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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 ..."

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  

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.

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 (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. 

Today, there's a new beat coming out of Nashville, Tennessee (aka Music City, USA).  Tennessee Governor Phil Bredesen has changed his tune and announced that on March 1 enrollment will resume for CoverKids, the state's Children's Health Insurance Program (CHIP).  The Governor had frozen enrollment in November but, after a loud public outcry, he decided to tap a state savings account for public health programs to re-open enrollment for uninsured children.

The news is music to the ears of the parents of the 145,000 uninsured children in Tennessee who may be eligible for coverage if they are unable to find private health insurance.  The Tennessee Justice Center and other advocates have been urging the Governor to re-open enrollment.  Michele Johnson at the Justice Center blogged about the enrollment freeze on Say Ahhh! last month and credits the blog with helping to focus attention on the issue which led to the Governor's action to re-open CoverKids. 

In announcing the change in policy last night, the Governor was quoted as saying: "Fortunately, we've been able to dig deep and find additional funding to keep this option available to families in need."

Let's hope other Governors and state policymakers are paying attention and will "dig deep" before denying access to affordable coverage to children in need.

 

Donna Cohen Ross

Outreach Director, Center on Budget and Policy Priorities

One year ago last Thursday, President Obama signed the Children's Health Insurance Program Reauthorization Act (CHIPRA) into law.  The President's words that day reinvigorated a nationwide effort to ensure that children have the health coverage they need.

We have made significant strides since then, as CMS details in a new report. Despite grim budget conditions, states have expanded coverage, streamlined enrollment procedures, and stepped up outreach efforts.  And, when the weak economy generated increased need, Medicaid and CHIP rose to the challenge, covering 2.6 million previously uninsured children last year.

My memory of last year's bill-signing got me thinking about two incredible people who exemplify the challenge that lies before us:  Greg Secrest and Ann Walker, both from Martinsville, a once-robust manufacturing town in southern Virginia.  Greg used to work for a furniture manufacturer, but was laid off when the company moved overseas.  Without health insurance or a job, Greg found help at Project Connect (a program funded by the Virginia Health Care Foundation and Anthem Blue Cross Blue Shield Foundation), where Ann, an outreach advocate, helped dispel his skepticism about CHIP and signed up his two sons. 

Invited to the White House CHIPRA signing ceremony last year, the entire Secrest family traveled to Washington to join the President and other distinguished guests.  President Obama mentioned the Secrest family in his remarks saying:  "Let's give Americans the support they need to weather this crisis... In the end, that's really all that folks like the Secrests are looking for -- the chance to work hard and to have that hard work translate into a good life for their kids." 

I called Ann and Greg last week for an update. Ann is still working hard to help unemployed families find the help they need.  "Anywhere there's a door," says Ann, "I'm still sticking my toe in. I'm a nagger.  I'm a stalker." 

Greg gives Ann high praise: "If I could give Ms. Walker a medal, I would. She gave me peace of mind.  Because of her, I have health insurance for my children and I don't have to worry when my kids go out to play."  That had been a motivating force -- Greg's 16-year-old had wanted to play football and join ROTC, but his parents worried about what would happen if he got injured and didn't have health insurance.

Martinsville has the state's highest unemployment rate, at over 20 percent. With many more companies downsizing or shutting their doors, Ann keeps sticking her toes in where she has to -- Stanley Furniture, Stuart Flooring, CP Films, even Food Lion.  She has been invited by the local Virginia Employment Commission to be a part of the "rapid response team" that visits firms laying off workers to give them swift access to information about applying for available benefits.  As Ann points out, the VEC visit may be her first, but it's rarely her last.  It may take awhile to reassure parents that Medicaid and CHIP aren't "handouts" -- they were designed to help people get through tough times like these. 

Greg Secrest is now a full-time community college student with his eye on a business degree.  His wife, Rileen, found a part-time job keeping the books for a biodiesel company.  CHIP coverage has helped enormously.  During the year, a football injury sent one son to the doctor.  Sinus medicine for the other would have set the family back $50 or $60 if it hadn't been for insurance.  The Secrests have renewed CHIP coverage for their boys, although they needed Ann once again to troubleshoot when the paperwork they submitted got lost. 

To build on last year's progress, on CHIPRA's anniversary, Secretary Sebelius issued a new challenge: Cover the remaining 5 million uninsured children who are eligible for Medicaid and CHIP in the next five years.  To do that, we'll need many more Ann Walkers, with their unrelenting spirit and willingness to stick their toes in lots of doors -- but they're going to need more help from us as well.  We need to redouble our efforts to reduce the paperwork barriers that keep eligible children from getting and keeping coverage.  We need to acknowledge, as Secretary Sebelius did, that Recovery Act funds have been instrumental in bolstering state finances and protecting Medicaid from cuts.  Convincing Congress to renew that support is absolutely critical.  

Finally, we can't forget that it's not just children who need coverage. Greg Secrest didn't mince words when he said, "We as a country need good health reform."  Despite his family's trials, Greg remains an optimist.  "There's a light at the end of the tunnel; we just have to go a little further to see it. It will get better.  I want my kids to know that." 

As we ended our phone call, Greg said he especially wanted to thank everyone who worked for health coverage.  I just want to thank Ann and Greg for sharing their stories of perseverance with all of us.  

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

(Editor's Note:  Ann Walker is pictured above helping families access affordable health coverage for their children.  She is one of the many hard-working outreach workers helping families secure coverage for their uninsured children.)   

 

In many cultures, the first birthday of a child is a major community celebration.  It signifies that the baby has made it through the critical first year and is now destined for great things.  

We should be celebrating the first year of the Children's Health Insurance Reauthorization Act (CHIPRA).  CHIPRA renewed the Children's Health Insurance Program (CHIP) and gave states new tools and fiscal incentives to enroll more uninsured children in CHIP and its larger companion program, Medicaid.  Unfortunately, for many of us, it just doesn't seem right to have a big celebration when there is so much uncertainty over the future of health reform.  I confess that I was reluctant to celebrate CHIPRA but when I thought about how the past year would have been without it, I came to my senses.  Without CHIPRA and the temporary increase in federal funding for Medicaid included in the economic stimulus package, the health needs of so many more children would have gone unmet. 

In the past year, while private insurance has become less available and more expensive and families faced the most difficult economic times since the Great Depression, the renewed CHIP program and Medicaid have offered a vital lifeline to America's children.  Thanks to the strong resolve of national and state leaders, many of our children have been sheltered from this economic storm.  

CHIPRA, and the increased funding for Medicaid, helped states strengthen and maintain their commitment to children's health coverage just when they needed it most.  While the financial investment was relatively small, it made a huge difference in the lives of the people it helped.  Just ask the Simpson family from Benton Arkansas who were able to maintain CHIP coverage for their children when Mr. Simpson lost his job as an electrician. 

This is but one example of the lives touched by the positive actions of national and state leaders to sustain and strengthen children's health coverage over the past year.  Families with children who had asthma, diabetes or autism who couldn't afford private insurance had access to health coverage so they could get their children the treatment and preventive care so crucial to their well-being.  Parents who lost their jobs and health insurance were able to turn to CHIP or Medicaid to secure coverage for their children.  (It would be better for the entire family if the parents also had access to stable, affordable health coverage that didn't disappear when they lost their jobs but we'll have to wait for broader health reform to make that improvement to the health care system.) 

CHIPRA was not intended to solve all of the gaps in our health care system but was designed as a bridge until our nation's leaders were able to pass broader health reform.  While the timing of health reform is uncertain, one fact remains clear - children and families need access to secure, stable, affordable health coverage that won't be taken away if they lose a job or become sick. 

So what should we give CHIPRA on her first birthday?  How about a sibling named Health Reform?

"...let's talk about honoring our most important responsibility as Iowans. That is, our duty as parents, and as shepherds of our children's future. You know, I'm proud of the fact, that working together, we've made a long-term investment in the health and education of "all" children... Together, we must continue this investment, and my budget will reflect this."


I recently returned from maternity leave and had no idea what the state of children and family health coverage would be given the protracted battle on health reform and the challenges facing state budgets. I was pleasantly surprised to see that while there is still a lot of anxiety about current state budget woes and health care reform, that many lawmakers, like Governor Culver, are vigorously defending the improvements they've made for children's coverage in recent years. 

Like everyone else in D.C. health policy circles, I've spent much of the last few days obsessively checking for updates on whether there is a coherent plan emerging from the White House and Congress for moving forward on health reform. Not yet, which means that instead of rolling up my sleeves and thinking about how CCF might best help to implement health care reform, I have some time to contemplate all that would be lost if policymakers fail to move forward on reform or decide to scale it back.

The worst thought is giving up on the opportunity to create a more compassionate and fair health care system.If reform passes, we can expect millions of children to gain coverage as their parents come forward to apply for insurance. These children no longer will go untreated for medical conditions that could affect their trajectory in life.As importantly, if reform passes, children no longer would have to see their parents and other adults in their lives struggling with the untreated medical conditions or the medical debt that can come with being uninsured.  As my colleague, Martha Heberlein, has pointed out, the research is unequivocal on the point that children fare better when their parents also have insurance, presumably due to both the financial stability it confers and because it is tough to be an effective parent when coping with an untreated medical condition.

More immediately, the failure to pass reform would mean that children could still be denied coverage because they have a pre-existing coverage, such as asthma, diabetes, or autism. And, we wouldn't get the benefit of improvements to benefits for children contained in both reform bills, which means millions of children could miss out on hearing tests, eye tests, dental care, and, in more serious cases, developmental assessments that could dramatically affect their ability to grow and develop.
 
Finally, reform holds out the tantalizing prospect of stabilizing and strengthening the successful Medicaid and Children's Health Insurance Program, which together cover close to one in three of America's children. Medicaid is slated to receive a major investment of federal funds for extending coverage to more people, and, also, possibly, for increasing access by improving Medicaid reimbursement rates. If reform fails, we not only lose a valuable chance to stabilize and strengthen these programs, but face the prospect of states cutting back on Medicaid when fiscal relief runs out at the end of this year. We could see more states try to solve their state fiscal problems, in part, by putting uninsured children on waiting lists for coverage, as already has occurred in Tennessee and Arizona.

There has been a lot of rumbling about a scaled-back version taking on the necessary insurance reforms such as prohibiting insurance companies from denying coverage due to pre-existing conditions, but this isn't a viable option. Many have pointed out that those reforms will actually increase insurance policy costs if we don't also expand those who are insured by making insurance coverage more affordable. If it were possible to ban pre-existing conditions without having the harder debate about broader health reform, it likely would have happened long ago.

I'm still optimistic that the nation's policymakers will find a way to move forward on health reform that offers pathways to affordable coverage for everyone. The cost of failing to do so is simply too high.