Recently in CHIP Category

I know I've said it dozens of times - states are different. Like people themselves, they have their own characteristics, quirks, and personalities that make them unique. But what about within states - are there differences of note? Why, of course (I'm sure we can all think of a long list of differences between, say New York City and upstate NY). And lucky for us, a recent data release from the Census highlights how health insurance coverage varies within states' very own borders.

(Quick methodological note for those of you who are interested in such things: the Small Area Health Insurance Estimates (aka SAHIE) are model-based and combine data from a variety of sources. These data represent coverage in 2007, prior to the economic downturn. They are currently the Census' only data source on health insurance for every county in the US. For more on the various measures Census has on health coverage, check out this helpful fact sheet. The Census also computes small area estimates for income and poverty (aka SAIPE).

Now back to the data at hand - at 26.8%, Texas has the highest rate of uninsured in the country. But where are those 5.8 million folks living? The range in the uninsured rate is quite wide, from 16.6% in Collin County to 49.5% in Kennedy County. What makes these two counties in the same state so wildly different in terms of health coverage? A quick look at some demographic data provides us some idea:

Collin County, located just north of Dallas, is about 850 square miles and has about 765,000 people. In 2007, the median household income was around $80,000.

Kennedy County is located on the Gulf Coast between Brownsville and Corpus Cristi. It's almost twice the size of Collin County, 1,450 square miles, but has less than 400 residents, with a median income of about $30,000 in 2007.

I think it's fair to say that we don't have to pick on Texas as an example, as other states are bound to have within-state variation (even Massachusetts - known for its low uninsured rate of 7.8% - has a range of 6.6% to 13.9%).

State officials and advocates should find these data very helpful in identifying which areas of their states have the greatest number of uninsured residents and possibly understanding the reasons for such differences. (Note - although I didn't do it here, you can also look at the data by age ranges and income levels). And when making the case for targeting outreach efforts, both for those who may already be eligible for coverage through Medicaid and CHIP and, in 2014, for those who will become newly eligible, having data to support your claims will make your case that much stronger. 

Last week, Cindy Mann blogged about the importance of kids' coverage on healthcare.gov. "As back-to-school time approaches, families are thinking about making sure their children have every opportunity to learn. Now is also the time to make sure that kids have the coverage they need to be healthy - the first step to a successful school year."

Luckily, many kids already have an affordable coverage option through Medicaid and CHIP. As part of the challenge to get all eligible kids signed up, CMS has launched Get Covered. Get in the Game. to bring coaches, schools, families, and communities together to raise awareness. (Maryland's Suzanne Schlattman blogged about the campaign for us earlier this month.)

Check it out to see how you or your organization can help get children covered and in the game.

By Suzanne Schlattman, Maryland Citizens' Health Initiative Education Fund, Inc.

This week, the U.S. Department of Health and Human Services (HHS) announced the Get Covered. Get in the Game  initiative which will be launched in seven pilot states across the country including: Colorado, Florida, Maryland, New York, Oregon, Ohio and Wisconsin. The initiative brings together coaches, schools, and communities to educate families with children who are eligible for Medicaid or CHIP about the immediate availability of free and low-cost health care programs for children.

What a great idea! In public health, we stress prevention and leading an active lifestyle is one health behavior that pays the greatest dividends for preventing poor health. However, uninsured kids often miss out on organized youth sporting activities because they cannot afford the necessary physical or because their families are afraid that they won't be able to pay the medical bills if their child gets hurt. Providing coaches with information about affordable health insurance options for children is a great way to promote coverage among eligible families and promote the adoption of healthy behaviors.

In Maryland, we played around with this theme when we launched our "Got healthcare?" campaign after the state expanded Medicaid eligibility for adults in 2007. Local sports heroes from the Baltimore Ravens and Washington Redskins volunteered to help promote the program. We ran radio ads, partnered with local hotlines and put up posters in every hospital to alert people.  Having sports celebs promote enrollment in Medicaid helped raise awareness about the program, break down the stereotype that Medicaid was only for pregnant women and children, and again repeated the theme of leading an active lifestyle.  Over 200,000 Marylanders have gained access to free and low cost health care services since this campaign began.

Check out one of the great radio ads that was part of this campaign:

Chris Samuels of the Washington Redskins with Maryland Governor Martin O'Malley

And the poster with Ed Reed of the Baltimore Ravens:

It makes a lot of sense to involve youth sports leaders with our enrollment efforts as an estimated 44 million children participate in organized youth sports.  Coaches for youth sporting leagues are local celebs in their communities too -- and to have these folks promote enrollment in children's health insurance programs across the country is great news.  

In announcing the initiative, HHS Secretary Kathleen Sebelius reminded us of why we all work so hard to connect children with coverage:  

"Healthy kids do better in school and in life because they are able to participate fully in activities that develop their bodies and their minds," Secretary Sebelius said. "Kids should not have to miss out on their favorite sports and other activities that get them moving because they lack health insurance coverage."

All states can use the materials developed for the pilot states to get coaches involved in outreach efforts to enroll eligible children.  More information about the Get Covered: Get in the Game initiative is available at www.InsureKidsNow.gov.

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

For all those wondering what was going on with the 2010 federal poverty level, your answer arrived today in the Federal Register. But while I have your attention, here's the back-story.

A decline in the average CPI-U during 2009 would have required HHS to issue poverty guidelines in 2010 that were actually lower than those in 2009, leading to a reduction in eligibility for the safety net programs that rely on the guidelines, including Medicaid. (This would have been an unprecedented event - the only reduction since the issuance of the first poverty guidelines in 1965).

In December, the Department of Defense Appropriations Act (go figure) included a provision to freeze the poverty guidelines at 2009 levels through March 1, 2010. This freeze has been extended twice more until at least May 31, 2010. (I say at least, because all three extensions included language stipulating that the poverty levels would remain in place until updated guidelines were published, hence the somewhat fungible deadlines).

I don't know about you, but I've been on pins and needles since the end of May waiting for the publication of the updated guidelines. Well, the wait is over... ASPE modified the procedure for updating the guidelines to take into account the changes in the CPI-U during the freeze. (Typically, ASPE uses price changes through the most recent "completed" year. In this case, they also took into account the changes between January 2009 and May 31, 2010.) 

The percentage increase in the CPI-U was so small that as a result, the poverty guideline figures for the remainder of 2010 are unchanged from the 2009 poverty guideline figures. These guidelines will remain in effect until ASPE publishes the 2011 guidelines, which are expected in late January 2011.

One of the many lessons learned about advancing children's health coverage is how critical retention in Medicaid and CHIP is to our coverage goals. Dr. Benjamin Sommers drove this point home in a study that concluded that one-third of all eligible, uninsured children in 2006 had actually been enrolled in Medicaid or CHIP in the prior year. A recent update of Dr. Sommer's study in Health Affairs shows that we have made progress on this front with this key statistic dropping to 25% in a little over two years.

Over the years the importance of customer retention, a long-standing best practice in the business world, has gained equal footing with outreach and streamlining enrollment as effective strategies to reduce barriers to coverage. Dr. Sommer's report is good news for states that have made retention a priority and is a contributing factor in our continuing success in reducing the number of uninsured children. 

While the drop-out rate improved, there was some evidence in the study that take-up or new enrollment may have slipped. Dr. Benjamin Sommers points out that this change in trend coincided with new federal rules imposing complex paperwork requirements on states and applicants to document citizenship. The negative impact of the citizenship verification requirement on eligible, citizen children has been well documented. 

I'm optimistic that if Dr. Sommers updates his report in another three years we'll see improvement in both areas. More than one-third of states have had impressive results with a new data exchange with the Social Security Administration (SSA) to verify citizenship rather than requiring paperwork from individuals. Many more states are testing or planning to develop the SSA electronic interface as a means of documenting citizenship.

Additionally, states continue to innovate and replicate effective enrollment and retention strategies through major initiatives such as the Robert Wood Johnson funded Maximizing Enrollment for Kids and the State Health Access Grant Program.

Dr. Sommers research shows how policy and procedural decisions can make a difference, both positive and negative.  Taking stock of what is working in Medicaid and CHIP to promote enrollment and retention is essential to the expansion of coverage as we implement the Affordable Care Act efficiently, cost-effectively and with optimal results.

Summer vacation is not even half over and I'm already thinking about getting my kids ready to go back-to school.  It's not that I don't enjoy their company; I just want to get a jump-start on my to-do list so that I deliver them to school ready to learn.  Along with back-to-school shopping, they need their annual physicals and 6-month dental check-ups.  Child health advocates around the country have another major item on their back-to-school checklists - reaching out to the five million children who are eligible for Medicaid or CHIP but are unenrolled. 

This is an ideal time of year as the media and huge segments of our population are focused on children's needs as they prepare to head back to school. The National Covering Kids and Families Network (NCKFN) is helping groups leverage the increased attention to children's issues during the back-to-school period to help reach enroll eligible children in state Medicaid and Children's Health Insurance Program plans. They recently hosted a webinar to discuss messaging and strategies that work. (Georgetown CCF is providing technical assistance to NCKFN). 

Many of the NCKFN participants and other groups have been working on back-to-school efforts for many years and had a wealth of experience to share with each other. Some excellent messages have been developed for groups working on this initiative by GMMB with the support of the Robert Wood Johnson Foundation.  The trick is getting the right messengers to use the messages to reach families of uninsured children. Many of the NCKFN groups have had a lot of success working with school nurses, school administrators, social workers, community outreach workers and teachers. Two participants on the webinar focused on more non-traditional messengers - school board members and youth sport leaders. 

First, Donna Cohen Ross, senior advisor to the Office of External Affairs at CMS (and an expert on outreach), announced HHS's plan to launch a coaches campaign "Get Covered: Get in the Game" which will enlist youth sports leaders to help find uninsured children and get them enrolled (more details on the campaign to come in August). Coaches are great messengers.  (Just compare the sports section to the health section of your local newspaper if you doubt the ability of sports leaders to get a message across in your community.)  Coaches can pitch a different message to families by linking the importance of coverage with the ability to compete in team sports. As Donna pointed out, there is a strong link between good health care and sports as kids frequently are excluded from school sports participation if they don't have a physical.  Parents are also understandably reluctant to allow children to participate in sports if they aren't insured for fear of an injury that they can't afford to treat. 

As the mother of three boys, I'm involved with my fair share of youth sports teams and recall one heart-breaking incident when one of my son's soccer teammates suffered a concussion during a tournament.  I offered to drive him and his mother to the hospital but she said she didn't have insurance so she would just wait to see if he really needed care.  No mother should be faced with that choice and coaches could help make sure they are not.  Good coaches teach children more than just about sports, they teach them about the importance of teamwork, perseverance, and hard work and they make sure kids are doing as well off the field as they are doing on the field.   Youth sports participation helps children learn many valuable life lessons and it is tragic that some children are unable to fully participate in this aspect of childhood due to the lack of insurance coverage - especially for those who are eligible but unenrolled in CHIP or Medicaid. 

Second, April Griffin, a school board member from Hillsborough School District in Florida, spoke about the importance of getting buy-in at the top. (In other words - cultivating the grass tops as well as the grass-roots).   She pointed out that school district staff and teachers are stretched thin and are under pressure to raise test scores.  According to Ms. Griffin, the more groups are able to link children's health coverage with school performance, the more successful they should be in getting the buy-in of school system personnel. 

Her message also hit home.  A friend of mine tried to get our school district to include information about our state's Medicaid and CHIP programs in back-to-school packets.  The school district staff refused and said it was against school district policy.  My friend appealed to a school board member by pointing out that the school district included promotional materials of for-profit insurance companies in the packets.   The school board member was able to look at the "big picture" rather than reading a policy manual and gave the staff person the go-ahead to include the CHIP & Medicaid information in this fall's packets. 

There were a lot more great ideas shared on the NCKFN webinar and I encourage readers to check them out here.  In collaboration with the network, Donna Cohen Ross of CMS has scheduled a second webinar on school-based outreach efforts on July 29th. (All those of you who have read Donna's posts on this blog or have worked with her over the years know that Donna cares deeply about this topic and you won't want to miss this opportunity.)   

Last week, the National Association of Insurance Commissioners held a first of many planned meetings on health care reform.  In many ways, state insurance commissioners, have become the front lines of health reform implementation as they are responsible for ensuring that health plans are compliant with the insurance reforms in the Affordable Care Act and they will play a key role in the establishment of the exchanges.

For this meeting, at the top of the agenda was the exchanges and the discussion ran the gamut, from basic questions about exchange responsibilities to detailed analysis of how to limit adverse selection. The consumer perspective was well represented with our colleague at the Georgetown Health Policy Institute, Sabrina Corlette, who testified along with Tim Jost of Washington and Lee University. Tim shared his view that the success of an exchange will depend greatly on its ability to establish a streamlined enrollment and eligibility system that is seamlessly linked to Medicaid and CHIP.

Interestingly, the issue of coordination between the exchanges and Medicaid and CHIP brought forth many questions from the represented commissioners. More than once we heard reference to the fact that public programs, and the populations they serve, are a new world for insurance commissioners and that they are eager for more information. Key issues on their minds were how to maintain continuity of care between those moving back and forth between exchange and Medicaid/CHIP coverage, what IT funding and/or technical assistance will be available to assist Medicaid/CHIP agencies, and how to align the more "prescriptive" eligibility rules of Medicaid/CHIP with the tax credits so that enrollment in exchanges is consumer friendly.

The conversation was a good start - but also a good opening for ongoing dialogue with and education to state insurance commissioners on the central role that exchanges will play in helping people to secure subsidies for coverage and in facilitating their enrollment into Medicaid and CHIP. Georgetown CCF submitted comments to the NAIC on these critical issues.

For the meeting agenda and other materials, visit the NAIC site. 

By Jon Peacock, Wisconsin Council on Children and Families

It isn't often that state policymakers have to make program changes and policy choices because of a law passed in another state or territory of the U.S.  Thus, it came as a big surprise to learn that a law enacted in Puerto Rico forces states to make a choice about how they administer public benefit programs, including Medicaid and CHIP.    

The Puerto Rico law invalidates all certified copies of birth certificates issued by the Puerto Rico Health Department before July 1, 2010. The law was adopted by the commonwealth last year after it was informed that stolen birth certificates were being used fraudulently. Beginning on October 1, 2010, states may no longer use those birth certificates to document citizenship to identity those eligible for public benefit programs.  The new law was initially scheduled to take effect on July 1, but states and program applicants have been given three additional months to prepare for the change.

The older certified copies will not be valid for new applications starting October 1, but states have the option of not requiring Puerto Ricans who are already enrolled to obtain a new birth certificate when they come up for their annual review of eligibility.  Additional information on the new law, as well as application forms for new copies of birth certificates, can be found here. 

Wisconsin recently became one of the first states to tackle this issue:  the state decided not to make current program participants obtain new copies of their birth certificates. (See Operations Memos # 10-39.) The WI Department of Health Services (DHS) decided that requiring all enrolled Puerto Ricans to obtain new birth certificates would be a burden for those individuals and wouldn't be a cost-effective use of time for caseworkers.  

Wisconsin's BadgerCare Plus program has been extremely effective in giving nearly all Wisconsin children access to quality affordable health insurance, and in making enrollment and renewals easier for eligible families.  However, Wisconsin still has room for improvement in streamlining renewals, and DHS is working toward that goal.  The department's choice not to require new birth certificates for already-enrolled Puerto Ricans prevents what could have been a setback to Wisconsin's efforts to reduce churning among program participants.

For new Puerto Rican applicants, states can mitigate the potential burden of the law by taking advantage of the CHIPRA option to use Social Security numbers for automated verification of citizenship and identity.  Although Wisconsin does not currently employ that option, DHS is preparing to put it in place this fall--and many states are already up and running with it.    

There is no avoiding the fact that the Puerto Rico law will affect Medicaid and CHIP programs across the U.S and is likely to delay some applications.  However, the choices made in Wisconsin illustrate that states can minimize the additional burdens for program applicants, participants and caseworkers.  Especially when budgets are tight, smart decisions that avoid additional red tape can pay off for both state budgets and uninsured kids.

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

By Eugene Lewit and Liane Wong

The David and Lucile Packard Foundation

The percent of uninsured children has consistently declined, despite deterioration of coverage for adults and the economy. This is one of the significant but frequently overlooked good news stories of recent years.

The gains in children's coverage have been due in large part to actions taken by states to simplify enrollment and retention processes for their Medicaid and CHIP programs while expanding eligibility for those programs. In many states, policy advocacy groups have played important roles in spurring and supporting progress in their states. These organizations are likely to continue to be important players in the implementation of CHIPRA and broader health care reform. Yet, there has been little rigorous, systematic research on how advocacy groups do their work and the strategies they employ to achieve their objectives.

Two recently released issue briefs based on findings from an on-going evaluation of the David and Lucile Packard Foundation's Insuring America's Children: States Leading the Way (IAC) grantmaking strategy attempt to fill some of this knowledge void. The briefs examine some of the state-based advocacy work supported through IAC and identify the lessons that have been learned regarding how to effectively support and promote growth of children's health coverage.

In the first brief, State-Based Advocacy as a Tool for Expanding Children's Coverage: Lessons from Site Visits to Six IAC Grantee States. Evaluation Brief 1, the authors summarize key findings gleaned from in-depth site visits to states where IAC has made its most substantial investment in advocacy through multiyear "Finish Line" grants. These findings describe how persistence, flexibility, creativity and commitment to conducting effective states-based advocacy, especially in a changing environment, can benefit coverage expansion to all children. They also describe the importance of building strong and broad-based coalitions that include both grassroots and state-level stakeholders, an often key step toward maintaining a unified voice among a sometimes crowded community of advocates working to improve children's well being. While acknowledging that much work remains, the brief pinpoints a number of important gains in children's coverage since the IAC efforts began -- gains that have resulted despite a severe and ongoing economic downturn.

The second brief, Strategic Engagement of Policymakers is Key to Advancing a Children's Health Care Policy Agenda. Evaluation Brief 2, examines the benefit that positive engagement of policymakers can have for advocates to move the children's health care coverage agenda forward in states, as well as the strategies for making this engagement happen. Understanding states' unique political environments is one important first step toward this engagement. Further strategies include identifying, nurturing, and supporting political champions; creating strategic links between grassroots organizations and policy advocacy groups; creating effective, appealing messages for policymakers; establishing advocacy groups as the "go-to" resource for reliable data and information; and sharing ownership of agendas and successes with champions and key policymakers.

These briefs provide objective validation of the advocacy strategies and tactical innovations employed by veteran advocates throughout the country. They also offer practical and field-tested ideas for advocates looking for new ways to accelerate the pace of change. Most importantly, they remind us that tough, smart advocates can guide and support leaders in continuing the children's coverage success story.   

Dr. Fairbrother and her colleagues at Cincinnati Children's hospital have just come out with an excellent new study that takes a clear-eyed look at how often children end up losing health coverage after a parent loses a job.  The results are powerful, but not pretty -- between 2000 and 2004, almost one in three kids lost coverage when their parents lost a job (311 out of every 1,000).  And, the rate is much higher for low-income children (456 low-income children out of every 1,000 lost their coverage when a parent lost a job).   With the latest government data indicating that in 2009, there were 9.4 million families with at least one unemployed member, these are alarming findings. 

As bad as this news seems, one bright spot is that this is a problem we can fix by helping these children secure affordable coverage options through Medicaid and CHIP as their parents get back on their feet.  And, I'm willing to bet that we've actually already made some significant progress since 2004, the latest year for which data were available for the new study.  Thanks to the hard work of Governors, state-based advocates, and political leaders in Washington who have made a strong commitment to covering children, many of the children in families losing jobs now are eligible for Medicaid or CHIP and, increasingly, they are facing easier, more family-friendly enrollment procedures.  Especially before their budget situations deteriorated, states across the country were getting rid of red-tape barriers to coverage and extending Medicaid and CHIP eligibility to additional children. 

Since the downturn, states have largely held onto the gains in coverage (although concerns are increasing about cuts to provider reimbursement rates) and some are continuing to push forward.  This ability to "weather the storm" has been due in large part to a short-term, temporary increase in the help that the federal government provides states in financing Medicaid.

Now, however, we are coming up on a critical moment that brings the importance of Dr. Fairbrother's research into sharp focus. At the end of this year, the extra help the federal government has given states is slated to expire even though state budgets continue to be battered by rising demand for services. Without a short-term continuation of the extra help, states will be under enormous pressure to scale back Medicaid and CHIP, including children's coverage.  (They can't do it directly because the new health law requires a maintenance-of-effort when it comes to Medicaid and CHIP eligibility rules and procedures but there are indirect ways to cut back on coverage that states may be forced to consider such as slashing the number of state workers who can process applications or cutting reimbursement rates so deeply that children cannot secure needed care.)  If this happens, the reality documented by Dr. Fairbrother that children often lose their private coverage when their parents lose a job will translate into more and more uninsured children.  We will have a much harder time "catching" them in Medicaid and CHIP, and offering their families the peace of mind that comes with knowing that at least their children can still get health care.  On a more global scale, we could end up with a deeply disturbing result - more children becoming uninsured even as the country moves forward on implementation of broader health reform in 2014.

At Georgetown, we work closely with state officials and advocates who are addressing these issues in the states, and the sense of urgency is palpable.   If leaders in Washington don't come through quickly with an extension of federal fiscal relief, it may threaten a lifeline that can help millions of families stay afloat in the midst of unprecedented job loss.