Say Ahhh!

By Jon Peacock, Wisconsin Council on Children and Families

It isn't often that state policymakers have to make program changes and policy choices because of a law passed in another state or territory of the U.S.  Thus, it came as a big surprise to learn that a law enacted in Puerto Rico forces states to make a choice about how they administer public benefit programs, including Medicaid and CHIP.    

The Puerto Rico law invalidates all certified copies of birth certificates issued by the Puerto Rico Health Department before July 1, 2010. The law was adopted by the commonwealth last year after it was informed that stolen birth certificates were being used fraudulently. Beginning on October 1, 2010, states may no longer use those birth certificates to document citizenship to identity those eligible for public benefit programs.  The new law was initially scheduled to take effect on July 1, but states and program applicants have been given three additional months to prepare for the change.

The older certified copies will not be valid for new applications starting October 1, but states have the option of not requiring Puerto Ricans who are already enrolled to obtain a new birth certificate when they come up for their annual review of eligibility.  Additional information on the new law, as well as application forms for new copies of birth certificates, can be found here. 

Wisconsin recently became one of the first states to tackle this issue:  the state decided not to make current program participants obtain new copies of their birth certificates. (See Operations Memos # 10-39.) The WI Department of Health Services (DHS) decided that requiring all enrolled Puerto Ricans to obtain new birth certificates would be a burden for those individuals and wouldn't be a cost-effective use of time for caseworkers.  

Wisconsin's BadgerCare Plus program has been extremely effective in giving nearly all Wisconsin children access to quality affordable health insurance, and in making enrollment and renewals easier for eligible families.  However, Wisconsin still has room for improvement in streamlining renewals, and DHS is working toward that goal.  The department's choice not to require new birth certificates for already-enrolled Puerto Ricans prevents what could have been a setback to Wisconsin's efforts to reduce churning among program participants.

For new Puerto Rican applicants, states can mitigate the potential burden of the law by taking advantage of the CHIPRA option to use Social Security numbers for automated verification of citizenship and identity.  Although Wisconsin does not currently employ that option, DHS is preparing to put it in place this fall--and many states are already up and running with it.    

There is no avoiding the fact that the Puerto Rico law will affect Medicaid and CHIP programs across the U.S and is likely to delay some applications.  However, the choices made in Wisconsin illustrate that states can minimize the additional burdens for program applicants, participants and caseworkers.  Especially when budgets are tight, smart decisions that avoid additional red tape can pay off for both state budgets and uninsured kids.

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

By Eugene Lewit and Liane Wong

The David and Lucile Packard Foundation

The percent of uninsured children has consistently declined, despite deterioration of coverage for adults and the economy. This is one of the significant but frequently overlooked good news stories of recent years.

The gains in children's coverage have been due in large part to actions taken by states to simplify enrollment and retention processes for their Medicaid and CHIP programs while expanding eligibility for those programs. In many states, policy advocacy groups have played important roles in spurring and supporting progress in their states. These organizations are likely to continue to be important players in the implementation of CHIPRA and broader health care reform. Yet, there has been little rigorous, systematic research on how advocacy groups do their work and the strategies they employ to achieve their objectives.

Two recently released issue briefs based on findings from an on-going evaluation of the David and Lucile Packard Foundation's Insuring America's Children: States Leading the Way (IAC) grantmaking strategy attempt to fill some of this knowledge void. The briefs examine some of the state-based advocacy work supported through IAC and identify the lessons that have been learned regarding how to effectively support and promote growth of children's health coverage.

In the first brief, State-Based Advocacy as a Tool for Expanding Children's Coverage: Lessons from Site Visits to Six IAC Grantee States. Evaluation Brief 1, the authors summarize key findings gleaned from in-depth site visits to states where IAC has made its most substantial investment in advocacy through multiyear "Finish Line" grants. These findings describe how persistence, flexibility, creativity and commitment to conducting effective states-based advocacy, especially in a changing environment, can benefit coverage expansion to all children. They also describe the importance of building strong and broad-based coalitions that include both grassroots and state-level stakeholders, an often key step toward maintaining a unified voice among a sometimes crowded community of advocates working to improve children's well being. While acknowledging that much work remains, the brief pinpoints a number of important gains in children's coverage since the IAC efforts began -- gains that have resulted despite a severe and ongoing economic downturn.

The second brief, Strategic Engagement of Policymakers is Key to Advancing a Children's Health Care Policy Agenda. Evaluation Brief 2, examines the benefit that positive engagement of policymakers can have for advocates to move the children's health care coverage agenda forward in states, as well as the strategies for making this engagement happen. Understanding states' unique political environments is one important first step toward this engagement. Further strategies include identifying, nurturing, and supporting political champions; creating strategic links between grassroots organizations and policy advocacy groups; creating effective, appealing messages for policymakers; establishing advocacy groups as the "go-to" resource for reliable data and information; and sharing ownership of agendas and successes with champions and key policymakers.

These briefs provide objective validation of the advocacy strategies and tactical innovations employed by veteran advocates throughout the country. They also offer practical and field-tested ideas for advocates looking for new ways to accelerate the pace of change. Most importantly, they remind us that tough, smart advocates can guide and support leaders in continuing the children's coverage success story.   

As we've noted previously Congress has yet to reach agreement on extending the increased Medicaid funding it originally granted in the 2009 economic recovery legislation.  The increased payments are scheduled to end in December 2010, but most state budgets are looking no better than they were a year and a half ago.  It seems like federal lawmakers would like to help states maintain Medicaid for the children and families who need it--Medicaid fiscal relief has passed both houses of Congress separately, but never in the same piece of legislation, so it is not law.

About half the states responded to this demonstrated interest by Congress--they included a six month extension of the increased Medicaid funds in their fiscal year 2011 budgets (see the map that employs data from the National Conference of State Legislatures) .  Since fiscal 2011 is already underway, states will be forced to make jarring budget adjustments if the extension does not come through.  

(Click to enlarge graphic)

In its absence, states will face budget holes of tens of millions in smaller states to more than a billion dollars in states like New York and California.  That means cuts to services state residents depend on or tax increases at a time when the economy remains fragile.  And because federal law protects eligibility standards and procedures in Medicaid, only limited parts of the program can be cut by state policymakers.  That makes the Medicaid funding extension an issue for all parts of the state budget--from education to economic development to the support for local governments that funds police and fire services.  Failure to extend Medicaid funding will have a ripple effect through the budgets and economies of many cash-strapped states.

The U.S. Senate moved yesterday toward extending unemployment benefits for those who have lost their jobs, recognizing that the recovery has not yet reached many workers.  It hasn't reached state budgets either, so an extension of Medicaid fiscal relief would help states maintain the services that families are counting on now more than ever.        

Since the last time we talked about state estimates of the cost of health reform, several more have put them out.

A few, in particular, struck me - Maine, Maryland, and Wisconsin. Why, you might ask? Because these three states found that health reform would save them money.

John Holahan of the Urban Institute suggested just this when he put out some estimates of state spending back in May, saying that "the states will come out ahead."(My colleague Jocelyn Guyer blogged about his findings.) But much of what we've heard from the states themselves has been "it's going to cost us $(fill in the blank)."

Let's start with Maine. An estimate put out by the state back in mid-June, found that the state is projecting to save $31.8 million in 2014. Wisconsin takes a longer view, estimating  savings of at least $745 million between 2014 and 2019. Maryland looks even more long term, projecting  savings of $1 billion over ten years.

As is always the case with state-by-state data, it's important to remember that each one is different (as are the assumptions the states are using to come up with their estimates in the first place). Maine, Wisconsin, and Maryland, have all been leaders in coverage and, as a result, will now reap some of the financial benefits of health reform. Other states may have to spend some money in order to see the coverage gains expected as the Affordable Care Act is implemented (which given their current budgets can understandably be seen as a daunting task).

But, the most important number to remember, whether your state saves or spends, is 32. As a result of health reform, 32 million more people will have coverage. How much is it worth to you to have a healthier America?

By Judith S. Palfrey, MD, FAAP

President, American Academy of Pediatrics

On Wednesday, I was honored to attend an event in DC unveiling the US Department of Health and Human Services' (HHS) Interim Final Rule on preventive services under health reform. To so many of us in the business of taking care of children, the achievement of passing the law last March was a time of historic celebration, and now, as one of the most significant pieces of the law takes shape, we realize just how much better off our children will be under health reform.

One of the earliest provisions of the Patient Protection and Affordable Care Act to take effect is Section 2713, which requires health plans to cover, at absolutely no out-of-pocket cost to families, preventive care services outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Supported by the Health Resources and Services Administration, Bright Futures is the definitive standard of pediatric well-child and preventive care developed by an evidence-informed, active collaboration led by the American Academy of Pediatrics (AAP).

Perhaps the best-known aspect of Bright Futures is the schedule of "well-baby and well-child visits" it establishes--31 visits between birth and age 21 years (to pediatricians and other clinicians, it is also known as the "periodicity schedule"). The interim rule clearly states that all components of pediatric well-child visits--including physical exams, immunizations, hearing and vision screening, developmental and behavioral screening, and anticipatory guidance--in accordance with the Bright Futures periodicity schedule must be free of financial barriers, including co-pays and deductibles. Insurers may not exclude any of these services from coverage, and cost-sharing cannot be imposed on families.

This landmark investment in preventive services will eventually allow all families, regardless of income, the opportunity to visit their pediatrician regularly during their children's most critical years of development. Having coverage for the clinically appropriate well-child visits will allow pediatricians to identify and treat health problems in children before they start. This, in turn, should help bring down the prevalence of chronic conditions that place significant financial and physical strain on children and families.

The Academy will continue to work with HHS on the development of a Final Rule, and in the process, will continue to advocate for the following: all plans--including those retaining "grandfather status"--to cover Bright Futures services; Bright Futures to be appropriately integrated into other initiatives and standards, such as meaningful use and quality measures; and for insurance companies to eliminate cost-sharing while making up those dollars for pediatricians and other health care providers.

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

Editor's Note:  CCF's Dawn Horner also blogged about the preventive health services rule.