Say Ahhh!

The election of Scott Brown to the U.S. Senate changes many things, but it doesn't change one simple fact:  children and families still need better access to quality, affordable health coverage.  

While figuring a way out of this sticky situation is above my pay grade, there are a lot of savvy legislative strategists working on the next step for health reform legislation.   It's very likely that the reconciliation process will be part of the solution.  As we all anxiously wait to see what's next, we might want to channel our nervous energy into refreshing our understanding of the reconciliation process by re-reading last Fall's entry by CBPP's Edwin Park.  

Here's a condensed version of Edwin's earlier post:

 What is Reconciliation?

First, the basics.  A reconciliation bill is a single piece of legislation that typically includes multiple provisions (generally developed by several committees) all of which affect the federal budget -- whether on the mandatory (or entitlement) spending side, the tax side, or both.  Under House and Senate rules implemented when the Democrats took control of Congress in 2007, reconciliation cannot be used for legislation that would increase the deficit so any reconciliation bill must be fully offset, that is it must include mandatory savings and/or revenue increases that pay for any higher spending and/or tax cuts in the bill.  Reconciliation, of course, can also be used, as it was originally, to reduce the deficit.  Reconciliation is generally used to speed passage of legislation through the Senate by providing special procedures that make it easier for a bill to pass.

 

 

There has been much discussion about states' ability (and willingness) to help finance health reform, especially as it concerns an expansion of Medicaid. A little background data may help to illuminate the debate.

While significant, Medicaid's role in state budgets is far more modest than the headlines often suggest. Medicaid constitutes 16.2% of state general fund spending, leaving it well behind elementary and secondary education (in fact, as shown below, states spend nearly twice as much of their own money on elementary and secondary education (35.1%) as on Medicaid).

It is often, misleadingly, suggested that Medicaid consumes a larger share of state budgets than any other item. Misleadingly because the numbers cited to make this point include federal Medicaid matching funds states receive. So while this may be true for total state spending (if you include federal funds), it is not the case if you consider Medicaid spending as a share of a state's own general fund (basically just the state's money). In fiscal year 2009, state funds spent on Medicaid actually decreased by 2.2% from fiscal year 2008 due to the increased federal Medicaid support made available by ARRA - the federal stimulus legislation.

As the health reform debate continues, it is important to acknowledge state concerns regarding their dismal fiscal conditions and realize that there are certainly options to adjust the formula in order to make it more equitable across states.

However, it is also vital not to lose sight of the larger point - states are getting a pretty good deal out of health reform: near universal coverage with marginal costs. Yes, their budgets are in disarray and yes the federal government (not to mention their citizens) are expecting a bit more of them. But these requirements are years away, as states would not be expected to contribute to the cost of the newly eligible until 2015 in the House bill and 2017 in the Senate bill.

There's a risk of exaggerating claims without a full understanding of the fiscal implications of health reform (or current Medicaid spending). Everybody would be better served by having an honest debate about the true costs of reform and how best they can be shared.

(Editor's Note: John Bouman is the President of the Shriver Center. He is recognized for being one of the most effective and thoughtful public-benefit advocates in the country. Say Ahhh! asked him for his thoughts on national health reform.)



We all worry about our children so of course we are concerned about the treatment of children in health reform. There is worry about the House bill's ultimate elimination of the CHIP program and switch of covered children into either Medicaid or "the exchange". The exchange is said to be too uncertain, because premiums and co-payments could be too high and result in families not buying coverage, which could then result in the family's children becoming uninsured.

Those are legitimate concerns and worthy of the strong advocacy they are getting. Children's advocates have worked hard to preserve the CHIP program at least until the "exchange" plans prove themselves as vehicles for children's coverage. But it is also important to work to achieve the best possible affordability of insurance in the exchange. Arguably, it is the higher priority.

The best way for a child to be healthy is for the child to be part of healthy family. If the parents understand prevention and early treatment, and pursue their own health, the children are much more likely to be on that course themselves. For children to be healthy, they not only need coverage, but they need to be enrolled, connected to a doctor, and then actually conveyed to the doctor at the right time by their parents (or other caregivers), which is much more likely if the parents are healthy and focused on their own healthcare.

So the top option for a health system, from the children's point of view, is a system that serves families well, prompts smart healthcare behavior by the adults, and maximizes family health. If we can't have that, then the fallback is a system that at least does what it can to serve the children. That's the current U.S. system as it applies to low and moderate- income families. We fail the parents and young adults, but we do what we can through Medicaid and CHIP to help the children and a few adults. Because the system, by failing to cover adults, blocks most of them from establishing a medical home and pursuing the smartest health care possible, their children are denied the chance to live in a healthy family and thus denied the best chance to be healthy themselves. Because we have a fallback system, recently improved through CHIPRA, the children still have a chance for a healthy life, but it's a second best chance.

The best way to achieve children's health is through whole family health. Children's advocates should not leave advocating for a strong exchange to other health care advocates. A strong and affordable exchange should be the first priority for children because it includes the whole family, which is the healthiest situation for children. The children's groups should be leaders in support of the affordability of exchange policies, even as we continue to fight hard to make sure that CHIP is there for kids who need it.

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

Right after the question of how the incredibly busy OMB director Peter Orszag managed to find the time for such an exciting personal life, the major topic in D.C. policy circles is what will be in the final health care bill. For the latest "big pictures" stories, check out Politico and the New York Times. But, here is what we've been able to glean on issues of particular importance to kids and families.

On Medicaid. Long-time Medicaid champion, Representative Henry Waxman, Chairman of the House Energy and Commerce Committee, is pushing hard to address access concerns in Medicaid by increasing reimbursement rates for primary care services to Medicare levels. With Medicaid slated to be a cornerstone of health care reform, the argument is that now is the time to tackle this issue. In the House bill, the initiative was estimated to cost $57 billion, which means if it is in a final bill, it is quite possible that it will be in a scaled-back form with a less hefty price tag.

As for the larger question of whether the bill will take Medicaid eligibility to 150 percent of the federal poverty level (House) or 133 percent of the federal poverty level, we have no good clues. The Senate seems adamantly opposed and the nation's Governors already are up-in-arms about the fiscal impact on states of Medicaid expansions. On the other hand, it is less expensive to cover people through Medicaid than Exchange plans and right now, anything that helps lower the federal cost of health reform is likely to be considered.

On CHIP. It increasingly looks like the final bill may adopt the Senate's strategy of continuing CHIP, although nothing is certain at this stage. Over the weekend, Rebecca Adams with Congressional Quarterly reported the following: Many analysts expect that some version of the Senate language will prevail in the final bill. Not only do many child advocacy groups prefer it, but so do health insurers. Lobbyists for America's Health Insurance Plans, an industry trade group, say that shifting people into different programs could be disruptive and confusing, which could lead to some children ending up uninsured. And, Mike Lillis of the Washington Independent just ran a story entitled "Waxman Not Married to CHIP Repeal," in which he reports that while Waxman strongly favors his approach on CHIP, he may not insist on it. "I'm not drawing lines in the sand on anything," Waxman said.

On Affordability. Consumer advocacy and faith-based groups are pushing hard for improvements to the subsidy structure for low-income Americans and, in particular, for the final bill to draw on the House's approach for people below 250 percent of the federal poverty level. But, no hints are emerging in the public domain on where this is heading. It will come down to money.(As my kids routinely say to any and all bits of information that I share with them, "obvious.")

Where do you think these issues are headed? Any clues you'd like to share with the Say Ahhh community?

Each celebration of a new year brings a renewed sense of optimism and 2010 offers tremendous promise in mitigating the chilling impact of the citizenship documentation requirement imposed by the 2005 Deficit Reduction Act (DRA) on Medicaid. The citizenship documentation requirement not only made it more difficult for eligible citizens to enroll in Medicaid but states have also spent millions of dollars in administrative costs to comply with the regulation. The title of a study by the Government Accountability Office says it well: "States Reported that Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens."