Say Ahhh!

The current health reform proposals have so many moving parts it's been hard at times to parse out where children will land. Thankfully, Jenny Kenney and Allison Cook at the Urban Institute have provided us with some guidance.

Using 2007 coverage numbers, they examine both the House and Senate bills to determine where current Medicaid and CHIP kids will end up.

[A quick refresher: in the House bill, Medicaid is expanded to 150% of the FPL and CHIP is discontinued; in the Senate bill, Medicaid is expanded to 133% of the FPL and CHIP is maintained (although with no additional funding after 2013).]

If the policies were implemented in 2007, here's what the transition would look like for children currently enrolled in separate CHIP programs (the authors suggest that adjusting forward to 2014, the numbers would be about 2.5 times higher):

A big caveat here - because the Senate bill does not currently provide funding for CHIP, the 2.3 million children who would have retained CHIP coverage would instead go into the Exchange. However, there are some efforts currently underway to provide funding for CHIP, at least on a transitional basis.

Health reform has a lot of moving parts and a lot of moving people. It is vital that a thoughtful and well-coordinated plan is devised to enroll and retain children in coverage; otherwise, it is quite possible that some children will fall through the cracks, possibly ending up uninsured. And those CHIP kids, wherever they land, it will be important that they get comparable coverage, both in terms of cost sharing and benefits to what they get now.

Donna Cohen Ross, Outreach Director, Center on Budget and Policy Priorities.



Editor's Note:  Donna Cohen Ross has been tracking state eligibility rules, enrollment and renewal procedures and cost-sharing practices in Medicaid and CHIP for more than a decade.  Her much anticipated annual survey was released last week by the Kaiser Commission on Medicaid and the Uninsured and the Center on Budget and Policy Priorities.  We asked Donna to give us the highlights in a guest blog entry.

What's most striking in this year's 50-state survey on Medicaid and CHIP is that despite the deep, deep "downs" of the economy, many states were reporting impressive "ups" for children's health coverage.  In fact, a substantial number of states did more than survive in the depressed economic environment -- they reached new heights (which is consistent with CCF's Weathering the Storm findings).  

How did they manage to do that?  Flip the pages of the calendar back to February 2009 for the answer.  That month, CHIPRA was signed into law, providing sufficient resources to cover, by 2013, an additional 4.1 million children under Medicaid and CHIP who would otherwise remain uninsured.  In addition, an Executive Order rescinded the August 17th directive, removing the constraints that had hampered states' ability to expand coverage to children in more moderate-income families.  Later that same month, the American Recovery and Reinvestment Act (ARRA) was enacted, infusing states with fiscal relief by bumping up federal matching funds for Medicaid and prohibiting states from cutting Medicaid eligibility or putting up procedural barriers to enrollment. (These eligibility and enrollment protections did not apply to CHIP, leaving that program vulnerable to cuts.)

It's now clear these measures were vital in helping health coverage programs rise to the challenge of providing coverage for low-income families as they faced what have been the toughest times many have ever experienced.  Let's take a look at the specific ups and downs of 2009:

The Ups:

• In 2009, more than half the states (26) took at least one step to advance health coverage for low-income children, parents and pregnant women, with children being the biggest beneficiaries.  Nine states expanded income eligibility for children so that the median income eligibility for children rose to 235 percent of the federal poverty line from 200 percent, and now 24 states (including DC) cover children in families at 250 percent of the federal poverty line or higher.

• Nine states took steps to simplify enrollment and renewal procedures -- notably, five adopted 12-month continuous eligibility, which guarantees eligible children a full year of coverage, an important step in fostering retention.
  

• There is no doubt that the tools and incentives states got from CHIPRA helped push them forward. More than one-third of the states (18) have submitted state plan amendments to cover immigrant children and pregnant women who have been legally residing in the U.S. for less than five years; and more than half the states (27) said they plan to conduct data matches with SSA to meet the citizenship documentation requirement, rather than requiring families to come up with documents like passports, original birth certificates and picture IDs.  State officials also said they were interested in trying out the new Express Lane Eligibility option and a handful said they will provide language and interpreter services (and get enhanced federal administrative match) for enrollment activities.  
  

The Downs:

• To be sure, there also were some "downs," with 15 states restricting access for children. Increasing CHIP premiums was the action states took most frequently in response to economic pressures. In some states the premium jumps were big, but even after these recent increases, overall, CHIP premiums remain modest with the median charge for two children in a family with income at 200 percent of the federal poverty line is $480 per year ($40 per month), just 1.3 percent of annual income.  Another "down" is that two states -- California and Tennessee -- froze CHIP enrollment for at least part of the year.  California reopened enrollment, but Tennessee remains closed.  Of greatest concern is that these access-restricting measures mean that eligible children can't enroll and will remain uninsured.  So, a sick child can't see a doctor or get the medicine she needs and her family may face compelling financial choices -- pay the rent or pay for a prescription -- even though the child qualifies for coverage.

Where do we end up as 2009 comes to a close?  The stabilizing effects of ARRA gave states the support they needed to safeguard coverage for low-income families and move forward. But, the federal fiscal relief and enrollment protections are scheduled to expire at the end of 2010.  If that happens, states will no longer have the emergency resources that have been instrumental in keeping their programs intact.  While there are indications that the economy may be beginning to recover, the recession continues to take a toll on families and communities across the nation.  If fiscal relief is not replenished and Medicaid is not protected as under ARRA, many states may buckle under the pressure they are facing to make substantial cuts in programs like Medicaid and CHIP.  Will the "ups" of 2009 turn upside down in 2010?

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

Wendy Lazarus, Founder and Co-President, The Children's Partnership




As the health reform debate in Congress moves further forward than it ever has before, the potential real-world impacts on children and families are becoming clearer.  Even from 3,000 miles away, those of us in California - home of the nation's largest and hugely successful CHIP program - can see the promise and the perils ahead.  Although today I live and work in California, where one in every eight children in the US also lives, my perspective is shaped by having worked as a child advocate in four other states and in Washington DC, starting in 1973.  Based on these many years of being in the reform trenches, I can honestly say today feels quite different---something very real is emerging with the potential, still, to be a major gain for America's children or a monumental step backwards.

The promise lies in the enormous success that our nation generally, and California specifically, has made in covering children.  Like many other states, California has made great strides in covering children this decade.  Our uninsured rate has fallen from 10.2% in 2001 to 6.4% in 2007, thanks to Medi-Cal (our Medicaid program), and Healthy Families (our CHIP program), functioning as the effective safety nets they were intended to be. California children in families at or below 250% of poverty currently have access to coverage their parents can afford, that provides comprehensive benefits, and that protects families from high out-of-pocket expenses.  California has also implemented a number of pioneering reforms to help families find and keep coverage for their children, such as providing expedited "express lane enrollment" for children who receive free or reduced-price school lunch. Evaluation after evaluation has shown that more children in California are now healthier, are at less risk of suffering from preventable illnesses, have better access to needed health care services, and are better prepared to learn.

But as the health reform debate winds to its end, we cannot count on these good things to continue for kids. Unless the final bill includes the right choices on some still unresolved matters, devastating impacts on children's health and readiness to learn could result.  We have the knowledge and we still have the time to make sure the final package does, indeed, build effectively on the strong foundation that already exists.

To a great extent, the current House and Senate bills do build on that strong foundation.  Today's coverage standards would clearly be maintained or even improved for many children.  Because both bills expand and strengthen Medicaid, more children - more than 300,000 children in California alone, under the House bill - would gain access to the affordability and comprehensive benefits it provides, including important preventive benefits through the Early and Periodic Screening, Diagnosis, and Treatment program.  

But for millions of California children above the new Medicaid income thresholds, the results are not necessarily positive. Both the House and Senate bills create new coverage pathways, through some combination of parents' employer-based coverage, CHIP, and/or the new health insurance exchange.  The specifics differ under each bill and are very complex, but the essential element to watch for is this:  Do the reforms result in children in having access to at least the level of affordability and benefits that they have today?  The answer could be "yes" for any of the potential pathways if they were structured appropriately.  At the moment, however, neither bill has strong enough affordability and minimum benefit requirements for either employer-based coverage or coverage provided through the exchange to guarantee that current standards for children's coverage will be maintained.

Until the standards for employer-based and exchange coverage are strengthened, CHIP is left as the only coverage pathway for maintaining the successes that we, as a nation, have achieved for children.  Both the House and Senate bills maintain CHIP for some period of time for at least some children but important limitations exist in both bills that would leave children in California particularly at risk. Because the House bill only maintains CHIP in those states that implemented their programs as Medicaid expansions, California - with its stand-alone Healthy Families program - would, fairly soon after reform is implemented, need to move 1.7 million children from CHIP to Exchange and employer coverage. Under the Senate bill, California's CHIP program would be maintained through a transition phase - but without any funding after 2013.  Fully funding and guaranteeing CHIP coverage until at least the same benefit and cost-sharing protections are available in the Exchange would protect the gains made to date.

California's brinksmanship this year provides a sobering example of the perils to families if these funding concerns are not addressed.  Earlier this year, California enacted deep funding cuts for Healthy Families that resulted in the program being closed to new enrollees temporarily, leaving nearly 90,000 children on a waiting list for coverage in just 60 days and putting the coverage of nearly one million children at risk.  Fortunately, state leaders came together to find alternate funding sources to fill the shortfall and reopen the program. But these "fixes" were temporary, and with the state's continued fiscal crisis we are likely to see more cuts ahead.  

The lesson for health reform is clear: For the health bill that passes to be true reform, whatever pathways cover our children need to be modern, simple, sized right for children and available even in times of economic stress.

My garage is brimming over with files labeled "national health reform" that span three decades.  But it is the health reform documents being produced over the weeks ahead that will govern the fate of children born today and in the years to come.  We have decades of experience that tell us the right thing to do.  And we still have the time and the necessary leadership to do it.

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

Details are starting to emerge on what is in the new Senate deal on a public option, but we're still trying to figure out what it means for low-income children and families.  So far, we know it does not include a Medicaid expansion to 150 percent of the federal poverty level, which would have helped lots of additional children secure the EPSDT benefit (the "gold standard" of coverage for kids) and secure better cost-sharing and premium protection for their parents and other adults. (But, this issue likely will still be on the table for discussions between the House and the Senate - -the House bill includes the Medicaid expansion to 150 percent of the FPL.)

Also, sounds like it may include some improvements to the Children's Health Insurance Program.  Both the New York Times and Wall Street Journal are now reporting that the negotiators might include a 2-year extension of the Children's Health Insurance Program. It isn't clear yet what this means, nor whether it has implications for the efforts of Senator Bob Casey to pursue a far broader set of improvements for children's coverage. Stay tuned.

In the meantime, Donna Cohen Ross has come out with the latest in her definitive, comprehensive series of annual surveys for the Kaiser Commission on Medicaid and the Uninsured of where states are on coverage of children and families in Medicaid and CHIP.  She has promised to blog on the new findings later this week, but, for now, the bottom line is that "despite the economic downturn that's busting state budgets from Sacramento to Tallahassee, 26 states this year made it easier for low-income children, parents or pregnant women to get health coverage, according to a report released Tuesday by the Kaiser Family Foundation". Great news, but.. and you knew there might be a "but"... the report warns that this progress may be at risk if steps aren't taken to continue to help states with their budget crises past the end of 2010.  

Remember CHIPRA?  Wisconsin does and it's putting it to use to get closer to its goal of providing affordable health coverage options to ALL kids.  

CHIPRA, signed into law in February, provided states with the ability to cover lawfully residing immigrant children and pregnant women without a five-year waiting period.  Wisconsin Governor Jim Doyle has consistently said that the goal of "BadgerCare Plus (BC+)" is to make quality, affordable health insurance available to "all kids," regardless of income.  

The state made progress toward that goal this fall when the Wisconsin Department of Health Services announced that it was taking advantage of CHIPRA to get federal matching funds for extending health insurance to certain "lawfully residing" immigrant children and pregnant immigrant women.  As a result, those Wisconsin children and women will no longer have to reside in the U.S. for five years before they are eligible for BC+.   

Jon Peacock, research director for the Wisconsin Council on Children and Families, explained this policy in an interview as part of the CCF Postcard series.  Jon points out that removing the five-year bar makes hundreds of additional children eligible but it is also likely to produce a "welcome mat" effect for many mixed status families who may not have realized their children were eligible even under the old rules.

Join CCF in cheering on our friends in Wisconsin and wish them well as they continue to strive to reach the goal of covering all kids.  The lyrics to "On Wisconsin!" certainly ring true as the state moves forward and its flame (a symbol of welcome to immigrants) glows a little brighter with this change in policy.