Say Ahhh!

By John McInerney, Health Policy Director, The Commonwealth Institute for Fiscal Analysis

Families in Virginia can breathe a bit easier these days, as efforts by Governor Bob McDonnell and the House of Delegates to tighten eligibility in the states' CHIP program have failed.

Virginia's program is called Family Access to Medical Insurance Security (FAMIS), and it covers children and pregnant women up to 200 percent of the federal poverty level (FPL).  While the eligibility standard is among the lowest in the nation (Virginia has a gross income standard, with no deductions), the program has still been able to enroll a lot of low-income kids.  Over 155,000 received FAMIS coverage at some point in the 2009 federal fiscal year.  For the past several years, FAMIS has enjoyed overwhelming support from lawmakers and the public as a cost-effective and efficient way to cover low-income children and pregnant women. 

This year, however, Virginia faced a two-year budget shortfall of over $4 billion. Instead of taking a balanced approach, the Governor targeted education and health care for cuts (the Governor and the General Assembly rejected options to preserve these important priorities by raising additional revenue).  Health care is the second largest share of Virginia's budget, although we are less generous than most other states.  In fact, Virginia is one of the 10 wealthiest states in the country, but ranks 48th in per-capita Medicaid expenditures. The state only covers children up to the federal minimum of 133 percent of FPL.  Parents fare even worse, with eligibility only extending up to 29 percent of FPL, just over $6,000 a year for a family of three. 

With very few optional Medicaid spending programs to cut, Governor McDonnell proposed in February to freeze enrollment in FAMIS, a change that would result in a reduced enrollment of over 28,000 kids and pregnant women within two years.  A few days later, the House of Delegates released their budget proposal, rejecting the Governor's proposed freeze and instead proposing to lower income eligibility from 200 percent to 175 percent of FPL.  This proposal would kick about 30,000 children and pregnant women from FAMIS and would reduce state spending by over $37 million over two years.  If enacted, Virginia (again, one of the 10 wealthiest states) would be competing with North Dakota for the most restrictive income eligibility in the nation for our CHIP program. 

Fortunately for supporters of the program, the Virginia Senate did not seek to reduce FAMIS eligibility in their version of the state budget (In fact the Senate passed, but did not fund, legislation to increase FAMIS eligibility to 225% FPL.). Thus, in a compromise, the final budget deal reached on March 14 postponed the cuts to FAMIS until July 1, 2011 and stated that the reduction would be completely reversed if Congress passed a six-month extension in enhanced federal Medicaid assistance that could provide Virginia approximately $370 million in additional  federal funding for the overall program. 

The news improved even more on March 23 when President Obama signed the Patient Protection and Affordable Care Act (ACA).  The maintenance-of-effort requirement in the new law will protect state Medicaid and CHIP programs from eligibility and benefit cuts until the ACA's coverage expansions begin in 2014. 

Yet, although a significant reduction was averted in 2010, challenges still remain.  Virginia's Attorney General and Governor are pursuing questionable lawsuits and challenges to the ACA, and a new law was enacted that seeks to prevent any federal mandates to purchase health insurance.  Certainly, attempts to circumvent the maintenance-of-effort are possible in our state.  So, while our modest FAMIS and Medicaid coverage for kids and families remain protected for now, we will still need to stay vigilant against efforts to weaken them in the coming years.    

(* Jill Hanken with the Virginia Poverty Law Center contributed to this post.)

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

By Donna Cohen Ross, Center on Budget and Policy Priorities 

All in one night -- February 11 -- 10,484 eligible children were enrolled into Louisiana's Medicaid program. 

Are you trying to imagine this? If so, you're probably picturing mile-long lines of children winding through Baton Rouge, parents in tow, clutching packets of forms and documents.  A winter storm warning is in effect -- so said the Baton Rouge newspaper that day -- and freezing rain is already pelting the city, with an accumulation of 1 to 2 inches of snow expected overnight. The crowd of babies and toddlers, tweens and teens, and thousands of others are just waiting, waiting, waiting.  You're thinking this is an ill-advised stunt.  Can't be done.  Not even with every eligibility worker plugging away, all night, nonstop. Not even with every family equipped with every bit of paperwork in hand, exactly in order. No way. Your anxiety level is out of control just thinking about it.

If this is where your imagination has taken you, relax.  What really happened in Baton Rouge that night took place calmly and efficiently while those thousands of children, families and eligibility workers were fast asleep.  What really happened was that 10,484 children got enrolled in one fell swoop through a new CHIPRA option called Express Lane Eligibility. 

All together, in one night ... done!  And they did it using findings from the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, to determine Medicaid eligibility.  Make no mistake, however.  Louisiana officials didn't just snap their fingers. It took many months of careful planning and preparation -- and coordination with the separate agency that administers SNAP in Louisiana -- to be sure the process would substantially ease enrollment and at the same time preserve program integrity. 

Here's how it worked: State officials started with the knowledge that children who qualify for SNAP are in families with income that meets the test for Medicaid, and a significant proportion are likely to be uninsured.  A file containing all children receiving SNAP benefits was transferred electronically from the computer system at the Department of Social Services to the computer system at the Department of Health and Hospitals, where Medicaid resides. Children already on Medicaid were removed.  The remaining file of children receiving SNAP but not Medicaid provided income findings, as determined based on food stamp rules, as well as the children's Social Security numbers, residency and age.

Under Express Lane there is no need to recalculate income using Medicaid rules. So, these "borrowed" findings are used, along with other necessary information obtained from available data bases (such as U.S. citizenship from the Social Security data base) to determine Medicaid eligibility and enroll the children.

Next, Medicaid cards and decision notices were mailed to the families.  At that point, they were  informed that the last step in this process -- affirming they want to enroll their child in Medicaid -- would happen the first time they use the card to see a doctor or fill a prescription. 

Ruth Kennedy, Louisiana's Medicaid Deputy Director, explains the significance of the February 11th feat:  "Express Lane Eligibility is a huge administrative efficiency and takes advantage of 21st century technology. It demonstrates that we can reduce duplication of effort when government agencies work together."  Ruth says that the state will be monitoring the system to refine the process and make sure that children enrolled through Express Lane are using their health care benefits -- a sign that the new system really works.  Going forward, she anticipates that SNAP findings will be used to automatically enroll children in Medicaid when they are determined eligible for food assistance.  Isn't this just the kind of coordination Secretary Sebelius and Secretary Vilsack were talking about when they joined together to celebrate the first anniversary of CHIPRA last month?  

So, are you still visualizing those 10,484 children standing in line with their families to gain access to health benefits?  Erase that image and instead picture them avoiding unnecessary ER visits, getting critical preventive care, medical treatment and the prescription medications they need.  Nice picture, huh?  Not bad for a night's work!

(Editor's Note:  While CCF staff had their noses buried in legislative language and watched the health reform debate from the comforts of their own homes, PICO's Gordon Whitman was out on the front lines. From what we saw on our televisions, there was a lot of commotion as protestors on both sides of the issue gathered on the Capitol grounds.  An immigration march also took place that day adding to the crowd. We asked Gordon to share his observations from the final climactic stages of the health reform debate.  The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.) 

By Gordon Whitman, PICO National Network of faith-based community organizations

Sunday, March 21st, was one of those days that remind you how change is not linear in our crazy mixed-up Democracy.  At five o'clock in the afternoon, as the House of Representatives inched toward a final vote on health reform, many of the estimated 200,000 people who were on the Mall to breathe life into immigration reform streamed up and around the Capitol.  These were mostly young Latino families, many waiving or draping themselves in American Flags.   It was surreal watching the immigration march - which was virtually invisible in the media (not unlike its protagonists) - flow around the several hundred people protesting against and for health reform.  

I watched an older Anglo women lecture (in Spanish) a group of young Latino men, who were sitting on the wall, behind the Capitol about the evils of Obama-care.  "Obama-care is Communism. You didn't come to this country for Communism, you came for liberty."  One man replied, "Ma'am, I'm not a citizen, so I don't think I can tell Congress what to do about health care.  But let me become a citizen and then I'll take a position."  Suffice to say, there wasn't a lot of persuasion taking place.

As a community organizer, (saying that used to provoke blank stares, now it feels like picking a fight) it was a bit odd to be escorted through the protests into the Capitol Building to watch the final vote from the Speaker's box in the House Gallery.  A year earlier, during the final vote on CHIP Reauthorization, I'd sat in the same spot with Rev. Heyward Wiggins, who pastors an inner-city church in Camden, New Jersey.  Rev. Wiggins co-chairs PICO's National Steering Committee and has led our work on health reform.  It was hard not to feel a bit vindicated, those of us who argued against much opposition that a victory on covering children would be an ideal stepping stone for broader reform, rather than an excuse for putting off the fight for universal coverage (it is nice to be able to use the word universal again).

It was quite an experience watching the social interactions among Members and staff on the floor.  You see how important senior staff are to the process; and how divided the chamber is physically and how much rancor there is between Republicans and Democrats. The Republicans were clearly frustrated and angry; and the Democrats were celebrating. Speaker Pelosi looked thrilled. She was able to round up the votes plus a bit of a cushion ahead of time, so the Leadership avoided what many people expected to be intense arm-twisting on the floor leading up the vote.

As the President said earlier in the month, after a year of debate, almost everything that could be said about health reform has been said; so much of what was being said on the House floor echoed the talking points that we've heard all year.  I thought Rep. Debbie Wasserman Shultz broke through emotionally when she talked about being a breast-cancer survivor and what reform would mean for women like her who have life-threatening pre-existing conditions.

The high emotion of this week reflects the reality of how close reform came to failing.  Doubt is an unavoidable emotion.  Avoiding death is an exhilarating experience.  As organizers, we believe that social change happens when people realize how much power they really have.  Coming up short on an organizing campaign (which almost always happens at some point) teaches us that we need more power; winning teaches us that we are more powerful than we ever thought.   The moral arc of the universe bends toward justice because we bend it as we grasp the power that comes from being human.  

The fight to make health care a right in the United States spans generations.  In 1965, a gifted President committed to lifting people out of poverty met up with a Civil Rights Movement at the height of its influence to create a remarkable environment for large-scale legislative change.  In the course of less than a year, Congress passed Medicare (and Medicaid) which broke the link between aging and poverty for tens of millions of Americas; the Voting Rights Act, which institutionalized the political liberation of African-Americans in communities across the United States; and the Immigration and Naturalization Act, which ended racial quotas in the immigration system and opened the doors of the nation to a generation of immigrants from Asia and Latin America.

In the 45 years between 1965 and 2010, Americans grew to love Medicare, but progress toward truly universal coverage was incremental and uneven at best.  Congress took important steps to expand the Medicaid program to cover more poor families; and in 1994 it created the State Children's Health Insurance Program.   Mostly, though, there were failures, most spectacularly the Clinton health reform debacle in 1993-94.  As Health Care Economist Len Nichols has said, not a single soul was covered as a result of the Clinton reform effort, and perhaps as many as one-quarter million people died prematurely as a result of that failure.

Between 1994 and 2004, most of the action was at the state level, as state advocates and organizers and state governments used Medicaid and SCHIP to cobble together initiatives to expand health coverage.   Our PICO network's involvement in the health reform movement began during these years, as our affiliates responded to the growing number of uninsured families by joining with advocacy groups to fight for more funding for safety net clinics; and to help create the first county programs that provided truly universal coverage to all children, regardless of income or immigration status.  

The media is not good at history and is virtually incapable of covering the patient, sometimes very impatient, work of building the foundation for the kind of fundamental change that took place this week in Washington, DC.  National health reform rests on the foundation of local and state organizing and advocacy.

There is no way that our network could have participated in any meaningful way in the national health reform debate without first having worked to pass a strong children's health insurance bill, and there is no way we could have done that without the policy analysis by CCF and the support from the Center on Budget Policy and Priorities, Community Catalyst and other organizations.

We sent out a thank you note to our grassroots leadership, thanking people for all of their work, especially their laser-like focus on affordability for lower-income families.  We did not get everything we wanted in health reform, but the late addition of $122 billion in additional subsidies to lower premiums and out-of-pocket costs for lower-income families; the increase in primary care provider payments in Medicaid; the $12 billion in funding for Community Health Centers and the continuation of CHIP through 2019 were all important improvements in the final bill that will make reform work better for low-wage working families, which has always been PICO's primary reason for being in this debate.

A right to health care in America is no small thing.  But we know that between organized campaigns to repeal and undermine reform and recalcitrant insurance companies our work is cut out for us.  As we learned from the Civil Rights Movement, redeeming the right is always more difficult than winning the commitment. 

On Tuesday evening, after the signing ceremony at the White House, I was at CVS arguing on the phone with my insurance company to get them to cover medication that my son's pediatrician had prescribed for a really bad rash.  Blue Shield insisted they could not cover it because there was a different cream (not a generic) that was cheaper and they believed worked as effectively.  After asking to speak to a supervisor and explaining that the doctor's office was closed and I wanted to get my son moving on the medication tonight, I found myself saying (not too politely) you are standing between my son and his pediatrician.  I was given a "pay and educate" lecture, which I had no patience for, but felt empowered (perhaps by health reform) walking out with the medicine.  When I came home and told the story to my son, he asked, "Why did that happen, I thought President Obama signed health care today?"

PICO is a national network of faith-based community organizations working to create innovative solutions to problems facing urban, suburban and rural communities.

It's appropriate that we are celebrating the passage of health reform while enjoying the first signs of spring. With snow banks receding and the sun warming, we happily anticipate the bounty of health reform as we watch the early sprouts emerge.

Ongoing state budget woes, however, remind us that a spring snowstorm can still bring a chill to the air. But like the hardy daffodil, early provisions in health reform are intended to fortify current programs so we can focus on moving forward without losing ground.

Health reform relies on Medicaid and CHIP as fertile soil to yield a bigger crop of insured low-income adults and children: 16 million more. Growth can only be assured if we protect the coverage gains states have achieved through current CHIP and Medicaid programs as we plant the seeds to provide affordable health coverage for all.

To protect current programs from the frosty state budget climate, the health reform law discourages states from pruning current eligibility levels and imposing new paperwork and other barriers to enrollment and renewal. To ensure we reap the harvest of a smooth transition to health reform, this MOE is applicable through 2014 for adults and 2019 for children.

MOE's are not new. For example, when CHIP was created in 1997, states were required to maintain their Medicaid coverage for kids in order to tap enhanced CHIP federal funding to expand coverage. States are currently subject to an MOE on Medicaid as a condition of accepting the enhanced federal Medicaid match (FMAP) through the American Recovery and Reinvestment Act (ARRA).

There is a significant penalty if states choose to disregard the MOE in health reform. Program changes in violation of the MOE will result in the loss of all federal Medicaid funding. It doesn't seem like a tough row to hoe for states to extend the MOE to their CHIP programs considering the more significant losses - that is all Medicaid funding compared to only the enhanced federal match provided through ARRA.

The MOE doesn't mean children and families can rest easy during this transition phase.  States can still scale back by eliminating optional benefits or reducing provider reimbursement rates, which can have a chilling effect on access to services like a late frost damaging fragile seedlings.

Ultimately, the Centers for Medicaid and Medicare (CMS) will determine whether or not a state is maintaining its effort. It is not yet clear how CMS will enforce the MOE for states that have not implemented an approved enrollment freeze or cap if they exceed state appropriations. While awaiting guidance from CMS, if you want to dig deeper into this issue, check out the recently released "Holding the Line on Medicaid and CHIP" memo from CCF and the Center on Budget and Policy Priorities.

For some reason or another, there always seems to be a lot of misinformation swirling around when it comes to Medicaid.  At CCF, we received a flurry of calls about how health reform's Medicaid provisions would impact state budgets.  One call came from WAMU (local public radio station) reporter Rebecca Blatt who was trying to explain to her listeners why Maryland was estimating that health reform would save the state money while its neighboring state of Virginia estimated that it would cost the state more money.

Here's Rebecca's report:

States are releasing their estimates of how much the new federal health care law will cost them. Virginia says it will amount to about $1 billion dollars over the next decade or so, but Maryland says the law will save it about $1 billion.

The key to the difference is the fact that Maryland already offers relatively generous benefits, while Virginia does not. For instance, to the tune of approximately $100 million a year, Maryland subsidizes insurance for high-risk people. John Colmers, Maryland's Secretary for Health and Mental Hygiene, says that will change.

"We will not have to do that when the insurance rules are rewritten to eliminate pre-existing condition restrictions," says Colmers.

There will be some cost to the new federal law. But Colmers says reductions in other services will more than make up for it in Maryland.

Not so in Virginia. Medicaid, the health insurance program for the poor, will be the Commonwealth's biggest expense. Virginia will have to cover many people who already would be covered in Maryland.

Joan Alker, co-executive director of Georgetown University's Center for Children and Families, says there are upsides to that. The federal government will pay for almost all the expansion.

"So for a state like Virginia, that has not been as generous as a state like Maryland in its coverage, they'll actually get more federal dollars and benefit more from the reform bill," says Alker.

But they'll also have to pay more. That's why the new law may cost Virginia money and save it for Maryland at the same time.

 (*Editor's Note: Health reform may benefit states far more than any of the early estimates predict -- particularly for those states that got out in front on covering uninsured residents.)

You can listen to the report on WAMU's website.

How is this issue being discussed in your states?