Say Ahhh!

CCF is hitting the road!  We've scheduled four meetings around the country to bring together child and family health advocates to discuss opportunities and challenges for moving forward on coverage.

Our first meeting, for the Southern region, took place last week in Tampa, Florida and despite how difficult it is to hold a health conference with the uncertainty surrounding health reform, it went very well. But you don't have to take my word for it -- Michele Johnson of the Tennessee Justice Center blogged about her experience at the meeting.  You can also find the presentations and materials from the meeting on our website. 

Next week, we'll be in Providence, Rhode Island for the Northeast region conference and April will find us in Salt Lake City, Utah, for the West and Cleveland, Ohio, for the Midwest meetings.  It's a great opportunity to meet with your neighbors to discuss what's working in their states.  If you can't make it when we visit a state near you, check the CCF website for materials and related resources.

By Michele Johnson

Managing Attorney and Co-Founder, Tennessee Justice Center

The Southern Regional Meeting of Transforming Health Care Coverage for Children and Families was just what the doctor ordered.  For anyone feeling down about health reform or frustrated with the status quo, you need to attend this meeting!  The technical information about the health care bill, the messaging workshop and success stories from other southern states were so valuable and hopeful.

The messaging workshop put on by Ed Walz from Spitfire Strategies was full of practical tips about how to be heard by policymakers and the public. Ed, always entertaining and compelling, gave us the recipe for communicating effectively. Among other things, he taught us how to write effective blog articles (like this one, I hope!), letters-to-the-editor, and blast emails. By day's end, I not only felt like I could do it, but we had actually done it in hands-on activities.

The presentations about both the nitty-gritty of the health reform bill and the opportunities of CHIPRA were extraordinary. They contained crucial data about the demographics of the eligible but uninsured children who are waiting for us to reach them now.  They laid out who will be helped by reform and how. What useful tools to have at our fingertips as we try to raise resources to reach these children! The health reform waiting game has seemed paralyzing in so many ways, but these presentations gave me a "to do list" of practical and immediate steps to enroll children and keep them enrolled.

My favorite part of the conference was seeing and hearing about the experiences of my southern sister states.  I heard from friends, old and new, about the challenges they are facing and overcoming. Sometimes working for health care for children in the South can be isolating and demoralizing, so hearing from others facing similar hurdles was moving. Amazing work is going on in our region!  I left the conference reminded of Anne Frank's quote "How wonderful that nobody need wait a single moment before starting to improve"...healthcare for children in the South!

Thanks, Georgetown Center for Children and Families and partner organizations for using your extraordinary talents to improve policies every single day for children in Tennessee and all over America. 

Editor's Note: Say Ahhh! readers aren't fooled by Michele's modesty as we've seen some great blogs out of her before.  With all the nice things she's saying about CCF and our friends, we just might have to make her a regular.

A recent subtext in the debate on health care reform has been about Medicaid's alleged failure to provide its enrollees with access to care - the argument goes that the parents and childless adults who would be added to Medicaid as a result of leading proposals would mean that 15-18 million people would be dumped into coverage where they wouldn't be able to see a doctor. As often is the case in Washington, the facts are considerably more nuanced than the talking points. 

First, research is very clear that Medicaid has increased access to care and reduced unmet health needs for both children and adults. In fact, in terms of primary and preventive care, access to care in Medicaid is approximately equivalent to that in private insurance. Access to care issues in Medicaid are more likely to arise in certain specialties (most notably such as access to dentist care) and in certain geographic areas and they most certainly exist. But having Medicaid has been critical in improving low-income children's access to needed care.

We're all aware (perhaps from our own experience of trying to find a doctor who will take our insurance) that having an insurance card does not necessarily ensure access to care. I have virtually given up finding an internist that will take my Georgetown University Blue Cross plan. Doctors and hospitals pick and choose which insurance plans they'll take.  A recent Center for Studying Health System Change survey asked physicians whether or not they were accepting new patients. Their answers varied by patient insurance type: 

Yes, there are more doctors who are not accepting any new Medicaid patients, compared with those accepting new patients covered by Medicare or private insurance. But overall, more than 70% of doctors are accepting at least some new patients covered by Medicaid.

Part of the issue with the slightly lower physician participation in Medicaid could have to do with lower reimbursement rates, which are about 72% of those paid in Medicare (and these rates are supposedly lower than private rates, but a true comparison is tough since that information is deemed "proprietary"). 

Now, people may legitimately say that adding an additional 15-18 million people to the program is likely to exacerbate access problems. It is true that adding that many people into the system requires consideration of the program's capacity to provide the care people will need. The most obvious solution -- an increase in reimbursement rates.

And there may be hope on the horizon for just such a solution. Following the health reform summit, the President has appeared to embrace this idea. The House included a provision in its health reform bill for a phased-in increase in Medicaid reimbursement rates and it also seems to have bipartisan support (Sen. Grassley (R-IA) raised it as an issue at the summit).

Medicaid has been instrumental in meeting the health needs of millions of children and families, and through health reform, the program would be expanded to meet the needs of millions more. So let's think about how to do that most effectively, but let's not use the access challenges, which happen in private and public coverage alike, to become an excuse not to do meaningful reform.

 Thanks to Martha Heberlein for helping with the research for this entry.

Having just survived a truly impressive tantrum this morning from one of my sons who was deeply committed to going to school this morning without shoes, I'm feeling primed for what promises to be a raucous final stage of the health reform debate. 

As far as we know, Congress is still proceeding with the plan of the House passing the Senate health reform bill (with many members kicking and screaming as vigorously as my son this morning), then the House and the Senate passing a smaller reconciliation package designed to improve the Senate bill and make it more palatable to House members.  I just hope we get through the week without anyone throwing shoes at an authority figure (at home or in Congress).

This week, RollCall reports that by the end of the week we may see the actual legislative language of the reconciliation bill and a CBO score, allowing us to fill in final details of what health reform might look like.  The White House continues to press for a final vote in mid-to-late March.

In the meantime, everyone is digging deeper on the arcane rules of budget reconciliation.  Our friends at CBPP have shared the gory details before, but the question of the day seems to be whether using reconciliation actually allows health reform proponents to proceed with a straight up-or-down vote.  The issue has flared up because there is a 20-hour limit on debate over a reconciliation bill, but the rules may allow opponents of health reform to offer an endless series of amendments OUTSIDE of the 20 hours of debate. If they take this route, Senate leaders will need to decide whether to call in Vice President Biden to declare the string of amendments "dilatory" and to dismiss them. 

Also, this week we'll be tracking where things are heading with a 6-month extension of Medicaid fiscal relief, which has enormous implications for the capacity of states to continue to sustain and strengthen their gains for kids and families.  The Medicaid fiscal relief is included in a jobs bill making its way through the Senate right now. To make things confusing, the term "jobs bill" has been used to describe three separate bills currently in motion: 1) a $17.6 billion package that mostly creates a tax credit for companies that hire unemployed people; 2) a short-term extension of unemployment insurance, COBRA and a few other items through end of March/early April (this is the one that Senator Bunning single-handedly held up on the Senate floor last week); and 3) a much bigger extension through December 31, 2010 of unemployment insurance, COBRA, and a few other items.

It is this THIRD so-called "jobs bill" that includes a 6-month extension of Medicaid fiscal relief from December 31, 2010 through June 30, 2011.  Congress Daily reports that the jobs bill (the third one) will be up on the Senate floor this week, and then it will need to go to the House for action. The House already has twice passed an extension of Medicaid fiscal relief in other bills and President Obama supports it, which means the prospects for passage are bright if it makes it through the Senate. 

The pressure to extend the temporary increase in the federal medical assistance percentage (FMAP) for Medicaid included in last year's stimulus bill is building. Widely credited with helping states through one of the worst fiscal crises on record, the provision also has been vital in stabilizing Medicaid coverage for children and others in families facing job loss. Currently, the provision is slated to expire December 31, 2010, right in the middle of most states' fiscal year. With most state legislatures in session right now trying to craft next year's budgets, they are looking for some assurances that the federal government will continue the extra help with Medicaid.

It looks increasingly likely that the nation's lawmakers may adopt an extension. In December of 2009, the House of Representatives passed a six-month extension that would provide states with fiscal relief through June 2011, which coincides with the end of most states' fiscal years. President Obama included the same proposal in his budget in February.

Now the Senate, which has been the most skittish on the issue, is planning to take the extension up as part of a larger jobs bill. On Monday, Senate Majority Leader Reid and Senate Finance Committee Chairman Baucus included the 6-month extension in a jobs bill. This bill also continues COBRA benefits and unemployment insurance through the end of the calendar year. (And, nope, this isn't the same jobs bill that Senator Bunning of Kentucky has been holding up on the Senate floor. The bill that caused Senator Bunning to miss the Kentucky-South Carolina game extended COBRA subsidies and unemployment insurance only for a few more weeks and does not include an extension of Medicaid fiscal relief.)

Outside the Beltway, a bipartisan group of 42 Governors of states and five Governors of U.S. territories have signed a letter in support of the FMAP extension. They state that "the length and depth of the recession means states and territories will continue to face significant budget shortfalls long after the enhanced FMAP provisions expire at the end of this calendar year." 

As in the past, Congress expects states to hold steady on their Medicaid eligibility levels and enrollment procedures in exchange for the extra federal help. One new twist to the "maintenance-of-effort" provision may be the addition in the Senate of a requirement designed to prevent Governors from having their cake and eating it too. Stung by criticism of the stimulus bill last year by Governors who willingly accepted the federal dollars, the amendment will likely require Governors (or possibly State Legislatures) to specifically request the additional help from the federal government. 

With unemployment benefits and COBRA subsidies now expected to expire at the end of March/early April, there will be pressure for Congress to act again quickly. This time, it looks more likely that Congress will include an extension of the FMAP if it can find its way forward on the next jobs bill.