Recently in Medicaid Category

After two weeks in New Hampshire and Maine and a few extra cups of coffee to get moving, I returned from vacation yesterday to find this very interesting development in my inbox - the nation's Medicaid directors are breaking away from the American Public Human Services Association to start their own independent organization - the National Association of Medicaid Directors.  In explaining why they are making the change, the new President of NAMD, Carol Steckel of Alabama Medicaid, explained "Healthcare reform is dramatically changing the face of Medicaid in all of our states and with those changes brings the need for a change to an organization specifically focused on Medicaid and its Directors."

Since I got myself in serious trouble over vacation by expressing an opinion on a family member's new boyfriend, I'm officially out of the business of offering my thoughts on anyone else's relationships, including that of the nation's Medicaid Directors with APHSA.  So, leaving aside whether the split was a good idea or not, I do think it is clear that Medicaid is entering a new era.  As a companion program created alongside Medicare in 1965, it long has been a cornerstone of the nation's health care system, especially for low-income children and families.  And, now it is destined for even greater things in the months and years ahead as we move toward broader health reform. 

The success of both organizations and close collaboration between them will be vital to fostering the critical connections between health care and other social services programs needed to improve the lives of America's families.

On August 10th, President Obama signed an extension of the state fiscal relief first authorized under ARRA. Under the extension, states will continue to receive a phased-out increase in their federal Medicaid matching rate through June of 2011, as opposed to it expiring at the end of this year.

CMS released guidance on the FMAP extension, clarifying that all the maintenance of effort requirements that applied to states under ARRA continue under the extension.

There was one change, however, to the manner in which states request and receive funds. Under the extension, as a condition of receiving the additional federal Medicaid funds, the Governor must submit a request within 45 days of enactment, or by September 24, 2010. 

I know I've said it dozens of times - states are different. Like people themselves, they have their own characteristics, quirks, and personalities that make them unique. But what about within states - are there differences of note? Why, of course (I'm sure we can all think of a long list of differences between, say New York City and upstate NY). And lucky for us, a recent data release from the Census highlights how health insurance coverage varies within states' very own borders.

(Quick methodological note for those of you who are interested in such things: the Small Area Health Insurance Estimates (aka SAHIE) are model-based and combine data from a variety of sources. These data represent coverage in 2007, prior to the economic downturn. They are currently the Census' only data source on health insurance for every county in the US. For more on the various measures Census has on health coverage, check out this helpful fact sheet. The Census also computes small area estimates for income and poverty (aka SAIPE).

Now back to the data at hand - at 26.8%, Texas has the highest rate of uninsured in the country. But where are those 5.8 million folks living? The range in the uninsured rate is quite wide, from 16.6% in Collin County to 49.5% in Kennedy County. What makes these two counties in the same state so wildly different in terms of health coverage? A quick look at some demographic data provides us some idea:

Collin County, located just north of Dallas, is about 850 square miles and has about 765,000 people. In 2007, the median household income was around $80,000.

Kennedy County is located on the Gulf Coast between Brownsville and Corpus Cristi. It's almost twice the size of Collin County, 1,450 square miles, but has less than 400 residents, with a median income of about $30,000 in 2007.

I think it's fair to say that we don't have to pick on Texas as an example, as other states are bound to have within-state variation (even Massachusetts - known for its low uninsured rate of 7.8% - has a range of 6.6% to 13.9%).

State officials and advocates should find these data very helpful in identifying which areas of their states have the greatest number of uninsured residents and possibly understanding the reasons for such differences. (Note - although I didn't do it here, you can also look at the data by age ranges and income levels). And when making the case for targeting outreach efforts, both for those who may already be eligible for coverage through Medicaid and CHIP and, in 2014, for those who will become newly eligible, having data to support your claims will make your case that much stronger. 

Last week, Cindy Mann blogged about the importance of kids' coverage on healthcare.gov. "As back-to-school time approaches, families are thinking about making sure their children have every opportunity to learn. Now is also the time to make sure that kids have the coverage they need to be healthy - the first step to a successful school year."

Luckily, many kids already have an affordable coverage option through Medicaid and CHIP. As part of the challenge to get all eligible kids signed up, CMS has launched Get Covered. Get in the Game. to bring coaches, schools, families, and communities together to raise awareness. (Maryland's Suzanne Schlattman blogged about the campaign for us earlier this month.)

Check it out to see how you or your organization can help get children covered and in the game.

Under the Affordable Care Act, states will have considerable flexibility, within federal guidelines, to design Medicaid benefit packages and cost-sharing rules that are appropriate for newly-eligible adult beneficiaries. The often-extensive health care needs and very low incomes of the newly-eligible adults are important considerations for states as they put the new law into effect, according to a new issue brief written by CCF and the Kaiser Commission on Medicaid and the Uninsured. 

Half of all uninsured adults below 133 percent FPL have income below 50 percent FPL. When it comes to their health status, about one-third have a diagnosed chronic condition, such as hypertension or depression, and about 1 in 6 are in fair or poor health.  Given the limited income and often-extensive health care needs of newly-eligible adult Medicaid beneficiaries, it will be critical that they be provided with benefits designed to reflect their unique needs if health reform is to work as intended.

Both the federal and state governments will play important roles in making sure the new law works for newly-eligible adult Medicaid beneficiaries. The issue brief identified two key areas for policyakers to consider as they move forward on implementing the new law:

• Benefit Packages: The content of the coverage provided to the millions of low-income adults slated to secure Medicaid coverage under the health reform law will depend, in part, on how the federal government addresses key issues, such as the definition of "essential health benefits." In addition to covering these essential benefits, the coverage for the newly eligible must be equal to coverage provided under one of three "benchmarks." Importantly, states can also provide additional benefits on top of the benchmark.
• Continuity of Care: Given that changes in income, health status, and other factors are common, coordination and consistency of coverage between Medicaid groups and over time are key aims. Because individuals may also shift between eligibility for Medicaid and Exchange coverage, identifying ways in which states can promote continuity of care between the two systems is a priority.

The responsibility of creating a coherent program that provides the full range of groups served by the Medicaid program with the benefits that they need when they need them falls mainly to the states. Thankfully, the federal government has helped make it easier on the states by making a commitment to finance the full cost of care for the newly-eligible Medicaid adults for the first three years of reform and at least 90 percent of the cost thereafter.

Hope for uninsured low-income adults is on the horizon.  Let's hope policymakers finish the job by making wise choices in how they design the benefit packages and address the need for continuity of care for newly eligible Medicaid beneficiaries.  

We've been following for some time the inconsistent progress of legislation that would extend increased federal Medicaid payments to states.  While versions of the legislation have previously passed both houses of Congress, the two chambers had not succeeded in making the extension law by agreeing to the same bill.  Today, they have, with the House interrupting its August recess to pass a bill approved by the Senate last week that includes both the Medicaid funding and more support for public schools.  The act will continue for six months a portion of the increased Medicaid funding that states have been receiving under the economic recovery legislation.  The funds had been scheduled to expire in December of this year, but instead will phase out through June of 2011. 

States have been receiving an extra 6.2 percentage points in federal matching funds for their Medicaid programs, plus an additional amount based on the state's unemployment rate.  Under the extension, this will drop to 3.2 percentage points in January 2011 and 1.2 percentage points in April, again with an additional increase based on unemployment figures.  See this Center on Budget and Policy Priorities report for an estimate of the amount each state will receive over the first six months of 2011.

This extension will give states a bit more breathing room in their 2011 budgets.  The Medicaid and education funds will help protect not only health coverage and kids' schooling, but should reduce pressure across states' budgets.  Many states had already counted on the extension in the budgets they approved earlier this year, so Congress's action is an important contribution to keeping those budgets intact.  State budgets remain challenged but it's good to see Congress take action to protect important services that are helping kids and families today.

With the Senate's approval today to extend the enhanced Medicaid matching rate (aka FMAP) until June 30, 2011, cash-strapped states and their most vulnerable residents can rest a bit easier.  This measure will now return to the House of Representatives where it is expected to be approved next week. 

As the bipartisan National Governors' Association (NGA) recently noted:

"Funding for FMAP is a particularly effective tool because it immediately allows Governors to eliminate planned budget cuts required to meet balanced budget requirements and continue services for those with the greatest need." 

My colleagues at CCF, Liz Arjun, Joe Touschner and Jocelyn Guyer have blogged extensively on this topic and articulated well why approval of fiscal relief to the states is so crucial.  Families USA and many others have been on the frontlines making sure Congress realized the severe consequences of failing to extend the increased Medicaid matching rate during these tough economic times. 

The legislation also provides $10 billion to local governments to help them avert layoffs of teachers and other public-sector workers like firemen and police officers.

By Suzanne Schlattman, Maryland Citizens' Health Initiative Education Fund, Inc.

This week, the U.S. Department of Health and Human Services (HHS) announced the Get Covered. Get in the Game  initiative which will be launched in seven pilot states across the country including: Colorado, Florida, Maryland, New York, Oregon, Ohio and Wisconsin. The initiative brings together coaches, schools, and communities to educate families with children who are eligible for Medicaid or CHIP about the immediate availability of free and low-cost health care programs for children.

What a great idea! In public health, we stress prevention and leading an active lifestyle is one health behavior that pays the greatest dividends for preventing poor health. However, uninsured kids often miss out on organized youth sporting activities because they cannot afford the necessary physical or because their families are afraid that they won't be able to pay the medical bills if their child gets hurt. Providing coaches with information about affordable health insurance options for children is a great way to promote coverage among eligible families and promote the adoption of healthy behaviors.

In Maryland, we played around with this theme when we launched our "Got healthcare?" campaign after the state expanded Medicaid eligibility for adults in 2007. Local sports heroes from the Baltimore Ravens and Washington Redskins volunteered to help promote the program. We ran radio ads, partnered with local hotlines and put up posters in every hospital to alert people.  Having sports celebs promote enrollment in Medicaid helped raise awareness about the program, break down the stereotype that Medicaid was only for pregnant women and children, and again repeated the theme of leading an active lifestyle.  Over 200,000 Marylanders have gained access to free and low cost health care services since this campaign began.

Check out one of the great radio ads that was part of this campaign:

Chris Samuels of the Washington Redskins with Maryland Governor Martin O'Malley

And the poster with Ed Reed of the Baltimore Ravens:

It makes a lot of sense to involve youth sports leaders with our enrollment efforts as an estimated 44 million children participate in organized youth sports.  Coaches for youth sporting leagues are local celebs in their communities too -- and to have these folks promote enrollment in children's health insurance programs across the country is great news.  

In announcing the initiative, HHS Secretary Kathleen Sebelius reminded us of why we all work so hard to connect children with coverage:  

"Healthy kids do better in school and in life because they are able to participate fully in activities that develop their bodies and their minds," Secretary Sebelius said. "Kids should not have to miss out on their favorite sports and other activities that get them moving because they lack health insurance coverage."

All states can use the materials developed for the pilot states to get coaches involved in outreach efforts to enroll eligible children.  More information about the Get Covered: Get in the Game initiative is available at www.InsureKidsNow.gov.

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

By Tom Birch, National Child Abuse Coalition

For the first time, with the passage of health care reform in March, federal funding will be available to states to support a range of voluntary home visitation services to pregnant women, young parents and their children, designed to improve maternal and child health, foster healthy child development, and prevent child maltreatment.  Priority for services would go to low-income families living in communities in need of services. 

The new measure authorizes $1.5 billion over five years - with $100 million in 2010 - for the Maternal, Infant, and Early Childhood Home Visiting Program funded by HRSA, in collaboration with the HHS Administration for Children and Families (ACF), through the Title V maternal and child health block grant.  A three-percent share of the funds is reserved for grants to Indian tribes.

Research over the years has produced a strong body of evidence that early childhood home visitation programs are effective in reducing the incidence of child abuse and neglect and in improving child health and development.  While a majority of states already provide early childhood home visitation services to a relatively small number of families, the challenge has been to take this proven effective prevention approach to scale.  The new home visiting program can help to move toward that goal.  

The new funding promises potential for a significant positive impact on children's health care.  Home visiting programs link families to health care resources and focus on healthy outcomes.  Through a strong emphasis on prenatal care, significant costs associated with pre-term births and developmental disabilities are reduced.  Linking families to consistent primary care and immunizations means reduced emergency room costs and reduction in chronic illness. 

Studies have proven the results we hope to see.  Families who received home visiting services were found to be more likely to have health insurance and a medical home, to seek prenatal and well-child care, and to get their children immunized.  Instances of child maltreatment have been lowered significantly.  Babies of parents enrolled prenatally in home visitation services have shown fewer birth complications and higher birth weights.  

On July 21, HHS announced the allocation of $88 million for the first year of funding of the home visiting grants to states, the District of Columbia and each of the five territories.  The allocations are based on the size of the population of children under the age of five living at or below 100% of the federal poverty level in each state. The grant amounts to the states in the first year range in size from $7.78 million to California down to $557,408 to Vermont.

States have completed or are now in the process of conducting statewide assessments to identify existing home visiting programs and areas of high need. States each have immediate access to $500,000 of their allocations for preparing the needs assessments and begin planning their programs.  The remainder of the grant funds will be released in September, after approval of a state's plan for addressing the home visiting needs identified. The law directs states, in conducting a needs assessment, to coordinate with and take into account other needs assessments already ongoing, including those required by the Maternal and Child Health Block Grant, Head Start, and Title II of the Child Abuse Prevention and Treatment Act (CAPTA).

The Administration for Children and Families (ACF) is taking the lead, in partnership with HRSA, in administering grant support for the Tribal Maternal, Infant, and Early Childhood Home Visiting Grant Program.  Applications are being accepted for a total of $3 million in funding available for award in fiscal year 2010.

In applying for the home visitation grants, states must establish quantifiable benchmarks to demonstrate improvements at intervals of three and five years for families participating in the program.  The benchmarks address maternal and newborn health, prevention of child maltreatment, school readiness, reduced crime or domestic violence, family economic self-sufficiency, and coordination with community support services.

The new grant program requires states to allocate at least 75 percent of funding to support home visiting models that are research-based and rigorously evaluated through randomized control trials or quasi-experimental research designs.  The remaining 25 percent of grant funding could go to support promising approaches yet to be evaluated by a similar rigorous process. 

On July 23, HHS published proposed criteria for evidence of effectiveness of home visiting program models to inform the funding decisions for the new program. Comments on the proposed criteria are due by August 17, 2010. 

In future years, the funding for the program would increase from $100 million in 2010 to $250 million in 2011, $350 million in 2012, and $400 million in each of 2013 and 2014 -- HHS plans to allocate the additional funds competitively.  While HHS proposes to give significant weight to the strength of the available evidence of effectiveness of the model or models employed by a state, HRSA and ACF are open to comments on what criteria are appropriate to judge states competitively.  It is anticipated that the criteria for evidence-based models will need to be altered over time as the state of the field changes, so HHS intends to review the evidence base for home visiting models on an ongoing basis to ensure that new evidence is incorporated.  How program models are evaluated and rated will be the key to allocating the competitive funds. 

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

For all those wondering what was going on with the 2010 federal poverty level, your answer arrived today in the Federal Register. But while I have your attention, here's the back-story.

A decline in the average CPI-U during 2009 would have required HHS to issue poverty guidelines in 2010 that were actually lower than those in 2009, leading to a reduction in eligibility for the safety net programs that rely on the guidelines, including Medicaid. (This would have been an unprecedented event - the only reduction since the issuance of the first poverty guidelines in 1965).

In December, the Department of Defense Appropriations Act (go figure) included a provision to freeze the poverty guidelines at 2009 levels through March 1, 2010. This freeze has been extended twice more until at least May 31, 2010. (I say at least, because all three extensions included language stipulating that the poverty levels would remain in place until updated guidelines were published, hence the somewhat fungible deadlines).

I don't know about you, but I've been on pins and needles since the end of May waiting for the publication of the updated guidelines. Well, the wait is over... ASPE modified the procedure for updating the guidelines to take into account the changes in the CPI-U during the freeze. (Typically, ASPE uses price changes through the most recent "completed" year. In this case, they also took into account the changes between January 2009 and May 31, 2010.) 

The percentage increase in the CPI-U was so small that as a result, the poverty guideline figures for the remainder of 2010 are unchanged from the 2009 poverty guideline figures. These guidelines will remain in effect until ASPE publishes the 2011 guidelines, which are expected in late January 2011.