Say Ahhh!

Having spent much of the summer in South America and without much access to American media, I was curious to see how things had changed when I returned to work this week.  Hmmm.  Not so good. Controversy over the health reform bill seems as rhetoric laden and inflammatory as ever as the election approaches.

That is why I was interested to see in my inbox a note about a new analysis done by the Congressional Budget Office on August 24th which estimates that if the health reform law (PPACA) was repealed, the deficit would actually rise significantly -- by $455 billion over a ten-year period 2010-2019.  CBO found that PPACA will reduce the deficit by $28 billion in 2020. Sen. Crapo (R-ID) had requested the estimate. 

I guess the good news here is that should Congress flip, it will be hard to repeal PPACA because it will cost money. Real money. But the likelihood of this kind of information breaking through the current heated debate seems slim. Say Ahhh! likes to share these little factoids with you though!

I had a chance to go to a fantastic event this morning sponsored by Secretary Sebelius on the Connecting Kids to Coverage Challenge, which aims to reach the nation's 4.7 million uninsured children who already are eligible for Medicaid or CHIP.  She made a compelling pitch that nothing is more important to our future than the health of America's children and that is why Medicaid and CHIP were created.  Thanks to these programs, tens of millions of Americans have the peace of mind that comes from knowing that their child is safe.

In recognition that millions of our children are heading back to school this week, the event also featured Education Secretary Arne Duncan who tackled the issue from an education perspective.  He argued that some foundational things have to be in place for students to be able to excel.  If they can't see the blackboard, or if they are coping with untreated asthma, it is pretty tough to expect them to do well.  He pledged to work with some of the major school districts in the states that have the furthest to go in covering uninsured children.  (California, Florida, and Texas account for 40% of all uninsured kids, according to powerful new data released today by the Urban Institute.  See my colleague Martha Heberlein's blog for more on the report).

The star of the morning, though, was probably Bonnie, a mom from Maryland.  "I speak to you as a mother and as an American," she began before going on to explain that her husband is an auto-mechanic who doesn't have any affordable employer-based coverage.   So, when she lost her job, she found her family uninsured.  Luckily, she hooked up with a community-based organization that helped her file an application for child health coverage.  It took only 15 minutes from start to finish, and within 24 hours she got a call that her son qualified.  Since her son has asthma, it was an enormous source of peace of mind in a time of need.  As she concluded, "No mother, no parents should have to choose their mortgage and utilities over health care" for their child. 

I left encouraged about the level of commitment shown by two key leaders in the Obama Administration, as well as impressed by the broad array of national organizations they've already signed up to work on the Connecting Kids to Coverage Challenge.

Most of you know the CPS - the annual social and economic supplement (ASEC) has been our go to source for health insurance coverage on a national and state-by-state basis for years. However, given the nature of the sample, analysis has been somewhat limited, especially for those smaller states and for those interested in data on a sub-state level. 

Now there's a new kid on the block. In 2008, a question on health insurance coverage was added to the American Community Survey. Like the CPS, the ACS is a national survey, but it has a much larger sample size (the CPS looks at about 78,000 households annually, whereas the ACS surveys 250,000 per month). It may seem somewhat counterintuitive, but the bigger the sample size, the smaller the area (geographic or demographic) that you can examine. We may just be able to get answers to some of those long-standing research questions.

One such question that has long plagued those of us looking to enroll eligible children in Medicaid and CHIP is: who are those kids and where can we find them? Thanks to the ACS (and some very talented folks over at the Urban Institute) we now have a much better idea, as today in Health Affairs, Dr. Genevieve Kenney and her colleagues released a paper that looks at that very question. (The report will also be highlighted at a media event today where HHS Secretary Sebelius will relaunch her Connecting Kids to Coverage Campaign.  You can watch it live here).

They found that of the 7.2 million uninsured children in the U.S., 4.7 million or 65% were eligible for Medicaid or CHIP. Of those, about a third are concentrated in just three large states (California, Texas, and Florida), a piece of data that certainly highlights the need for outreach and enrollment efforts in those states.

But I think an equally appropriate (and far more upbeat) view of the data is the success states have had enrolling children in their Medicaid and CHIP programs. Nationwide, the participation rate in Medicaid and CHIP is 82% (high compared to other means-tested programs). And 11 states were shown to have participation rates that were close to or above 90%. Those are amazing numbers and states should celebrate their well-deserved accomplishments.

For those of you doubters who say, "well, that could never happen in my state," I beg to differ. To quote the authors: "since these states constitute a diverse group in terms of their size, income distribution, racial and ethnic composition, and region, it suggests that high participation rates can be achieved across a range of different circumstances." In other words, while it is certainly not easy to get all the eligible kids in your state covered, there are plenty of places to look to as role models, and ones that may be very much like your own.

By Mike Odeh (Children Now) and Kristen Golden Testa (The Children's Partnership) with the 100% Campaign 

And we're off! Implementation of the Affordable Care Act (ACA) is officially underway! Less than six months after Congress passed the ACA, California has blazed the trail as the first state in the nation to create a statewide Health Insurance Exchange under the Act. Two complementary pieces of legislation create the California Health Benefit Exchange and are headed to Governor Schwarzenegger's desk for an expected signature - (AB 1602 creates the Exchange and SB 900 creates a decision-making board).

By creating the Exchange, the State has built a framework that will dramatically improve the way many Californians, particularly the uninsured, get health coverage and will set the right trajectory for health reform implementation by providing new affordable coverage opportunities for millions of children and their families!

Make no mistake - creating the Exchange was no easy task. The legislation that created the California Health Benefit Exchange only came about (on party-line votes) through strong legislative and gubernatorial leadership, thoughtful and dedicated staff, and the efforts of a broad coalition of health and consumer advocates. Certain insurers (ones that are apparently afraid of transparency and a little competition) worked throughout the process to water down the legislation and tried desperately to kill the bill in the final hours. Thankfully, other insurers were supportive and engaged earnestly in negotiating amendments.

CCF's recent blog and issue brief on Health Insurance Exchanges lays out some of the primary responsibilities of an Exchange and identifies some opportunities within the broader federal framework to coordinate among the Exchange and existing programs, like Medicaid and CHIP.

So, as many of you probably know, the ACA allows states to make some important choices, not least of which is the decision whether or not to create a state Exchange in the first place. Given that California is home to nearly 1.5 million uninsured children,  the infamous 39% premium increase proposal and a seemingly infinite state budget stalemate, we really need a custom-designed Exchange that will work for California. Alan Weil and Jon Kingsdale cautioned the California Legislature that making an Exchange work by 2014 would require a lot of strategic planning, thoughtful coordination and time. It's a good thing the Legislature was listening and has been able to take the first step forward for California.

Although the authorizing Exchange legislation creates a governance structure and outlines a framework for the core responsibilities of the Exchange in California, some of the details of coverage in the Exchange, such as the benefit design for the child-only insurance products, will be determined by the governing Exchange Board along with future federal guidance. That's why we believed it was very important that the Exchange be run by a qualified Board with expertise and the authority to negotiate health plan contracts based on price and value while not having conflicting financial interests.  The board also needs representation from those that recognize the importance of coordinating with existing health care programs, systems, agencies, and regulators, so that children are protected and don't fall through the cracks and lose health coverage unnecessarily. Along with minimum benefit standards and cost-sharing limits in the federal law, we believe these factors are critical to ensuring that the coverage offered in the California Exchange is much more meaningful and more affordable than coverage today.

In fact, one of the key features is that the five-member appointed Board is authorized to be an "active purchaser" and will select health plans to participate in the Exchange through a competitive bidding process. Because Exchange board members will be required to have experience with health coverage, administration, and financing, they will be qualified and savvy in negotiating contracts with health plans based on price and value for an estimated 8.3 million lives (including 3.8 million small-business owners and employees and their dependents). 

The legislation also lays out the overall duties and responsibilities of the Exchange, many of which are explicitly required in the federal law (e.g., operating a toll-free telephone hotline and website with comparative plan information) and some of which just make good sense (e.g., authorizing the Exchange board to maximally collaborate with existing health agencies and applying the same standards for insurers and health plans inside and outside the Exchange). It also will allow California to be one of the first states to apply for the federal planning grants that can be used to establish the Board, promulgate strong consumer protections regulations, and develop a process to coordinate effectively with existing state health insurance programs like Medi-Cal (Medicaid) and Healthy Families (California's CHIP).

Since the federal law builds upon (and protects) Medi-Cal and Healthy Families, it is critically important that the Exchange coordinate with existing state and local programs as much as possible. The Children's Partnership and the Kaiser Commission on Medicaid and the Uninsured point out in a recent issue brief that the ACA requires enrollment systems that are consumer-friendly, coordinated, simplified, and technology-enabled. But getting into the "nuts and bolts" of creating enrollment systems that will effectively talk to one another and be easy for families to use requires thoughtful planning and sufficient lead time. That is why we continue to recommend that, as the Board develops the enrollment system for the Exchange and its subsidies, the State buckle down now and start planning for the streamlining and coordination of the other enrollment systems, like Medi-Cal and Healthy Families.

The hard work is just beginning! The 100% Campaign and our partners will continue to advocate (administratively) for better and more program coordination among the Exchange and other programs - not just at enrollment but also during renewal (something we didn't get in the final bill) and at transitions (included in the bill but could still be strengthened). Coordination is especially important when families will be split across programs, for example, when a parent is covered through the Exchange while their child is enrolled in Healthy Families. We will be laying out detailed recommendations for the Board on seamless enrollment, renewal and transition coordination and protections to ensure that only the minimum necessary information is collected from families to determine eligibility for coverage.

While we pushed to get the state Exchange law as strong as possible, we recognize that many detailed decisions of the Board will be determined by federal guidance. That's why we are sharing our thoughts and concerns with the Office of Consumer Information and Insurance Oversight about how the Exchange should coordinate with other programs, and urge them to provide helpful regulatory guidance on the issue. Like stakeholders in other states, we are weighing-in as the federal government develops these guidelines, rules, and regulations, but here in California we are in the unique position of simultaneously sailing ahead into uncharted waters.

So we can't wait passively for guidance to be issued and instead need to focus like a laser on ensuring that we get clear federal guidance that will address such critical issues such as children's benefit design, access to databases for existing eligibility information, and assurances of a coordinated and streamlined enrollment system.

Furthermore, as part of our effort to ensure that families know about and actually enroll in available coverage, we continue to recommend a preferential role for experienced community-based organizations as navigators. Based on our experience here, health care advocates in other states should be prepared for attempts to narrow the navigator role to licensed brokers/agents.

In the end, our State did not develop a perfect bill - the 100% Campaign and our partners had hoped for greater public/consumer representation on the Exchange board, stronger conflict-of-interest prohibitions, more comprehensive coordination requirements, and a preferential navigator role for experienced local community-based organizations. Yet, we are pleased to have a strong starting point and hope to make improvements in the months and years ahead. The new legislation helps structure the incredible amount of work that will be needed to turn the concept of an "Exchange" into an actual gateway to affordable coverage for millions of Californian kids and their families when 2014 rolls around.

Editor's Note: The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

It used to be that late August in Washington, D.C. was the perfect time to clean the junk out of your office, delete old emails, and go to the dentist. Now, though, the high energy folks in the Obama Administration charged with implementing health reform are bringing yet more change to Washington, D.C..  Yesterday, they sponsored an all-day listening session with stakeholders to gather thoughts and insights on the new Exchanges that are so central to health reform.  They brought together employers, labor leaders, consumer advocates, insurers, and a host of other experts to cover exchange issues such as how to communicate with consumers; small businesses and exchanges; governance issues; promoting delivery system reform; and the role of exchanges in determining eligibility for premium and cost-sharing subsidies and coordinating with Medicaid.

The discussion was incredibly rich, but one theme that emerged over the course of the day - and that also was very much in keeping with HHS's vision for the meeting - is the importance of securing consumer input into health reform implementation and using a transparent decision-making process.  Glen Schor with the Massachusetts' Connector was particularly eloquent on this point, calling transparency a "hallmark" of how Massachusetts has succeeded in implementing health reform.  He and others noted it can be time consuming and cumbersome to solicit consumer input and to share all sorts of details about policymaking, but it is ultimately vital to helping people feel comfortable with major changes.

From a consumer perspective, there also was a fascinating discussion about the kinds of information that people will need to make decisions about their health care coverage under reform.  Of particular note, I thought, were comments by DeAnn Friedholm of Consumers Union about the importance of recognizing that people make decisions in different ways.  Drawing on Consumers Union's experience with publishing Consumer Reports, she pointed out that not everyone is likely to want a detailed chart comparing a health plan along a zillion different dimensions.  Instead, some people may want a much simpler set of information, such as three good health plan options from which they can choose.   While I personally am a huge fan of multi-dimensional charts and love a good spreadsheet, I'm guessing that much of America will want dramatically simplified information about how to secure coverage and enroll in subsidies.

I participated in a panel headed by Director of the Center for Medicaid and State Operations Cindy Mann on coordinating Medicaid and Exchange coverage.  Many of the ideas will be deeply familiar to long-time Medicaid and CHIP experts and advocates, including the need for unified and simplified application and retention procedures for Medicaid and the Exchange; the importance of building a strong information technology infrastructure for eligibility determinations that allows linkages between the Exchanges, Medicaid and CHIP and databases that can be used to verify eligibility; and the value of providing people with multiple ways to apply for (renew) coverage, such as the option to submit applications on-line and/or to secure help from a community-based organization.  At the same time, we discussed that the tax credits for premium assistance and cost-sharing subsidies pose some unprecedented challenges, including that the tax system is based on annualized income and is not designed to respond when incomes fluctuate over the course of a year. 

As intended, the day raised more questions than answers, but, all-in-all, was much better than a trip to the dentist.  Seriously, it was impressive to the extent to which people are beginning to roll up their sleeves and work on turning the health reform law into a practical reality.