Say Ahhh!

It was a great victory for children and families when Congress included a maintenance of effort (MOE) requirement in health reform so states wouldn't cutback on Medicaid and CHIP coverage before affordable coverage was available through the state Exchanges.  Now, as with so many issues in health care reform, the way it works out for children and their families will depend on how these provisions are interpreted by policymakers in Washington, D.C. and implemented by states. 

Fortunately, the House and Senate leadership and key health reform negotiators are keeping a close eye on the situation.  This week, they stepped forward to urge Secretary Sebelius to issue MOE guidance that will make it clear to states that they cannot set up new enrollment caps or freezes in their Children's Health Insurance program (CHIP), making it harder for eligible uninsured children to secure coverage.  Specifically, they point out in a new letter to the Secretary that the law prohibits "the implementation of enrollment caps and freezes or other restrictive eligibility procedures that were not already in place and operational as of March 23, 2010". 

The letter was signed by Speaker Pelosi, Senate Majority Leader Reid, Senate Finance Chairman Baucus, House Energy and Commerce Chairman Waxman, Senate Health Care Subcommittee Chairman Rockefeller and House Health Subcommittee Chairman Pallone.  They wrote:  "Working together, we are confident that we can continue the nation's successful track record of covering low-income children even as we move forward on a parallel track to implement broader reform that covers millions of Americans for the first time." 

I agree with that sentiment, don't you?

Mark your calendars - on July 1, 2010, HHS plans on launching the new health reform web portal to provide state-level information about affordable health coverage options. In anticipation of the launch, regulations were released today detailing what information the portal will include and how the data will be collected.

The portal will be designed to help individuals and small businesses learn about coverage options in their state. It will include information on:

• Medicaid and CHIP,
•  Health coverage options offered on the individual market,
•  Existing state high risk pools, as well as the new high risk pools established by the PPACA, and
•  Coverage within the small group market for small businesses and their employees.

In order to promote the ability of consumers to understand the information, it will be provided in a standardized format designed to "minimize the use of technical language, jargon, or excessive complexity." 

As July 1st is a pretty tight timeline, the initial release of the web portal will only contain basic information on issuers and their products. Consumers will be able to learn about issuers that sell individual and small group products in their area and follow links to benefit information for those products, as well as access some educational information on the individual market. The portal also will include information for small businesses and coverage available through the high-risk pools.

A more comprehensive version of the portal will be launched in October. This version will have benefit and pricing information, including premiums, cost sharing options, types of services covered, coverage limitations, and exclusions. 

Importantly (and beginning with the initial launch in July), the portal will also provide information on eligibility and services for Medicaid and CHIP, including contact information and websites for the state programs. (Think of it as an upgrade on insurekidsnow.gov with coverage options for parents and adults, too!)

Having all this information in one place will help families learn about and connect with Medicaid and CHIP, as well as other sources of coverage, and provide the tools that enable more people to obtain health insurance between now and 2014.

Last week my son turned in his final paper and defended his senior thesis, his last acts as a college senior. In a few short weeks, he'll join the 3 million young adults graduating from college this year. Fortunately, this year's crop of grads (and their parents) will have one less thing to worry about as they transition to work or further education: health insurance. Thanks to health reform and advocacy efforts by the White House and HHS, many major insurers have announced they will voluntarily allow adult children to stay on their parents' health plan earlier than is required by the new health reform law.

Continuing access to their family's health plan for young adults - the age group with the highest uninsured rates - is one of the significant early wins in health reform for children and families. As of September 23, 2010, all new or renewing plans will be required to cover young adults up to the age of 26 as dependents regardless of their student status (unless they are eligible for employer-sponsored health insurance). About two-thirds of the states had previously taken similar action but the individual state laws did not apply to large group and self-insured plans governed by federal regulations. These states often excluded young adults who were married or did not live at home.

Until March 30, 2010, those continuing dependent benefits provided through state laws had also been subject to federal tax causing additional administrative work on the part of employers and incurring tax liability on the part of families who were able to continue coverage for their young adult children. Health reform has taken care of this problem as well by making these benefits tax-exempt. The tax exemption also applies to qualified medical expenditures under flexible spending accounts for adult children.

Luckily, my son has a job that will provide health insurance. But I am relieved he has something to fall back on should he experience a gap in employment or decide to tackle graduate school. And I'm thrilled to see tangible and early results from the new health reform law in improving access to health coverage for children and families.

Where we left off: I was musing that the new CHIPRA options to do premium assistance may not prove to be all that much more attractive than the existing ones. Some states may reconfigure their programs (if they can) to qualify for the performance bonus.  So far there hasn't been a rush to pick up these options.  But as we know from the GAO report, a majority of states are already doing some form of premium assistance today.

Yet what about in 2014 when the Medicaid expansion in PPACA kicks in?? On the Medicaid side, states will have two options - the existing Section1906 option and the CHIPRA 1906a option that will be extended to new populations as of January 1, 2014 by PPACA. When states move to an across-the-board eligibility of 133% of FPL, what will this mean for the success or failure of premium assistance programs in Medicaid?

In some ways, premium assistance may be more attractive to states that currently have low parent eligibility levels because the whole family will now be covered through Medicaid. This will make the cost-effectiveness equation more favorable, and eliminate the problem I described in Part III of this blog about states having to provide a wraparound for parents in the new Section 1906a option. But enrollees in most premium assistance programs that I have looked at tend to cluster at the higher end of the income eligibility scale - which is usually above 133% of FPL - because access to employer-sponsored insurance is so scarce at these low income levels. And we are talking really low -- recent data from the Urban Institute suggests that only 14% of people below 133% have employer-sponsored insurance.

For families above 133% of FPL, the question is more complicated - especially in states with more generous income eligibility today. The maintenance of effort requirements for kids in Medicaid and CHIP are in effect until 2019 while their parents are most likely going to be in the new Exchanges receiving a premium subsidy or receiving coverage through their employer. This might make premium assistance an attractive option from the perspective of keeping the family together - assuming kids don't lose benefits or cost-sharing protections in the process. The impact of reform on costs in the private markets may prove a factor in states' thinking about whether to pursue premium assistance options. So, a lot to mull through there and food for future blogging thoughts. That will have to wait for the Appendices.

While the federal government still has a great deal on its plate in terms of implementing health reform (we at CCF are eagerly awaiting every bit of guidance and regulation CMS can throw at us!), many key tasks now move to the states.

Should we set up a new high-risk pool? What should our exchange look like? Who should run it? How do the new insurance reforms interact with our current protections? To help sort through all these complicated and intertwined issues, seven states have set up commissions, advisory councils, or offices of health reform to take a look at their options and help guide implementation.

Connecticut was first out of the box, with the Governor establishing a 15-member board (the Connecticut Health Care Reform Advisory Board) way back in July. Since then, Colorado, Maryland, Michigan, Washington, and Wisconsin have stepped forward. And, just last week, the Governor of Maine signed an executive order establishing the Health Reform Implementation Steering Committee.

These commissions/offices are comprised of agency heads (like the Secretary of Health and Human Services and the Insurance Commissioner) and sometimes include other interested parties (such as representatives of the hospital industry). While none include a consumer or advocate voice on the panel itself, most provide some sort of mechanism for public comment. Take Colorado as an example - where the board can establish task forces that include outside groups, including consumer advocates.

As health reform moves toward implementation, it's important to keep tabs on what your state is doing. Have they established a commission? Are consumers and advocates represented on these boards? If not, is there a way to expand representation or does the public have another outlet to provide comments?

Depending on the state, these commissions may yield a great deal of power in influencing what reform looks like. It's important that all voices are heard in the process.

If you want more details on the various commissions and links to the executive orders, check out RWJF's State Coverage Initiatives' States Take Different Approaches to Respond to Federal Health Reform.)