Say Ahhh!

Michele Johnson, Managing Attorney, Tennessee Justice Center





In 2006, Governor Phil Bredesen pledged to make our state "an island of excellence" by making sure "every child in Tennessee" had health coverage. He established a new program, to be known as CoverKids.

CoverKids would be Tennessee's version of the Children's Health Insurance Program, or CHIP. The federal government covers 75% of the cost for CHIP in Tennessee, and even with that favorable funding, Tennessee remained the only state without a CHIP program. CoverKids would get Tennessee out of last place and put us "in the top ten states in the nation in terms of the percentage of children covered by health insurance."

Tennessee just became an "island" alright, but not the kind the Governor envisioned. On December 1, Tennessee became the only state in the country to close enrollment in its CHIP program. On that day, the state slammed the door of CoverKids to new applicants.  Far from ensuring coverage for "every child in Tennessee", as the Governor promised, CoverKids coverage is frozen at 49,000 children, leaving Tennessee's other 150,000 uninsured kids out in the cold.  

When that decision drew criticism, the state announced that another program, AccessTN, would enroll children. Sadly, that is more about providing cover for elected officials than coverage for kids. AccessTN sells insurance only to people who cannot buy coverage elsewhere because of pre-existing conditions. Last month, the head of AccessTN said the program had no money to help families afford AccessTN's high premiums. As a result, the program reaches less than 4,000 people statewide. AccessTN is no answer for uninsured children shut out by CoverKids.

Tennessee is the last state in the nation that can afford to neglect the health of its children. Infant mortality in Tennessee is worse than in many developing countries, and the rate of infant deaths in Memphis is the worst of any city in America. The Commonwealth Fund, a foundation that sponsors health quality research, recently ranked Tennessee 47th in children's health care, measured by the number of children who die of causes that could have been prevented by health care. A state this unhealthy for kids should be striving hard to improve children's health coverage. Instead, Tennessee has just become an island of neglect, in terms of the health of its children.

Shortchanging children's health is justified as a budget necessity imposed by the recession. But that is an excuse, not a reason. Every state has been hammered by the recession, some far worse than Tennessee. And unlike other states, Tennessee has $350 million in unspent TennCare reserves. The federal government contributes a higher share of CHIP costs in Tennessee than in most states. Yet no other has responded to its budget problems by abandoning its uninsured children. In fact, 26 states took steps to advance health coverage this past year, and our neighbor, Alabama, expanded eligibility in its CHIP program.

Other states' leaders know that, if times are hard for state governments, they are even harder for uninsured children and their families. They realize that playing Scrooge not only robs some kids of their health. It costs their states tens of millions of federal dollars and adds to social and medical costs for decades to come.

That's why, even in a recession, every other state makes children's health a priority. Tennessee should, too.

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

To learn more about the Tennessee Justice Center please visit their Website, Facebook page, and blog. 

While the rest of the nation took a break to celebrate the holidays, the gears in Washington continued the churn bringing us ever closer to health reform legislation being signed into law.   Now our attention turns to the House and Senate conference committee that has not yet been officially appointed but staff is already laying the groundwork for agreement.  

One big question the conferees will decide is what will happen to the children and families that rely on the Children's Health Insurance Program.  The House bill eliminates CHIP in 2014 and moves the children into Medicaid and the Exchange with a federal subsidy to offset the cost while the Senate would continue CHIP through 2019 (but, currently funds the program only through fiscal year 2015).  

David Herszenhorn writes in the NY Times Prescriptions that many children's health advocates are concerned about children losing coverage because it is unaffordable or that the shift from one program to another isn't done in a seamless manner.  He quotes Genny Kenney and Allison Cook's report for the Urban Institute "that some children who lose CHIP coverage could fall through the cracks and become uninsured." 

CCF's Jocelyn Guyer is also quoted in the Herszenhorn's blog pointing out that we've made remarkable gains in covering kids in recent years and that "it would be a major problem if health reform undercut these gains by shutting CHIP down too abruptly or by moving kids into coverage that isn't as affordable and as well-designed to get them the care they need to develop and grow."

Notably, Herszenhorn's blog also digs deeper into some of the other issues of equal importance to kids, including the fate of the House's efforts to increase Medicaid reimbursement rates for primary care.   With Medicaid already covering 7 to 8 times as many children as CHIP, it is critical that this program work well for children and their families (as well as the millions of uninsured adults who will be covered by the program under reform) and provide needed access to care.  And, of course, an overarching issue for all kids and their families is the affordability of coverage provided through the Exchange.

The conferees will have to resolve these different approaches and many other issues quickly if they are to meet the goal of getting the bill to President Obama in time for his State of the Union address.   What do you think they should do?

This morning the Senate passed its version of the health care reform bill, the Patient Protection and Affordable Care Act. As we wind down the year here at CCF, comprehensive reform remains closer at hand than at any time in recent history. While the bill is far from perfect, children and their parents have an enormous amount to gain from reform moving forward. (For the full scoop on the latest Senate version, check out CCF's latest factsheet on all the relevant provisions.) We look forward to the New Year in the hopes that it will bring much needed change to our health care system. 

It is indeed fitting - with the holidays focused on children and giving -  that HHS Secretary Kathleen Sebelius awarded more than $72 million in bonus payments last week to nine states for their success in enrolling low-income children in Medicaid. Like little kids during the holidays, we have awaited the announcement of these performance bonuses with excitement and gleeful anticipation. Drum roll, please.....Alaska, Illinois, Louisiana, Michigan, New Jersey, New Mexico, Oregon and Washington earned bonuses ranging from $1.5 to $9.1 million but Alabama is the big winner earning more than half ($39 million) of the total award.

The performance bonus  is one of the new tools and options created through the Children's Health Insurance Reauthorization Act  (CHIPRA). It give states a financial incentive to meet specific Medicaid enrollment targets if they also adopt at least 5 of 8 enrollment and retention simplification strategies such as 12-month continuous eligibility and streamlined administrative renewals.  

States qualifying for the bonus receive payments equal to 15% of the annual cost of Medicaid services for the number of children enrolled above the target enrollment. To meet the target, a state's average monthly Medicaid enrollment for children in federal fiscal year 2009 (FFY 09) had to be approximately 8% above the average enrollment in FFY 07 with adjustments for any change (positive or negative) in the child population.

The significantly larger award was granted to Alabama because it was the only state to qualify for the higher "tier 2" bonus level. A state qualifies for the tier 2 bonus if the average number of enrollees exceeds the base (tier 1) enrollment target by 10%. At the tier 2 level, states receive a bonus equal to a joyful 62.5% of their share of Medicaid costs for the average number of children enrolled above the tier 2 target. For Alabama, this reduces the state's share of Medicaid for children enrolled above the tier 2 target to less than 9%.

In announcing the awards, the Center for Medicaid and State Operations within CMS issued a State Official Letter (SHO) explaining the performance bonus calculations and describing the eight enrollment and retention strategies. This was the tenth in a series of SHO letters, which provide guidance to the states in implementing the provisions of CHIPRA. The public announcement of the bonuses also coincided with the re-launch of "Insure Kids Now" as a more robust website focused on Medicaid and CHIP including state specific program information.

We send our congratulations to the State Medicaid and CHIP agencies in the nine performance bonus states for a job well done and our wishes to all for a holiday season filled with warmth and laughter.

Today on a snowy day in DC, agreement was reached on the Senate health care bill making it likely that Senator Reid has enough votes to pass the bill before Christmas. The Senator also filed his Manager's Amendment to the bill. The Congressional Budget Office followed soon after with the bill's score. 

Tucked between the more controversial provisions of the Manager's Amendment are some noteworthy improvements to children's coverage. This is good news for kids and due in large part to the efforts by children's groups to raise the profile of these issues within the larger debate and the leadership of Senators Rockefeller and Casey. Some of the changes include:  

• CHIP funding is continued for another two years (September 30, 2013 through September 30 2015). Originally, the bill provided funding only through September 30, 2013. This funding ensures that children can keep their CHIP coverage during a critical period when health reform is just getting off the ground. 

• States will still need to maintain current Medicaid and CHIP eligibility and enrollment procedures for children above 133% of the FPL through fiscal year 2019. However, the amendment clarifies that states must meet this "maintenance of effort" requirement or lose their Medicaid funding.

• States will still receive the 23 percentage points increase in their CHIP match rate but its timing was delayed for two years. Now the increase will go into effect October 1, 2015. Since the bill assumes coverage will be maintained through 2019 but there is no funding after 2015, Congress will need to further revisit these funding issues.

• As before, if there is no federal funding children previously eligible for CHIP will be enrolled in the Exchange. The amendment strengthens this provision by requiring that children first be screened for Medicaid and, if eligible, enrolled. For children not eligible for Medicaid, the state must establish procedures to enroll the children in comparable coverage. 

• The Secretary of HHS will be required to review and certify which plans in the Exchange provide CHIP-comparable benefits and cost sharing, but it is unclear what mechanism will be in place to ensure that these plans exist in the Exchange.

• Extends and increases funding provided in CHIPRA for Medicaid and CHIP enrollment and renewal activities. Now, $140 million (an increase of $40 million) will be available through 2015. 

• Creates a new option for states to provide CHIP coverage to children of state employees eligible for health benefits. These children can now enroll in CHIP if the employee's premiums and cost sharing exceeds 5 percent of the family's income. To utilize this option, a state cannot have decreased its premium contribution for family coverage below 1997 levels (adjusted for inflation).

• Requires the Secretary of HHS to issue regulations to establish a more defined process for public input for section 1115 waivers in Medicaid and CHIP.

• Makes technical changes to tighten up the definition of cost-effectiveness in the new CHIPRA premium assistance option and removes the requirement that Medicaid programs do premium assistance as part of the Medicaid expansion in the underlying bill.

• Immediately prohibits insurers from denying coverage to children for pre-existing conditions. The new regulation would go into effect for adults with the rest of the legislation, in 2014.

We are still combing through the Manager's Amendment and will keep you posted on other noteworthy changes.