Say Ahhh!

We've said it before, but it bears repeating--we don't have to wait until 2014 to expand access to health coverage or to get started on reform efforts.  Medicaid and CHIP coverage is already available to most of the nation's uninsured kids (and it's time to get them enrolled). Important benefits of the health reform law are also here already:  The Patient Protection and Affordable Care Act contains a range of opportunities for states (and in some cases, other entities) to claim federal funds this year for new program options, demonstration grants, and extensions of existing programs.  Other grants are available next year and in the future.  

The National Conference of State Legislatures has compiled the details on many of these opportunities.  A few are particularly intriguing for those interested in coverage for low- and moderate-income children and families:

•  Consumer Assistance/Ombudsman Programs.  Keeping people informed of the new protections that will be available for private coverage and the new coverage options available in Medicaid, CHIP, and the Exchanges will take some effort.  The law provides for federal support for state offices of health insurance consumer assistance or health insurance ombudsman programs.  While these programs will certainly include information on private health insurance, it's important for advocates for Medicaid and CHIP to speak up to make sure that families can get assistance in one place on all the options available to them--including public programs.  Find out more on consumer assistance from Community Catalyst.  
• Maternal, Infant, and Early Childhood Home Visitation Grant Program.  Home visits from nurses, social workers, or other child development specialists can help kids and parents stay healthy and on track for proper development.  Health reform devotes funding to states for planning and carrying out home visitation programs.  The funding is available this year and each state must conduct a needs assessment by September, so the time is now to find those in your state working on this topic, likely in the Maternal and Child Health office.  HRSA has opened applications for the initial round of funding under this grant program.  
•  Exchange Planning Grants.  Other than Massachusetts and Utah, states have very little experience setting up and running health insurance exchanges.  To help states plan for the Exchanges, states will be eligible for grants by March of 2011 under a formula to be determined by the Secretary of HHS.  State plans under these grants will be the first steps toward key decisions like who will run the eligibility systems for the exchanges and how they'll be structured.  We'll be sure to share further details once they're available and we'd love to hear updates from you on any state activity in advance of these grants.
• Other grants will support the development of health homes for Medicaid enrollees with chronic conditions, pregnancy assistance services delivered by high schools and colleges, and school-based health centers.  

The NCSL link above will help you keep track of the amounts, year of implementation, eligibility, and other details of these grant opportunities.  But for a quick reference guide for the grants as well as a range of other state responsibilities and options under health reform, check out this Policy Brief from the Center for Healthcare Research and Transformation, a partnership between the University of Michigan and Blue Cross Blue Shield of Michigan.  It only provides a brief bullet point on each provision, so be sure to check elsewhere for complete details; nonetheless, it's a handy guide that breaks down state requirements and options by year of implementation.  

By Gretchen Hammer, Colorado Coalition for the 

Medically Underserved

and Ashlin Spinden of Metro Area for People

Colorado Governor Bill Ritter, Jr. has a new health care mantra:  "Because we didn't wait for Washington, Colorado is now one of the best-positioned states in the nation to effectively implement health care reform."  Governor Ritter has made this statement in public appearances, signing ceremonies, and everywhere else he has been to talk about health care in the last few months.   And, he is right.  Colorado is taking bold actions to propel us forward toward successful implementation.

As a key first step, Governor Ritter has established, through an Executive Order, a state Director of Health Care Reform Implementation, naming Lorez Meinhold, his current Senior Health Policy Analyst to the position.  The Executive Order also established the Interagency Health Reform Implementing Board which will provide an administrative infrastructure for the numerous departments and agencies working on implementation.  In addition, the state has established a central website for all things related to health reform.

Another key component of our progress toward reform is the expansion of Medicaid for parents up to 100% of the Federal Poverty Level.  This expansion, as well as the expansion of our CHIP program (Child Health Plan Plus) to 250% of FPL became effective May 1, 2010 as part of the Colorado Healthcare Affordability Act passed by the state legislature in 2009.  Financed through a hospital provider fee and using no state general funds, this law increases payment for hospitals and funds a number of public coverage expansions.  The Colorado Department of Health Care Policy and Financing estimates 44,000 parents and 24,000 children and pregnant women are eligible through these expansions.

In the state's third bold act, Colorado State Senate President Brandon Shaffer publicly agreed to take the HHS Secretary's Connecting Kids To Coverage Challenge.  During a meeting to promote access to health care for all children sponsored by the Boulder Valley Community Action Network, a member of Metro Organizations for People and the All Kids Covered Initiative, Senate President Shaffer heard personal testimony from members of the community about Medicaid and CHP+ being a life-saving resource for their families.  Boulder Valley Community Action Network then asked Senate President Shaffer to accept "The Secretary's Challenge: Connecting Kids to Coverage."  The "challenge" is a five-year campaign challenging leaders to build on the successes of the CHIP and Medicaid program by finding the remaining five million eligible but unenrolled children nationwide.  Without hesitation, Senate President Shaffer accepted the challenge and shared his vision of a streamlined enrollment process free of barriers, public service announcements educating the public about these programs, and implementing the recently passed 12-month continuous eligibility to ensure that all eligible families are enrolled into Medicaid and CHP+.  As one of the first elected officials in the country to accept the Secretary's challenge, Senate President Shaffer has set a high bar for all of us to continue to act boldly and get all kids in Colorado covered.

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

Under the health care reform law, employer health plans or those on the individual market in existence on March 23 (when the legislation was signed by President Obama) have been exempted from some, but not all, of the insurance reforms in the bill. This "grandfather" provision is a critical component of health care reform because it ensures that families can keep the coverage they have now.

New interim rules recently released by the Administration maintain this safeguard while also making certain that employers cannot create additional burdens for individuals by cutting benefits or increasing costs.  If they do, it triggers the additional protections in the bill, like ensuring that children receive critical medical and developmental screenings at no cost or ensuring family members who are sick cannot be denied coverage. (For a list of insurance provisions that apply to grandfather status, see the chart developed by HHS.) 

Under the rules, health plans and employers will lose their "grandfathered" status if they:

o Eliminate or substantially reduce benefits related to a particular health condition.

o Increase copayments by more than $5 or the cost of medical inflation plus 15 percentage points, whichever is greater. Deductibles could also not be raised by the same medical inflation calculation. (Note that medical inflation has averaged 4 to 5 percent in recent years.)

o Decrease the employer contribution by more than 5 percentage points.

o Increase co-insurance charges (a fixed percentage of the medical charge paid by the patient).

o Apply new annual limit restrictions or tighten limits already in place.

o Switch insurance companies. (Only that particular plan would lose the grandfather status, other plans offered by an employer through an existing insurance company would retain their grandfather status.)

Federal authorities estimate that by 2013 about half of employer-sponsored plans will lose grandfather status because of significant changes made to the scope and cost of coverage. With the new rules in place, however, these millions of children and families will be assured that they receive the same protections under health reform as others newly signing up for coverage. Now that's something to tell our grandchildren about!

For more information see the Administration's fact sheet on the new interim rules.

The National Academy of State Health Policy (NASHP) is an independent academy of state health policymakers working together to identify emerging issues, develop policy solutions, and improve state health policy and practice. Recently, its executive committee identified ten aspects of health reform that states must get right in order to successfully implement federal health reform. Like the health reform law, the top ten list covers a broad range of objectives and responsibilities:

1) Be Strategic with Insurance Exchanges

2) Regulate the Commercial Health Insurance Market Effectively

3) Simplify and Integrate Eligibility Systems

4) Expand Provider and Health System Capacity

5) Attend to Benefit Design

6) Focus on the Dually Eligible

7) Use Your Data

8) Pursue Population Health Goals

9) Engage the Public in Policy Development and Implementation

10) Demand Quality and Efficiency from the Health Care System

With the dust settling on the passage of health reform, attention is shifting from the early provisions of the law such as coverage for young adults under their parent's plan and consumer-friendly insurance reforms including eliminating pre-existing exclusions for children, lifetime caps and rescissions of policies. Many states have launched formal or informal groups to begin the planning and decision-making process. According to the National Governors Association (NGA), at least a quarter of the states have formally launched commissions, task forces or advisory groups. The lack of consumer representation on these state structures is a bit disappointing given that engaging the public has been flagged as one of the top ten critical areas.

Two of my favorites among the top ten are simplifying and integrating eligibility systems and using data to analyze and improve your programs. Those of us working on children's coverage know how important these aspects of program administration are to the ultimate success of enrolling all eligible children and families. Both rely on well-designed, high-functioning technology based on simplified processes and streamlined procedures.

The NASHP brief puts it bluntly: "36 million Americans cannot be enrolled in Medicaid or the new exchanges by relying upon what, in most states, is a county-based eligibility platform designed around the cumbersome and intrusive processes of the welfare eligibility system." Touche`!

Effective systems are expensive and time-consuming to build and implement. There is an important role here for the federal government to assist states in system procurement, to standardize data reporting requirements and to require that systems meet data reporting standards as a condition of federal funding. We cannot hope to meet our coverage goals without data to analyze how well our programs are working and identify where improvements are needed. Public reporting of data on enrollment, retention, access to care, health outcomes and much more will be the best way for Americans to know when states are truly getting it right!!

So as Part 1 described it is a little hard to predict what the role of waivers will be in the new world. But one thing we do know is that more standards regarding transparency and public participation are coming our way.  And they are coming soon - one of the first things out of the box. Yeah!!

OK, I know, this is a niche thing but we have been highlighting the need for more transparency and public participation in the waiver process for years (and years). Often critical and high stakes decisions about Medicaid financing, and the benefits that beneficiaries will receive (among other things) are made in closed-door negotiations between the state and the federal government. Beneficiaries and their advocates and providers have little input into the process. Members of both parties in Congress have been concerned about this trend for some time, and the GAO has issued numerous reports over the years highlighting these concerns.

So in two separate provisions, the Patient Protection and Affordable Care Act (PPACA) directs the Secretary of Health and Human Services to promulgate regulations that establish a process for public notice and comment at the state and federal levels (Geeky bill readers see Section 10201 (i)  and Section 1332 (a)(4)(B) for the new waiver for state innovation provision.) And the statute directs the Secretary to issue the rules within 180 days of the date of enactment (that would be on or about September 23, 2010). So this is one of the first things that CMS has to do and they are already hard at work thinking about it.

To help them think those great thoughts, we developed a set of recommendations in conjunction with our partner in crime on this issue, the Center on Budget and Policy Priorities, and a diverse list of consumer and provider groups who have followed waiver issues closely with us through an informal "Waiver Task Force" that I have co-chaired with Judy Solomon at CBPP for a number of years. Let us know if you have other ideas, and stay tuned for the regulations when they come out - no doubt they will be issued as proposed so there will be an opportunity for public comment in September.

Also while we are on the topic a big shout out to CMS for including a public notice requirement in their recent final regulation on "benchmark" benefit rules in Medicaid.

Even though these changes can be made through state plan amendments, they can be of fundamental importance to beneficiaries so having an opportunity for public notice and comment is essential.

So we will revisit this issue in the fall when the proposed rules come out. This is probably a good chance for me to mention that I will be in foreign lands for the summer with my family. To be specific, we are headed to Bolivia for about 8 weeks as my husband dives into some human rights questions there, and the girls and I attempt to learn some Spanish and soak up the culture. I will be back at work on September 1st just in time to pick up this issue for the next round!