Say Ahhh!

Health care "exchanges" are critical to fulfilling the promise of the Affordable Care Act and how states decide to meet their responsibility to establish them will have an enormous impact on children and families.  Today, the Department of Health and Human Services is hosting a stakeholder conference to discuss exchanges. To coincide with the conference, my colleagues, Dawn Horner and Sabrina Corlette, released an issue brief that takes a deeper look at exchanges and what's at stake for children and families. 

HHS's day-long conference is intended to engage stakeholders on the important policy decisions surrounding the establishment and operation of exchanges.  CCF's Jocelyn Guyer will take part in a panel discussion and Dawn Horner will attend the conference. (You can view the conference via be webcast here.)

We'll hear more from them about the conference tomorrow, so let's get back to the issue brief.  "Health Exchanges: New Coverage Options for Children and Families" provides a comprehensive overview of exchanges and key questions policymakers must consider when establishing exchanges.  It outlines the funding and design decisions the states will have to make fairly quickly and points out the broad responsibilities exchanges will have in ensuring that consumers can make informed health care coverage choices.  

For example, the Affordable Care Act requires plans to offer child-only policies (reflecting the importance policymakers placed on the need to ensure that children could secure coverage even if their parents were ineligible for an exchange plan).  Beyond the essential benefits packages, exchange plans must provide children with a comprehensive package of preventive care services (referred to as Bright Futures), including immunizations, well-child visits, vision and hearing tests, health and behavioral assessments, and developmental screenings, with no cost-sharing.  These federal standards are only a floor and states can require plans to cover services for adults and children that are not in the minimum package.  In fact, a number of states already have policies mandating that plans cover specific services, some of them critical to children. (Sixteen states and the District of Columbia mandate that insurers offer at least some level of services for autism.)

Another issue that could impact many families is how well states meet the "no wrong door" policy established by the new law.  It is vital that exchanges coordinate closely with Medicaid and CHIP because many people will move back and forth between subsidized exchange coverage and public program eligibility as their income fluctuates.  The brief points out that states should consider ensuring that some plans offered in the exchange also serve Medicaid and CHIP beneficiaries, creating overlapping provider networks and requiring plans to help facilitate transitions for those in the middle of treatment.

The brief also covers the importance of dynamic technology applications to the success of the exchanges.  The exchange procedures envisioned under the ACA rely heavily on the application of smart technology systems. States should consider setting up a working group now to begin to build these systems. As a first step, a state can pave the way toward electronic interfaces by implementing the proven Medicaid and CHIP automated linkage with the Social Security Administration allowed under CHIPRA to verify citizenship status.

These are but a few of the insights included in the issue brief.  I hope you'll take the time to read it for yourself and share it with others in your state.  We would also love to hear from you on how your state is approaching the establishment of its exchange.

After two weeks in New Hampshire and Maine and a few extra cups of coffee to get moving, I returned from vacation yesterday to find this very interesting development in my inbox - the nation's Medicaid directors are breaking away from the American Public Human Services Association to start their own independent organization - the National Association of Medicaid Directors.  In explaining why they are making the change, the new President of NAMD, Carol Steckel of Alabama Medicaid, explained "Healthcare reform is dramatically changing the face of Medicaid in all of our states and with those changes brings the need for a change to an organization specifically focused on Medicaid and its Directors."

Since I got myself in serious trouble over vacation by expressing an opinion on a family member's new boyfriend, I'm officially out of the business of offering my thoughts on anyone else's relationships, including that of the nation's Medicaid Directors with APHSA.  So, leaving aside whether the split was a good idea or not, I do think it is clear that Medicaid is entering a new era.  As a companion program created alongside Medicare in 1965, it long has been a cornerstone of the nation's health care system, especially for low-income children and families.  And, now it is destined for even greater things in the months and years ahead as we move toward broader health reform. 

The success of both organizations and close collaboration between them will be vital to fostering the critical connections between health care and other social services programs needed to improve the lives of America's families.

On August 10th, President Obama signed an extension of the state fiscal relief first authorized under ARRA. Under the extension, states will continue to receive a phased-out increase in their federal Medicaid matching rate through June of 2011, as opposed to it expiring at the end of this year.

CMS released guidance on the FMAP extension, clarifying that all the maintenance of effort requirements that applied to states under ARRA continue under the extension.

There was one change, however, to the manner in which states request and receive funds. Under the extension, as a condition of receiving the additional federal Medicaid funds, the Governor must submit a request within 45 days of enactment, or by September 24, 2010. 

By Patrick Tigue, New England Alliance for Children's Health

While there are many provisions in the Affordable Care Act (ACA) that will benefit children and families, the expansion of dependent coverage to children up to age 26 is among the most important - especially in the short-term. In 2011 alone, as many as 1.64 million previously uninsured young adults are estimated to gain coverage under their parents' health plans. The provision takes effect after September 23, 2010.

Recently, the federal government issued regulations further explaining how this provision will work. Here at the New England Alliance for Children's Health, an initiative of Community Catalyst, we support these regulations because they clarify several important points that will benefit young adults and apply the law with their interests at heart:

• Young adults are eligible for coverage under their parents' plan regardless of what state they live in and whether they are tax dependent, financially independent, or a student, employed, or married.
• Premiums or benefits cannot vary based on the age of a young adult who qualifies as a dependent.
• The provision applies to all health plans and only grandfathered health plans (those in existence prior to March 23, 2010) can exclude young adults with access to an employer-sponsored plan until 2014. After 2014, this exception no longer applies.
• Insurance companies must provide prominent notice to enrollees about the special enrollment period for dependents.
• States have the option to extend dependent coverage beyond age 26.

All of these clarifications and others included in the regulations will ensure that dependent children and their families can take full advantage of this important opportunity to secure the health coverage they need.

While we are enthusiastic about the regulations, we've also been working collaboratively with a group of our partners to offer some suggestions to the federal government on how to improve them in a few key areas:

• Clarify that stepchildren and adopted children are included in the definition of a dependent child.
• Further explain the situations where grandfathered plans can remove young adults who are eligible for employer-sponsored insurance to ensure that this does not unduly burden young adults.
• Require that prominent notice be clear and conspicuous--ideally in the form of a stand-alone document highlighting the availability of the new coverage option and how to enroll.

It's our hope that the regulations will be revised soon to reflect these suggestions, but in the meantime you can find out more about the dependent coverage expansion here. This provision is one of the many examples of the very real opportunities that ACA provides to extend coverage to those who otherwise would go without.

This blog post was originally posted on the Health Policy Hub.  The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

Editor's Note:  CCF also submitted comments on the dependent coverage regulations which you can read here.  

I know I've said it dozens of times - states are different. Like people themselves, they have their own characteristics, quirks, and personalities that make them unique. But what about within states - are there differences of note? Why, of course (I'm sure we can all think of a long list of differences between, say New York City and upstate NY). And lucky for us, a recent data release from the Census highlights how health insurance coverage varies within states' very own borders.

(Quick methodological note for those of you who are interested in such things: the Small Area Health Insurance Estimates (aka SAHIE) are model-based and combine data from a variety of sources. These data represent coverage in 2007, prior to the economic downturn. They are currently the Census' only data source on health insurance for every county in the US. For more on the various measures Census has on health coverage, check out this helpful fact sheet. The Census also computes small area estimates for income and poverty (aka SAIPE).

Now back to the data at hand - at 26.8%, Texas has the highest rate of uninsured in the country. But where are those 5.8 million folks living? The range in the uninsured rate is quite wide, from 16.6% in Collin County to 49.5% in Kennedy County. What makes these two counties in the same state so wildly different in terms of health coverage? A quick look at some demographic data provides us some idea:

Collin County, located just north of Dallas, is about 850 square miles and has about 765,000 people. In 2007, the median household income was around $80,000.

Kennedy County is located on the Gulf Coast between Brownsville and Corpus Cristi. It's almost twice the size of Collin County, 1,450 square miles, but has less than 400 residents, with a median income of about $30,000 in 2007.

I think it's fair to say that we don't have to pick on Texas as an example, as other states are bound to have within-state variation (even Massachusetts - known for its low uninsured rate of 7.8% - has a range of 6.6% to 13.9%).

State officials and advocates should find these data very helpful in identifying which areas of their states have the greatest number of uninsured residents and possibly understanding the reasons for such differences. (Note - although I didn't do it here, you can also look at the data by age ranges and income levels). And when making the case for targeting outreach efforts, both for those who may already be eligible for coverage through Medicaid and CHIP and, in 2014, for those who will become newly eligible, having data to support your claims will make your case that much stronger.