Say Ahhh!

About 55 percent of Americans say they are confused about the new health reform law and more than half say they don't yet have enough information to understand how it will affect them personally according to Kaiser's latest tracking poll.  As was clearly evident during the health reform debate, people take their health coverage very personally.  In order to ensure that the promise of health reform becomes a reality for all, we must help people develop an accurate understanding of the bill and how it will touch their lives.

The following resources are a good place to start:

• The New York Times posted a simple, easy-to use graphic that is a great launching off point for those trying to figure out how health reform will impact them.  
• The Obama Administration maintains a site that shares the latest news on health reform and tracks how it is being implemented in each state.  The site is also the place to go for weekly webchats on health reform.  This Friday at 2:30 EDT, HHS Secretary Kathleen Sebelius and other health reform experts will focus on how stronger insurance company oversight will protect consumers.   You can submit questions by clicking here and watch it live here. 
• PICO, a national network of faith-based community organizations, created an informative poster to help community leaders and others reach out to help people understand and benefit from the new health reform law.
• Consumer Reports hosts a website dedicated to helping consumers navigate the changing health care system.  Award-winning reporter Nancy Metcalf accepts questions from consumers and posts the answers online. 

For those of you who are more concerned about the question of "what's in it for others", there have been a number of touching personal stories that demonstrate how the new law is already transforming lives. 

The McClatchy News wrote about a 12-year old boy from Fort Worth Texas with a seizure disorder whose family was unable to obtain insurance coverage for him from a private insurer.  His father agreed to a 50% cut in pay so that his son would qualify for CHIP coverage.  The enactment of health reform means the boy will either be able to move to private coverage under the elimination of pre-existing condition discrimination or a high-risk pool.  This will free up his father to earn a fair salary and start saving to buy a house (not only good news for the family but for the Ft. Worth housing market and U.S. economy).  

The Delaware News Journal ran an extensive story on the benefits of the new law and how it could help a single mother and her son who was diagnosed with diabetes just a few months before she lost her job.  

The Fiscal Times provided a very interesting snapshot of how the new law would impact coverage for individuals and families in a variety of circumstances.  

Finally, I was really impressed with the example set by a county councilwoman in Washington state who used her weekly column to help her constituents develop a better understanding of the new law.   Instead of passing the buck to federal and state lawmakers, her column demonstrates that she understands that we all have a part to play in making the promise of health reform a reality.  

All of us at CCF would be interested in hearing about what's going on in your communities to help people better understand and benefit from the new health reform law.  Please send us your comments.

So in the almost final installment of my musings on premium assistance, I am going to cover two issues and then wrap up this scintillating series (I hope - this might get toooooo long and we may have to go to Part 4 which would ruin my whole LOTR analogy.). The first question is about the new options available under CHIPRA to do premium assistance, and the second is to return to the question posed at the beginning of this series about the future of premium assistance post health reform.

CHIPRA created two new options to do premium assistance - the first through Section 301 in Title III which establishes a new option for states that have separate state CHIP programs, and the second, also found in Title III, established a new option that was added to the Medicaid statute - the elusive "1906a." This creates a new child-only option to do premium assistance in Medicaid. And other parts of Title III, as I discussed in the second part of this series , seek to remove barriers states face in running premium assistance programs. The intent of the new options was to provide federal support for the kind of premium assistance programs that make the most sense - kids receive coverage that is just as good or better - and federal and state dollars are used in a clearly cost-effective manner.

The language of these two sections is quite similar though differences in the underlying programs means in practice there are some ways in which they differ. Both options clearly require that kids have a "wraparound" benefit for services and cost-sharing protections so that they are not worse off in a premium assistance context. Both prohibit the subsidization of coverage in the individual market which is likely to be less comprehensive, more expensive, and by definition does not have an employer contribution to bring the costs down. Both require a 40% employer contribution to ensure that the coverage is cost-effective. (Note: I personally think it would be fine to get rid of this 40% requirement and just make sure that states have a rigorous cost-effectiveness test.) And the definition of cost-effectiveness is altered to explicitly include administrative costs.

Let's spend a minute on this last point - the inclusion of administrative costs in the cost-effectiveness definition. This is an important change because today some states include these costs and some don't in their assessments of cost-effectiveness. In programs with low enrollment and often-high administrative costs, this could be a very important piece of data to determine whether the program is a worthwhile use of public funds. Apparently Congress agrees, because the Patient Protection and Affordable Care Act (i.e. the health reform law) extends this new CHPRA definition to existing Section 1906 Medicaid programs, which as we discussed in Part 1, 29 states have today. (PPACA also makes some technical changes to the CHIPRA cost-effectiveness definition to clean it up but it would be REALLY boring and TMI to explain those.)

So are these new options really going to work? The language is fairly complex and states are not rushing to pick them up - wisely, I would say, given the limited payoff we have seen from premium assistance programs in the past. So far only one state, Okahoma, has had a state plan amendment approved to operate a new Section 301 premium assistance program. However, another feature of the CHIPRA law did lead to a mini-burst of interest because, in yet another example of somewhat irrational public policy making when it comes to the politics of premium assistance, having one of these new options in place helps a state to qualify for a CHIPRA performance bonus. I say irrational because the intent of the performance bonus provision is to streamline enrollment procedures, and adding a premium assistance program certainly does not do that. But there it is, so a number of states were intrigued by comments made by CMCS Director Cindy Mann, who suggested at our recently held regional meeting in Tampa, that a state could flip their 1906 program to a 1906a program in order to meet this test.

To date Wisconsin and possibly Washington have received approval to do so. But it's not quite as easy as it sounds at first blush. Two issues may deter states from making the switch. The first is that 1906a appears to include language that says that parents who are enrolled in the employer-sponsored coverage must also receive wraparound coverage even if they are not otherwise eligible for Medicaid. In states where parent eligibility is lower than kids, this is not likely to be a popular idea -even though it would be nice for parents to have those added cost-sharing protections and benefits that their private insurance might not cover. In fact there are a few states that we have heard from who are not pursuing the flip for this reason. Second, enrollment in1906a is voluntary whereas 1906 is not, so states will have to offer families the opportunity to opt-out on a monthly basis. This may have other repercussions especially for those families who are using the subsidy to purchase their coverage through a small employer - these policies often include requirement that the employer must cover a certain number of lives for a 12-month period. So some states might find this disruptive.

So it remains to be seen whether these new options really take off, and there are reasons to think that they won't. It may be that the old tried and true Section 1906 option in Medicaid remains the most viable route for states seeking to do premium assistance. And, yes, I think I am going to have to conclude this series in a 4th installment bringing us full circle to the future of premium assistance in 2014 when health reform kicks in.....

Welcome to Part 2 of my musings about the state of premium assistance. Part 1 left us with the teaser that CHIPRA includes new premium assistance options, which the new health reform law incorporates and expands to all Medicaid beneficiaries as of January 1, 2014. So let's take some time to explore where things stand with Title III of the CHIPRA law which is all about the integration of public and private coverage.

In our analysis of CHIPRA released in April 2009 we covered many of the key features of Title III the new law on p. 16. So I won't cover old ground but will pick up with some updates.

First, CHIPRA required the GAO to do a report on state premium assistance programs. That report was released in January 2010. The report is a nice summary of where states are with respect to premium assistance, although many key questions remain unanswered.  As I have found doing my own research on premium assistance states often do not keep good data on the costs of their premium assistance programs and they rarely track what kinds of coverage families are receiving. Since some premium assistance programs (generally those authorized under waivers) require families to pay all of the cost-sharing that their private plan requires, we don't know if these costs and benefit limits are preventing kids from getting the care they need.

But I digress. One of the most interesting aspects of the GAO report was that it was the first time that a 50-state survey has been done which asks states if they are subsidizing coverage under Section 1906 of the Medicaid law. This option allows states to require families to enroll in their group coverage if it is cost-effective for the state. All Medicaid beneficiaries who are enrolled in this coverage must receive wraparound benefits and cost-sharing subsidies. So this is premium assistance done right.

When I talk to state advocates who are thinking about pursuing premium assistance as a strategy, or are dealing with state policymakers who are thinking about it, especially if they are talking about pursuing a waiver, my first response is to say that your state may already be doing premium assistance through Section 1906 and it doesn't need a waiver. So now we know - 29 states are operating this kind of program. So the GAO report is a good place to start when thinking about premium assistance.

Another feature of  CHIPRA's Title III was that certain barriers to doing premium assistance that required federal statutory change were lifted. In particular, Medicaid and CHIP eligibility is now a "qualifying event" under federal law and plans have to offer a "special enrollment period." These are terms of art that mean certain happenings (like a birth or a death and now Medicaid/CHIP eligibility) allow you to enroll in a group health plan even when it is not open enrollment. Previously, in most cases, families that became eligible for premium assistance would have to wait until their open enrollment period. Now they don't.  And a child who loses Medicaid eligibility because their parents get a raise can be signed up for the employer's plan right away and not have to wait for open enrollment.

My final point of the second part is that Title III also created a Working Group which will issue a report the Secretaries of Labor and Health and Human Services and has two substantive charges:
1) To develop a model coverage coordination disclosure form and;
2) Identify impediments to the effective coordination of coverage between group health plans and Medicaid and CHIP.

Federal guidance on the special enrollment periods and information on the Working Group is available here http://www3.cms.gov/CHIPRA/09_Section311.asp

The Working Group is having its first of two meetings this coming Monday, April 26th and yours truly is a member. If you have any suggestions or thoughts to share please email me in the interim at jca25@georgetown.edu.

And as you Rings fans have already guessed, Whither Premium Assistance has evolved into a trilogy. So you will have to wait until the final installment to learn more about the elusive 1906A......

I started studying premium assistance programs in Medicaid and CHIP a decade ago with a large dose of skepticism. The idea of buying private coverage with public dollars when it is more expensive and typically covers fewer benefits than Medicaid struck me as a bad deal for beneficiaries and taxpayers alike. In many cases this is so. And most low-income families do not have access to decent employer coverage which has contributed to very low enrollment in most premium assistance programs. And because of the optics, many policymakers wildly over promise with respect to what premium assistance programs can deliver and pay scant attention to whether it will actually work and save money.

But over the years I have developed a more nuanced view about premium assistance - in some cases, if done right, premium assistance has advantages for families.  If families (and the taxpayers) don't have to pay more, and the benefits are just as good, premium assistance programs may offer a wider choice of providers and coverage for a parent who is otherwise ineligible because children's eligibility allows a family to pick up employer-sponsored dependent coverage for the whole family.

There are still many premium assistance proposals that come across my desk which reflect a rigid ideological bent and are not well conceived - the Florida legislature for example is currently considering a proposal for a waiver request to give all Medicaid beneficiaries a voucher to go out and buy private insurance - or as the Appropriations proviso reads "to allow Medicaid recipients to be integrated into the private insurance market". Hmmm.  Medicaid covers folks whose incomes are too low to be able to afford the costs of private insurance or whose chronic health care needs are often not covered by private insurance so how is that going to work without them losing access to the services they desperately need?? Sadly, rational discussions about premium assistance in the legislative world are few and far between.

But in light of the passage of health reform and CHIPRA it seems like a good time to re-evaluate where premium assistance is headed. Today let's cover the new health reform bill and tomorrow I will take a look at CHIPRA where there are some interesting developments.

The underlying health reform bill, which passed the Senate on December 24th, included a requirement that states do premium assistance if it is cost-effective. In fact Section 2003 of the bill is titled "Requirement to offer premium assistance for employer-sponsored insurance." This section amended a relatively obscure part of the CHIPRA law that created a new premium assistance option in Medicaid (known to policy wonks as "1906A") for kids, broadened it to all Medicaid beneficiaries and mandated states to do it as of January 1, 2014.

However, some Senators were not happy about this requirement, and the Manager's Amendment in Section 10203 which extends CHIP funding and includes "other CHIP-Related Provisions" deems the mandate "null, void and of no effect" in paragraph (b)(2)(B). So this leaves states with the same options they currently have under CHIPRA with an opportunity to apply the Medicaid option more broadly to all Medicaid beneficiaries as of January 1, 2014.  So in my "Whither Premium Assistance" blog part 2 I will explore the new CHIPRA options including the scintillating topic "Section 1906A" in more detail.

One of the exciting new options provided by the Children's Health Insurance Program Reauthorization Act (CHIPRA) is the ability of states to use an existing electronic data exchange with the Social Security Administration (SSA) to document citizenship. All states have entered into agreements with the SSA to use this new capability starting January 1, 2010. To date 27 states are actively using or testing the system.

The Center on Budget and Policy Priorities (CBPP) has released a report describing the early positive experience of states in using the electronic match in lieu of complex paperwork requirements to document citizenship. Author Donna Cohen Ross has followed the impact of the citizenship documentation requirement since it was implemented in 2006.

The report is the last publication written in Donna's capacity as Director of Outreach at CBPP. Later this month, Donna will join the staff in the Office of External Affairs at the Centers for Medicaid and Medicare (CMS). We are pleased to have another experienced and knowledgeable friend at CMS advocating for the systemic changes and simplification policies that will make a difference in enrolling and retaining all eligible children and individuals in Medicaid and CHIP. We wish Donna the best in her new role and thank her for this final report demonstrating successful strategies to reduce paperwork and make it easier for eligible individuals to secure Medicaid and CHIP coverage.

(Editor's Note:  Donna has been a frequent contributer to this blog and we will really miss her voice on outreach issues.)