a larger jobs bill. On Monday, Senate Majority Leader Reid and Senate Finance Committee Chairman Baucus included the 6-month extension in a jobs bill. This bill also continues COBRA benefits and unemployment insurance through the end of the calendar year. (And, nope, this isn't the same jobs bill that Senator Bunning of Kentucky has been holding up on the Senate floor. The bill that caused Senator Bunning to miss the Kentucky-South Carolina game extended COBRA subsidies and unemployment insurance only for a few more weeks and does not include an extension of Medicaid fiscal relief.)

Outside the Beltway, a bipartisan group of 42 Governors of states and five Governors of U.S. territories have signed a letter in support of the FMAP extension. They state that "the length and depth of the recession means states and territories will continue to face significant budget shortfalls long after the enhanced FMAP provisions expire at the end of this calendar year."

As in the past, Congress expects states to hold steady on their Medicaid eligibility levels and enrollment procedures in exchange for the extra federal help. One new twist to the "maintenance-of-effort" provision may be the addition in the Senate of a requirement designed to prevent Governors from having their cake and eating it too. Stung by criticism of the stimulus bill last year by Governors who willingly accepted the federal dollars, the amendment will likely require Governors (or possibly State Legislatures) to specifically request the additional help from the federal government.

With unemployment benefits and COBRA subsidies now expected to expire at the end of March/early April, there will be pressure for Congress to act again quickly. This time, it looks more likely that Congress will include an extension of the FMAP if it can find its way forward on the next jobs bill.

President Obama: It's Time to Bring this Journey to an End

2010-03-03T20:54:37Z

Following last week's health care summit and release of his health care reform proposal, the President today urged Congress to end the debate and bring health reform across the finish line. In his remarks, the President painted a vivid picture of what it means to not pass health reform, including more uninsured families, additional people denied coverage because they are sick, and skyrocketing premiums. Yesterday, we reported on what doing nothing would mean to families.

The Proposal

The President did not release a revised health care proposal but said he will incorporate at least two Republican ideas brought forward at the health care summit. This includes sending in "secret shoppers" to Medicare and Medicaid providers to combat fraud and abuse (an idea offered by Sen. Coburn) and providing a funding appropriation of $50 million in state demonstration grants to find alternatives to resolving medical malpractice disputes (similar proposals have been included in Republican bills).

On Tuesday, the President also sent a letter to congressional leaders outlining two other ideas that he is willing to consider for inclusion. One idea was suggested by Sen. Barrasso to allow the Health Savings Accounts (HSAs) in the Exchange.

The other idea (which was initially raised by Sen. Grassley at the summit) would address what the President acknowledged are "inadequate" reimbursement rates in Medicaid. Improving doctor reimbursement would help increase access to care for the millions of new families entering Medicaid under health reform. As you may recall, the House bill already includes a phased-in increase in Medicaid reimbursement rates (tied to those offered in Medicare) for primary care services, with the federal government picking up the tab for most of the increased costs. It is not evident whether this or a similar provision will ultimately make it into a bill but the President's recognition of the issue is a positive sign.

We expect legislative language soon and will provide more details then.

Timing/Process

President Obama said the time for discussion is over and that he wants an "up or down" vote scheduled within the next couple of weeks. Media reports suggest that Democratic leaders are indeed leaning toward going the reconciliation route. In the world of congressional rules, this means that the House would first pass the Senate health bill for the President's signature, followed by both chambers passing, through a simple majority vote, a second bill containing the various "fixes." Reports have continued to cite a middle to end of March timeline.

White House Health Reform Announcement Expected @ 1:45 p.m.

2010-03-03T17:10:39Z

President Obama is expected to make his much anticipated health reform announcement at 1:45 pm today in the East Room of the White House. He will be flanked by HHS Secretary Sebelius and health care professionals. He is expected to encourage Congress to move forward swiftly. Say Ahhh! bloggers will share our perspectives following the event.

What If Health Reform Efforts Fail?

2010-03-01T19:22:48Z

As leaders in Washington debate the future of a plan to get our nation's arms around the colossal health care system, it's worthwhile to take a look at how things would be different today if some past health reform efforts had succeeded.

What if ... President Nixon's plan had passed before he left office? According to The Commonwealth Fund, if President Nixon's plan had passed, the United States might be spending a trillion dollars a year less than it does now.

What if....President Clinton's efforts to pass health reform had succeeded? President Clinton's plan would have reduced spending by an estimated $500 billion a year according to The Commonwealth Fund report.

What if ... this latest attempt to get a handle on the health care system doesn't succeed?

Will typical family premiums double in ten years to $24,000 as predicted?
Will the number of uninsured really increase from 49 million today to between 57 million and 66 million by 2019?
Will states struggle to meet the staggering increases in the number of people who must rely on Medicaid and CHIP for affordable coverage?People think if we do nothing, we will have what we have now," said Karen Davis, the president of the Commonwealth Fund in an interview with the New York Times. "In fact, what we will have is a substantial deterioration in what we have."

If Congress and the Administration are unable to find a way to follow-through on health reform this time around, only time will tell how this missed opportunity would impact all of us, our children and our grandchildren. Let's hope they are able to rise to the challenge so future generations won't look back on this moment in history and think to themselves how much better life would be "if only ..."

White House Health Care Summit

2010-02-25T22:30:53Z

5:30 pm Signing off
Thanks for taking the time to follow the health reform summit. At CCF, we're anxious to hear your reaction to the summit and what it means for the prospects of health reform and its impact on children and families. For a transcript of the health reform summit, visit Kaiser health news. Don't forget to check out CCF's fact sheet on President Obama's health care proposal.

5:25 pm Health summit concludes
President Obama wrapped up the summit by saying there seemed to be broad areas where the two sides agreed but they had philosophical difference in approaches. The areas he mentioned were:

1) insurance market reforms (difference on how much or how little to regulate and whether or not to stop discrimination based on pre-existing conditions which hinges on requiring people to obtain coverage).
2) assisting small business owners and those trapped in the individual market (difference on whether or not risk pools would adequately serve people or whether they should be allowed to benefit from being in a larger pool such as an exchange which would bring down costs -- he compared the economic advantage of being in a larger pool to the advantage Walmart has in negotiating prices with consumers compared to small independent stores.)
3) allowing interstate purchase of health care (differences in whether or not to allow them to "race to the bottom" as happened with credit card companies or whether to ensure a baseline of coverage and consumer protection).
4) medical malpractice reform (approaches varied and actual savings questionable).
5) broad areas outlined by Senator Coburn such as eliminating waste, cracking down on fraud, reducing medical errors, encouraging price transparency and improving prevention (which President Obama pointed out were all in his proposal).

President Obama noted that for the first time, more people are getting health care coverage from the government and that it isn't due to actions by Congress or the Administration but due to the fact that employers are shedding health plans and people are losing coverage. He said that now that the public option has been dropped, the debate is no longer about whether or not the bill represents a "takeover of the health care system" but revolves around "how much should we regulate the insurance industry". He described his experiences talking to the parents of uninsured children with conditions such as diabetes and heart conditions and said "they don't want us to wait". He implored opponents of the health reform bill to do some "soul-searching" and decide if they were willing to work to get a bill passed.

4:20 pm Medicaid's role in health reform
The research on how people feel about Medicaid generally shows that they are very pleased to have it, and it has been a big boost to their families. According to a Kaiser Family Foundation study, fully 95% of low-income parents who know about Medicaid/CHIP think they are good programs. In addition, nearly 9 out of 10 with uninsured children say they would enroll them if it was a possibility, and the vast majority would be interested in enrolling along with their child. So, we were a bit surprised to hear Representative Roskam (Ill.) say, "it isn't working for anybody" and shouldn't be used to cover more people because it is a "weak foundation."

As with all kinds of insurance, there are some issues with Medicaid, including that it often doesn't pay providers as much as other public programs (CHIP, Medicare). This is a solvable problem. The House bill addressed the issue by providing federal funding to bring reimbursement rates in Medicaid for primary care services up to Medicare levels. (President Obama acknowledged the problem after Representative Roskam spoke, but, notably, did not include this improvement in his own proposal.)

Finally, we also were a bit surprised to hear President Obama say that very poor people already have coverage through Medicaid, which is superior to the options available to working families. In fact, Medicaid does not cover adults without children, even if they are living in deep poverty (unless they are lucky enough to live in the handful of states with special waivers to do so). And, in most states, parents are not eligible for Medicaid even if they are well below the poverty line. The situation is much better for children. Due to Medicaid expansions for children and the CHIP, children in poor and low-income working families generally can qualify for coverage. The result is that children are far less likely to be uninsured than their parents and other adults.

4:05 pm Barrosso argues for high deductible plans/HSAs
The sharp philosophical differences between the two parties on coverage issues are clearly on display in this final segment of the summit. Senator Barrosso, a surgeon from Wyoming, made a pitch for America providing the best health coverage in the world, citing a Premier of Canada recently deciding to come here for heart surgery. He argued that we could hold down health care costs if people had more information on health care costs and more incentive to be "prudent purchasers," such as provided under high deductible plans or HSAs. President Obama pushed back, arguing that most uninsured people in the United States aren't premiers or sultans and don't have much money with which to fill gaps in their health care coverage.

3:50 pm Moving to the topic of coverage - President's goal to cover 30 million uninsured
They are getting close to wrapping up, and just reaching the topic of coverage. President Obama kicked off the discussion, framing it as: can America, the wealthiest nation on earth, do what every other advanced nation does - make sure that every American has health insurance coverage? Before turning over to Senator Barrasso (Wyo.), President Obama made a pitch for acknowledging the reality that you can't "waive a magic wand" and cover all of these people without it costing some money.

3:25 pm Debate over paying for reform continues
Discussion continues on what health reform would mean for our budget deficits if health reform passes, with Democrats arguing it will help immensely and Republicans taking the opposite position. Some of the most intense debate is over the appropriateness of using cuts to Medicare Advantage to help pay for reform. From a child and family health perspective, this part of the discussion can seem pretty far removed from what matters to kids and families. But, the question of how to pay for health reform, including major expansions in coverage for low-income families, long has been the key reason why it is so hard to enact.

3:00 pm Discussion turns to impact of health care on deficit
Vice President Biden discusses the impact of rising health care costs on the deficit and how we can "bend the cost curve." Representative Paul Ryan (Wisc.) agrees that it is right to frame the debate on high costs and health inflation. However, there is disagreement between the parties on whether the President's bill would reduce deficit (as the CBO as determined).

2:40 pm President says families with insurance already spend up to $1,100 a year on uninsured people
President Obama argues that "independent economists" think families with insurance already spend $1,000 to $1,100 on the cost of providing care to uninsured people. He says that, for example, the uninsured kid with asthma in Senator Coburn's example, might well get care, but that the ER bill would end up being being paid for by families with insurance. Citing this kind of cost-sharing as a reason why an individual mandate or "responsibility" is required, the President admits he's argued against such mandates on the campaign trail and had to be brought "kicking and screaming" to the conclusion that they were necessary.

2:35 pm Even the son of a Rockefeller can be uninsured
Senator Rockefeller (W.Va.) describes how his son, who was old enough to buy insurance on his own, decided that he didn't really need it. Instead, he chose to go without insurance, apparently on the theory that he wouldn't get sick. Senator Rockefeller says that such cases are one reason why the country needs to mandate that people secure coverage (and also that he and his wife insisted that his son buy coverage the next day). To help address the problem that young people often think they don't need coverage -- and also that they often don't yet make enough money to buy it -- one of the reforms included in leading health reform bills is whether to give families the option to add young adults up to age 25 or 26 to their parents' insurance plans.

1:33 pm Quotes to ponder while waiting for summit to reconvene

"You can always get cheaper coverage if it has higher copays, higher deductibles and limited coverage." (President Obama after pointing out that is one thing to get insufficient coverage on a beat-up car but another thing if it's health coverage for a child)

"How do we wring out waste, fraud, abuse and duplication from the system without interfering with the care that we want every person on Medicare, Medicaid and private insurance to receive?" (Sen. Schumer)

"We need a patient-centered, market-based approach." (Sen.Coburn)

"We are trying to give people choice and competition in the private sector but requiring the private sector to operate under a set of rules." (Secretary Sebelius)

12:59 pm Break for lunch/House vote

Morning session consisted of discusions on small business purchasing pools, minimum benefit packages, addressing fraud and abuse in Medicaid and Medicare, buying insurance across states, and insurance market reforms. After lunch will finish insurance reform then move to deficit impact and coverage issues.

11:00 am Senator Coburn says kids can get care through ER; better preventive care needed
Senator Tom Coburn (Okla.) addresses President's remarks on taking his daughters to ER. The Senator believes that children, even if uninsured, can get the care they need for asthma and meningitis by going to the ER. He also suggests that even if they get care in the ER, we don't do a good job preventing acute asthma episodes. On this point, a recent study shows that uninsured children with asthma face barriers to care. However, enrollment in CHIP markedly helps kids get better treatment for asthma and obtain better outcomes.

10:48 am Reid shares story of father with sick child denied coverage
Senate Majority Leader Reid (Nev.) speaks about a restaurant owner in Reno, Nevada whose child was born with a cleft pallet. The insurer denied coverage saying the newborn had a pre-existing condition. He had paid his premiums and thought he had health insurance but now he's stuck with $90,000 in medical bills and his daughter needs additional medical attention.

10:40 am Pelosi touts CHIPRA as early advance for health reform
House Speaker Pelosi (Calif.) says CHIPRA was a running start on expanding access and moves us forward on addressing affordability, accessibility, and accountability.

10:30 am Alexander wants to take step-by-step approach; believes Medicaid unfunded mandate
Senator Lamar Alexander (Tenn.) opens the day to describe the Republican perspective. They believe that the goal should be to reduce health care costs and move step-by-step towards that goal. The bills that have passed the House and Senate are not the way to do it. The country is too big and too diverse for a comprehensive approach to work. With step-by-step as their preferred way to go, he offered suggestions such as medical malpractice reform and buying coverage across state lines as the best way to increase access is to reduce costs. Senator Alexander also describes Medicaid expansion as an "unfunded mandate," as one of the problems they see in the legislation, comparing "dumping" low-income people into a Medicaid program where 50% of doctors don't take patients to buying them a bus ticket for a line that only runs half the time.

For remainder of day, we will not post on what everyone says - but only highlight when issues affecting children and families comes up.

10:20 am President Obama asks what would happen if I didn't have "reliable" health care coverage for my daughters?
In his opening remarks, President Obama ties the need for health reform to the struggling economy. He believes it's critical to look at fundamental problems that are hurting families and businesses, as well as having a profound impact on budgets at both a national and state level. Health care is one of the biggest drags on our economy and one of the biggest hardships that families face. Every American, whether or not he/she has coverage, is affected and the problem is only getting worse.

President Obama describes health care from the perspective of a parent. He remembers well facing the scary situations in which Malia and Sasha became sick and needed immediate health care. He remembers sitting in the ER and thinking "what would happen if I didn't have "reliable" health care coverage."

The President wants the summit to focus not just on the differences, but where Democrats and Republicans agree, because there is significant agreement. As the day looks at lowering costs, ensuring the market works, addressing the long-term deficits, and providing more coverage, he wants to start where there is agreement and then focus on how to bridge the gaps where there isn't.

Thursday, February 24, 10:08 AM

The health reform summit is just underway. President Obama will open the meeting with a brief speech welcoming the attendees and will be followed by introductory remarks from a Republican and a Democratic member (chosen by their colleagues). The remainder of the day will be divided into four sections, focusing on controlling costs, insurance reforms, reducing the deficit, and expanding coverage and is expected to last from 10am to 4pm (with a break for lunch, of course!).

Wednesday, February 23, 2010

President Obama's bipartisan meeting on health reform starts at 10am EST on Thursday, February 25, 2010. Watch it on CSPAN or from the White House live feed. CCF staff - Jocelyn Guyer, Martha Heberlein, Cathy Hope, and Dawn Horner - will post developments from the meeting related to child and family health care issues.

Also make sure to check out CCF's fact sheet on President Obama's health care proposal.

Clawback Provision Brings More Fiscal Relief to States

2010-02-24T19:26:07Z

You know those Old Westerns where the hero rides in at that last minute to save the day. That's what last week's "clawback" reduction announcement must have felt like to many states trying to maintain their Medicaid programs in the wake of increased need and reduced revenues caused by the recession.

The trailer would go something like this:

"State coffers were running dry while residents were struggling to get by. Just when things were looking really grim, Secretary Sebelius and her Medicaid Director Cindy Mann ride into town to save the day."

While the "clawback" sounds like a character from a horror movie rather than the Western motif I'm trying to conjure up, it's really not all that scary. "Clawback" is just the stage name for the monthly payments states send to the federal government to pay a portion of the Medicare Part D prescription drug costs for "dual eligibles" or those people who are eligible for both Medicare and Medicaid. It comes into play in this scenario because HHS decided that the temporary increased federal match rate included in the American Recovery and Reinvestment Act (ARRA) should be applied to clawback payments. Now, states will receive about $4.3 billion in financial relief through a temporary reduction in their payments. This is welcome news to Medicaid Directors, state leaders, health care advocates and all the children, families and individuals who are relying on them for help to get through these tough times.

Meanwhile, back at the corral, HHS Secretary Sebelius encouraged states to use the savings to "continue to provide critical health care services to the nearly 60 million beneficiaries who depend upon it". Some states appear to be heading in that direction already. In Tennessee, which will save about $120 million, the TennCare director said he hopes to use the temporary savings to "mitigate or postpone" recently recommended caps limiting services to adult, nonpregnant enrollees on TennCare, the state's Medicaid program.

This temporary boost should help more states better cope with escalating health care costs, increasing numbers of uninsured residents and declining revenues. It's a brief respite of welcome news but there is certain to be more trouble around the bend if Congress fails to extend the ARRA fiscal relief provisions. Better keep those horses saddled up.

CHIPRA Strengthening Quality of Children's Health Care

2010-02-23T14:21:57Z

Charlie Homer
President and CEO, National Initiative for Children's Healthcare Quality

In this time of agonizing about broad health care reform, I take solace in celebrating the passage of CHIPRA (the Child Health Insurance Program Reauthorization Act) just over a year ago, and focusing on its productive implementation. CHIPRA not only expanded access to health insurance for children, but--as the regular readers of this blog know--included groundbreaking activities to strengthen the QUALITY of care that children who are insured through CHIP or Medicaid receive. These activities included substantial grants to states for demonstration projects (announced just yesterday) funding for an electronic health record that meets the specific needs of children, and two sequential activities around the measurement of quality of children's health care.

The first measurement activity mandated by the CHIPRA legislation was the creation of a "core" measurement set. The legislation called for a tight deadline, mandated the scope of the measures, and specified an inclusive process for selecting the measures. Last summer, the Agency for Healthcare Research and Quality (AHRQ) conducted a thoughtful, broadly inclusive process to create that core measurement set.

The process that AHRQ used is well described on their website. The panel included leaders of state Medicaid and CHIP programs, consumers, pediatricians and family physicians, dentists, and public health professionals. AHRQ contracted with experts to produce background information, too. The committee used a formal consensus process, voting on the validity, feasibility and importance of the measures. It then prioritized measures to make sure the set was balanced (e.g., acute, preventive and chronic care, inpatient and outpatient, and oral health). They recommended 25 measures that were subsequently reviewed by AHRQ's National Advisory Committee and ultimately the Secretary of Health and Human Services. This recommended measurement set is now out for public comment, with responses due by March 1st.

This set includes 13 measures of preventive care, 5 for management of children with acute conditions, 9 of care for children with chronic conditions, 1 of patient experience and 1 of availability.

Most of the preventive measures are relatively simple, emphasizing counting encounters (e.g., number of well child visits, frequency of prenatal care, and number receiving preventive dental care) rather than focusing on the content of the preventive care itself. Preventive content is addressed in assuring documentation of BMI (happily consistent with the current emphasis by the White House on obesity prevention), using standard tools for developmental screening, immunizations, and Chlamydia screening.

Acute care measures address appropriate use of antibiotics, catheter associated blood stream infections in intensive care inpatient settings (the only inpatient measure), counts of those EPSDT eligible children who receive dental treatment and counts of emergency departments visits in a population (presumably an outcome measure assessing prevention and integration of care more than quality of acute care itself).

The most common chronic conditions in childhood are addressed through a simple outcome measure for asthma (number of children over one year old with one or more asthma related emergency room visits), follow up for children on a medication for ADHD, follow up after mental illness hospitalization, and assessment of hemoglobin A1C for children with diabetes.

Rounding out the set, the list includes the CAHPS Health Plan survey including supplemental items for Medicaid and Children with Chronic Conditions and an indicator of access to primary care practitioners.

One can quibble with some of the measures (e.g., the inclusion of children under two in the asthma measure given the difficulty of diagnosis, the accuracy of coding, and effectiveness of treatment in that age group) and lament the generally low bar the measures establish (e.g., counts of visits receiving more emphasis than content). I also believe the committee could have recommended the measurement of the "medical home" through the use of the CAHPS survey rather than defer this measurement to the future.

Congress recognized that any initial measurement set would be inadequate and specified that CMS create a program to develop new measures to address gaps in the core measurement set. Indeed, this week, AHRQ is convening a panel to recommend criteria for the measures under this new program. The committee highlighted gaps in their measurement set, specifically highlighting the need for better measures of mental health and substance abuse service, inpatient and specialty care, duration of enrollment and coverage, medical home, and other means of care integration, and availability of services. We at the National Initiative for Children's Healthcare Quality--working with the National Quality Forum--recently convened an expert group that identified additional gap areas such as care coordination, broader indicators of population health, and special topics such as pediatric palliative care. We anticipate the Secretary will be seeking public comment on which topics the new program should address.

But, overall, for now, rather than critique the current set, it is far more important to commend the committee, AHRQ, CMS, and the Secretary for moving quickly, transparently and yet rigorously to assemble a thoughtful and credible measurement set. We should also urge HHS to move on to establishing effective mechanisms for collecting and reporting these data across all types of care provided in Medicaid and CHIP programs (e.g., fee-for-service and primary care case management as well as managed care), for encouraging universal, standardized reporting (not required under CHIPRA), and for assisting states and delivery organizations in using these data to improve care.

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

President Obama Releases Roadmap to Health Care Reform

2010-02-22T21:06:20Z

Just as Washington is finally thawing out from under all the snow, it seems that health reform was dug out too with the release today of President Obama's health reform proposal. The President's plan sets the stage for the bipartisan health reform summit that the White House is convening on Thursday. In an effort to add more transparency to the legislative process, the meeting will be streamed live. For those of you unable to watch, we'll fill you in via this blog.

In his proposal, the President lays out a clear roadmap of policies that he wants included in a comprehensive health reform bill. The basic framework is the same as leading bills developed in Congress over the past year of debate: insurance market reforms, new health insurance Exchanges and subsidies for those who need help purchasing coverage, an individual mandate to obtain coverage (with exceptions for those at lower incomes and those paying too much in premiums), and a number of health care delivery and access initiatives.

But, the new proposal adds improvements aimed at addressing concerns with the earlier congressional proposals, including provisions to strengthen the affordability of coverage, changes to the structure of the excise tax on high-cost plans, and new authority for the Secretary of HHS to monitor and, if appropriate, address sharp increases in health insurance premiums.

The President's proposal does not include legislative language so we don't have all the "nitty-gritty" details that some of us are eager for. But, here is a quick read on where it lands on the key issues affecting children and families (CCF has also released a fact sheet on the proposal):

Expands Medicaid up to 133% FPL and addresses some of the controversy over the financing of this coverage. The so-called "Cornhusker" fix, which gave Nebraska special help in coping with the new Medicaid costs, was eliminated. Instead, borrowing from both the House and Senate bills, all states would be eligible for a Medicaid matching rate (for those newly-eligible) of 100% for 2014 through 2017, 95% for 2018 and 2019, and 90% in subsequent years.
States that have already expanded Medicaid to adults (up to 100% FPL) would receive a matching rate increase of eight percentage points "on certain health care services".
CHIP would be continued through fiscal year (FY) 2019, with funding through FY 2015. States would receive a 23-percentage point increase in their CHIP match beginning in FY 2016.
Stronger affordability protections (relative to the Senate bill) would be in place so that individuals and families purchasing coverage through the Exchange at 100% FPL would pay no more than 2% of their income and those at 300% up to 400% FPL would pay no more than 9.5%. Cost-sharing assistance would also be provided to families up to 250% of the FPL.
Simplification measures for Medicaid, CHIP, and subsidies including using modified adjusted gross income (as in the House bill), a 5% income disregard for Medicaid eligibility to ensure coordination between the programs, and "seamless enrollment". Medicaid and CHIP individuals would enroll through "streamlined, easy to use, State-by-State websites".

With the release of the President's proposal, health care reform once again takes center stage. Stay tuned as we explore the implications for children and families.

More Families Seeking Health Coverage Than Ever Before: Medicaid Enrollment up by 3.3 Million (60 Percent Children)

2010-02-19T21:16:48Z

In this often-called "unprecedented" economic recession, it is easy to become jaded by the dire statistics thrown our way. This week however, the Kaiser Commission on Medicaid and the Uninsured (KCMU), gave us a positive number to consider: over the last year, 3.3 million more uninsured people (2 million who were children) were able to rely on Medicaid for health coverage. According to KCMU, this was the largest one-year increase in terms of numbers of people in the history of the program. When you think about it, it should come as no surprise. Since most people receive their health coverage through their jobs, the current high unemployment rate equates to millions of families also losing health coverage. Fortunately for these families, they were eligible for Medicaid (or CHIP) and did not have to forgo doctor's visits for themselves or their children.

But unfortunately, at the same time that many more families are seeking a safety valve to help them through these insecure times, states are facing their own economic uncertainties. Decreased revenues coupled with increased demand for services have put a strain on states, with a number considering Medicaid cuts just when families need it the most. A number of states have been able to hold the line due to a temporary increase in their Medicaid matching rate that was included in the stimulus bill. Since a condition of receiving the enhanced match was that states not cut Medicaid eligibility (referred to as a maintenance-of-effort requirement), the funding was critical in ensuring that the growing ranks of families needing Medicaid could obtain that care.

The KCMU report shows however that with the FMAP increase ending December 31, 2010, states are again looking at dramatic enrollment increases that they cannot sustain. As I previously described on this blog, the President's proposed budget includes a six-month expansion of the FMAP increase. There are also legislative proposals to do the same, including the House's inclusion of an extension in its "job's bill". Families USA released a report this week that explains the positive impact the FMAP increase and the maintenance-of-effort requirement has had for families, and what they could lose if it is not extended.

Let's think about that number again: Medicaid enrollment increased by over 3 million individuals. That is a lot of families who are struggling, and it is wonderful that this help is available to them (and hopefully will continue to be). But lets also not forget the millions more who became uninsured but were not eligible for Medicaid or CHIP. We will report next week on the President's health care summit for solutions put forth to address the growing ranks of the uninsured.

Backlogs Put Children's Health Coverage at Risk

2010-02-18T15:07:40Z

By Gary Brunk

President & CEO, Kansas Action for Children

"I just couldn't believe the state would cut personnel on a program that's for kids," commented Harold Stultz to a reporter from the CBS affiliate in Wichita, Kansas.

According to a local television news report, Harold's 12-year-old son Keenan had injured his knee during a wrestling match. Harold believed that Keenan was covered under HealthWave, the state's Medicaid and CHIP program, but was surprised to learn that the application had never been processed because of a backlog.

In fact, Keenan is one of many children in Kansas waiting for health care coverage because the state has not been able to process their applications.

The need for health coverage has been growing as the number of uninsured children in Kansas climbed from 51,000 to 72,000 in just three years. The pool of potential applicants was further expanded on January 1 of this year, when income eligibility for HealthWave increased from 200 to 250 percent of the federal poverty level.

Cuts in funding that reduce the state's ability to process applications, on top of the increase in demand, add up to a large backlog of unprocessed applications, now at around 20,000. The state is taking steps to simplify the application and renewal process that should result in long-term improvements, but the ongoing recession and a projected state deficit of around $400 million for the next fiscal year mean that reducing the backlog in the short-term will be extremely difficult.

The situation in Kansas underscores the pressing need for further fiscal relief for the states, and in particular for the FMAP extension proposed by Senators Rockefeller and Reid.

For self-employed Harold Stultz, the backlog means his family has $6,000 in medical bills they need to cover. But Harold knows he is not the only one affected. "It...upsets me even more that there are more people in my situation," he says.

How will Congress respond to the predicament of Harold's family - and the predicament that so many other families find themselves in during these tough economic times?

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

Express Lane Eligibility: Time to Put On Our Thinking Caps

2010-02-16T17:29:00Z

Express Lane Eligibility (ELE) is a relatively simple concept. There are millions of uninsured children eligible for Medicaid and enrolled in other public programs, like school lunch or food stamps. Since they serve the same populations and families have already submitted relevant information, we can create connections between the programs in order help more children access affordable health coverage. Such a commonsense approach doesn't sound like it should be too heavy of a lift, but once you get below the surface you'll find many layers that have to be peeled back.

As in many things in life, public programs have a tendency to operate within silos, each having its own applications, staff, rules, and computer systems. I witnessed this first hand when working for The Children's Partnership (the first group to use the term Express Lane Eligibility) in California to link free school lunch with Medicaid/CHIP (Medi-Cal and Healthy Families in the state). From legislation to implementation, it was really rewarding but tough: it hadn't been done before, the culture of working across programs wasn't there, and the different federal rules governing the programs were a mine field. We had mixed results, which you can read more about here.

The good news is that the experience in California and other states led to language in CHIPRA to provide more flexibility to states wanting to undertake ELE. (See CCF fact sheet on new CHIPRA options for states.) And last week, CMS released its guidance letter on the new provisions. The most important new tool in the arsenal: Medicaid/CHIP can now use a finding from another public program for purposes of determining eligibility, without regard to differences in methodology. So, if school lunch says a child is at 130% FPL, Medicaid can apply that income finding - even though school lunch counts income and household size differently.

The guidance outlines this and other options available to states, from what other programs can be used, new ways to address screen and enroll, and the potential of using automatic enrollment. CMS acknowledges that this is not "one size fits all" and that they will work with states as they consider different alternatives. To help get your juices flowing, the guidance includes key questions to consider and highlights ELE examples using food stamps and state income tax records. For those interested in pursuing ELE, here are a few of the lessons I learned:

Spend the time to build relationships. Don't assume that the other programs will automatically see the brilliance of your idea. And be sensitive to the other program's mission and workload issues. It will take time to build the relationships, and you many want to start by getting support from leadership, whether Secretary of Education or Tax Revenue Board.
Technology will make or break you. It all comes down to whether the different program computer systems can talk to each other. If they can, you can cut down on manual processes and better target your efforts. For example, simple data runs can cull out those children already enrolled in Medicaid or CHIP (otherwise you spend countless hours processing their applications).
The more stuff you ask for, the less successful you will be. Its human nature to not return forms, so the more information you can obtain from the public program or other databases the more likely you will be to enroll children.

The new ELE options maybe most importantly give us permission to be creative in our outreach and enrollment efforts. So let's all put on our thinking caps. To assist you, there are a number of great resources out there for you to use: Center on Budget and Policy Priorities, The Urban Institute and The Children's Partnership's Express Lane Toolkit.