Say Ahhh!

While not as riveting as the latest gossip on the White House "party crashers," the Senate began debate this week on its health reform bill. We have developed a fact sheet of the bill's key Medicaid, CHIP, and low-income provisions to help you navigate and understand where things stand for children and families.

Over the coming days, the Senate is expected to take up a number of amendments addressing the issues of interest. Most recently, Senator Casey introduced an amendment that would make a number of enhancements to CHIP (which is maintained in the Senate bill). These include providing full funding for the program through 2019, requiring states to cover children in CHIP up to at least 250% of the federal poverty level and providing EPSDT coverage to children in CHIP.

We will keep you posted as key amendments related to Medicaid and CHIP are introduced and move forward. In the meantime, a new report by Families USA provides a good overview of what issues are expected to arise.

An Interview with Brian Rosman, Research Director of Health Care For All in Massachusetts.

The success Massachusetts had in creating affordable, accessible, quality health coverage options for all residents of the Commonwealth has helped lead the way for national health reform. Now that we're getting beyond the larger conceptual phase of health reform and getting into the nitty-gritty details, we thought it would be helpful to check back in with someone in Massachusetts to enlighten us on how the Commonwealth was able to get over some of the stumbling blocks on the road to success. We tracked down Brian Rosman, research director of Health Care For All, to help us better understand how health reform worked in Massachusetts.


Cathy: How were you able to make health coverage affordable to families through the exchange?

Brian: An often-overlooked part of Massachusetts's health reform is the important role that Medicaid and CHIP played in providing affordable coverage options for children and families. We built on the strong base of underlying Medicaid coverage. The Commonwealth Care program filled in the gaps in coverage and a CHIP expansion for kids (up to 300% of the poverty level) allowed thousands of kids to get affordable coverage. The exchange, called the Health Connector in Massachusetts, offers subsidized coverage to adults only, through a program called Commonwealth Care. Under a reform instituted under Governor Patrick, who took over from Mitt Romney in 2007, CHIP premiums for children are waived if the parents are enrolled in Commonwealth Care. Medicaid, CHIP and subsidized coverage through the Health Connector have made coverage much more affordable for families.

Cathy: It's interesting that you mentioned CHIP as there's some disagreement in Washington about whether or not to eliminate CHIP and move children into the "Exchange" immediately. One reason to move CHIP eligible children into the "Exchange" immediately is to simplify the enrollment process for families. How has MassHealth managed to integrate CHIP and Medicaid with the Exchange?

Brian: Mass Health is what our state calls the combined Medicaid and CHIP programs. It operates as a unified program, and enrollees often don't know if they are in CHIP or in the Medicaid waiver program. It's all called MassHealth, and the program is consolidated. The Connector, which administers the Commonwealth Care program, uses the same application as MassHealth, and the MassHealth system processes the enrollment applications, as well as renewals and other systems. So it's seamless for enrollees, regardless of what program they are in.

Also, all of the MassHealth managed care plans are also available under Commonwealth Care, so families can be in the same health plan even if they are technically in different coverage programs.

Cathy: It sounds kind of complicated to integrate all those programs. How does it work for families?

Brian: Families aren't required to figure out the sometimes-complicated rules about program eligibility. They can file one application for everyone in the family, and the state's combined eligibility system will place each member of the family in the best program he or she is eligible for. For the most part, the family experiences seamless unified coverage.

Cathy: Another interesting aspect of Massachusetts' health reform plan is that it didn't mandate coverage for children but did mandate coverage for adults.What was the thinking behind that policy?

Brian:When Massachusetts passed its health reform legislation in 2006, we already had a very low uninsurance rate for children - just a few percent. The problem we had was growing uninsurance among low-income working adults. Since no state had ever required coverage before, there was reluctance to extend the mandate to children.

Cathy: How has it worked?

Brian:Since passage of the legislation, our child uninsured rate has dropped, even though kids were not included in the mandate. Parents have responded to the increased availability of affordable coverage, even without a mandate.

Cathy: Another hot topic in Washington these days surrounds the level of subsidy necessary to make insurance affordable.A family of three earning about $32,000 (or 175 percent of the poverty line) would have to pay about $1,738 per year under the bill currently being considered on the floor of the Senate.The family would pay about $1,360 under the House-passed bill. What would health coverage cost for a similar family under Massachusetts health reform?

Brian: For the two parents, the combined Commonwealth Care premiums would be $936 for the year. The parents would have a choice of up to 5 managed care plans. The plans have comprehensive benefits, no deductibles, and modest co-pays. The children would get MassHealth without any premiums.

Cathy: Do you think MassHealth would be as successful as it is at reaching so many families if it did not provide coverage at that rate?

Brian: The high premiums required of low-income families under the Senate bill concerns us greatly. We know many low-income families are stretching to survive, with higher fuel and utility costs eating into their tight budgets. The board of the Massachusetts Connector set the premium subsidies after we provided them with overwhelming evidence of the deep financial distress of many families in this income range. I worry that Congress is placing a burden on families that will not work.

Cathy: Finally, what will happen to the Massachusetts Connector if health reform passes?

Brian: The Connector is working to make sure that we don't lose the gains we have achieved. There is still some uncertainty, but we're hopeful that we'll be allowed to continue the programs that are working so well for kids and parents. 

Cathy: Thanks Brian.I also want to put in a plug for A Healthy Blog that was created by Brian's organization and is a great resource on what's happening with health coverage in Massachusetts.  Another helpful resources is the recently released Robert Wood Johnson Foundation's SHARE program report The Secrets of Massachusetts' Success:  Why 97% of State Residents Have Health Coverage.

For a change of pace, I thought I would post a video blog entry.  No, my intent is not to see whether Jocelyn had a good hair day or not, it's to see if a video can help jumpstart a dialogue better than written blog entries.  (We haven't inspired many of you to comment in recent months and we're not sure if that means you agree wholeheartedly and have nothing to add or whether we are just boring you.)  So, as an experiment, I decided to post this video to see if it will get readers to discuss important questions such as:

• Where are we with health coverage for kids today?
  

• What role have Medicaid and CHIP played in driving down the uninsured rate of children?

• What are some key lessons for health reform?

CCF Co-Director Jocelyn Guyer participated in an Alliance for Health Reform and Robert Wood Johnson Foundation sponsored briefing on the hill last month to address some of those questions.  Take it away Jocelyn ... (double-click the video to begin watching)

I hope you'll comment on the video even if it is just to say Jocelyn's hair looked great. If you want to see the other panelists, UT CHIP Director Nate Checketts and Urban Institute's Stan Dorn, please go to http://allhealth.org/briefing_detail.asp?bi=171

I was thrilled to see two very capable public servants, Vikki Wachino and Barb Coulter Edwards, agree to return to public service as part of the Center for Medicaid and State Operations team. Both were appointed to their positions earlier this week by CMSO Director Cindy Mann.

Vikki will serve as the Director of the Family and Children's Health Programs Group, which oversees the children and family aspects of the Medicaid program as well as CHIP.  She is a nationally recognized expert on health coverage issues with particular expertise in Medicaid and Children's Health Insurance Program (CHIP) policy.  Vikki served as the lead consultant on CCF's Strengthening Medicaid project where we worked together on, among other things, a series of issue briefs designed to identify constructive ways to improve the Medicaid program. Her in depth knowledge, commitment to beneficiaries, and dedication to her work will be extraordinary assets to CMS as it continues to implement CHIPRA, works to strengthen the EPSDT benefit for kids in Medicaid, and, should something pass, plays a key role in implementing health insurance reform changes.

Barb will serve as the Director of the Disabled and Elderly Health Programs Group.  Barb is the former Ohio State Medicaid Director and is also a nationally recognized expert in Medicaid policy, including managed care, cost containment, long-term care, and State and federal health care reform. Barb also spent six months as the Interim Director of the National Association of State Medicaid Directors.  In the small world category, Barb actually co-authored a paper with Vikki for our Strengthening Medicaid series program management in Medicaid so the two of them will be ready to hit the ground running as a team!! 

Vikki and Barb will be invaluable to CMSO as it faces the many challenges and opportunities that lie ahead.  We applaud their return to public service and look forward to working with them.

Medicaid, and it's companion program, CHIP have had amazing success in reducing the number of uninsured children over the years. The recent Census numbers highlight this fact - in 2008, the number of uninsured children was at its lowest in 20 years, due in large part to public programs filling in the gaps of declining employer-sponsored coverage. Yet, far too many children remain uninsured, with more than seven in ten of them living in low-income families.

A recent study released by the Urban Institute looked at how many of these uninsured children are eligible for Medicaid or CHIP but not enrolled in coverage. As of 2007, five million uninsured children (64% of all uninsured children) were eligible, with over 90% living in families with incomes below 200% of the FPL.

Why are there so many eligible, but uninsured children? According to a recent survey, 90% of low-income parents with uninsured children said they would enroll their children in Medicaid or CHIP if they were eligible, However, close to half do not think their child qualifies (despite the fact that most children with income less than 200% of the FPL are eligible). Parents often lack accurate information about Medicaid/CHIP programs, don't know how to get information, and don't know how to enroll their children. Others find the enrollment process difficult.

Although states have made great strides in improving participation rates over the years, they continue to grapple with how to reach more of these uninsured children, enrolling them in the coverage they are eligible for. There are numerous strategies they can employ: application and renewal processes can be streamlined; states can link with other public programs in which children may be enrolled; and expanded outreach and educational efforts can inform more parents about program details. Millions of uninsured, eligible children stand to gain coverage as a result of such measures.