Recently in State Health Policy Category

CCF is hitting the road!  We've scheduled four meetings around the country to bring together child and family health advocates to discuss opportunities and challenges for moving forward on coverage.

Our first meeting, for the Southern region, took place last week in Tampa, Florida and despite how difficult it is to hold a health conference with the uncertainty surrounding health reform, it went very well. But you don't have to take my word for it -- Michele Johnson of the Tennessee Justice Center blogged about her experience at the meeting.  You can also find the presentations and materials from the meeting on our website. 

Next week, we'll be in Providence, Rhode Island for the Northeast region conference and April will find us in Salt Lake City, Utah, for the West and Cleveland, Ohio, for the Midwest meetings.  It's a great opportunity to meet with your neighbors to discuss what's working in their states.  If you can't make it when we visit a state near you, check the CCF website for materials and related resources.

By Michele Johnson

Managing Attorney and Co-Founder, Tennessee Justice Center

The Southern Regional Meeting of Transforming Health Care Coverage for Children and Families was just what the doctor ordered.  For anyone feeling down about health reform or frustrated with the status quo, you need to attend this meeting!  The technical information about the health care bill, the messaging workshop and success stories from other southern states were so valuable and hopeful.

The messaging workshop put on by Ed Walz from Spitfire Strategies was full of practical tips about how to be heard by policymakers and the public. Ed, always entertaining and compelling, gave us the recipe for communicating effectively. Among other things, he taught us how to write effective blog articles (like this one, I hope!), letters-to-the-editor, and blast emails. By day's end, I not only felt like I could do it, but we had actually done it in hands-on activities.

The presentations about both the nitty-gritty of the health reform bill and the opportunities of CHIPRA were extraordinary. They contained crucial data about the demographics of the eligible but uninsured children who are waiting for us to reach them now.  They laid out who will be helped by reform and how. What useful tools to have at our fingertips as we try to raise resources to reach these children! The health reform waiting game has seemed paralyzing in so many ways, but these presentations gave me a "to do list" of practical and immediate steps to enroll children and keep them enrolled.

My favorite part of the conference was seeing and hearing about the experiences of my southern sister states.  I heard from friends, old and new, about the challenges they are facing and overcoming. Sometimes working for health care for children in the South can be isolating and demoralizing, so hearing from others facing similar hurdles was moving. Amazing work is going on in our region!  I left the conference reminded of Anne Frank's quote "How wonderful that nobody need wait a single moment before starting to improve"...healthcare for children in the South!

Thanks, Georgetown Center for Children and Families and partner organizations for using your extraordinary talents to improve policies every single day for children in Tennessee and all over America. 

Editor's Note: Say Ahhh! readers aren't fooled by Michele's modesty as we've seen some great blogs out of her before.  With all the nice things she's saying about CCF and our friends, we just might have to make her a regular.

Express Lane Eligibility (ELE) is a relatively simple concept. There are millions of uninsured children eligible for Medicaid and enrolled in other public programs, like school lunch or food stamps. Since they serve the same populations and families have already submitted relevant information, we can create connections between the programs in order help more children access affordable health coverage. Such a commonsense approach doesn't sound like it should be too heavy of a lift, but once you get below the surface you'll find many layers that have to be peeled back.

As in many things in life, public programs have a tendency to operate within silos, each having its own applications, staff, rules, and computer systems. I witnessed this first hand when working for The Children's Partnership (the first group to use the term Express Lane Eligibility) in California to link free school lunch with Medicaid/CHIP (Medi-Cal and Healthy Families in the state). From legislation to implementation, it was really rewarding but tough: it hadn't been done before, the culture of working across programs wasn't there, and the different federal rules governing the programs were a mine field. We had mixed results, which you can read more about here. 

Today, there's a new beat coming out of Nashville, Tennessee (aka Music City, USA).  Tennessee Governor Phil Bredesen has changed his tune and announced that on March 1 enrollment will resume for CoverKids, the state's Children's Health Insurance Program (CHIP).  The Governor had frozen enrollment in November but, after a loud public outcry, he decided to tap a state savings account for public health programs to re-open enrollment for uninsured children.

The news is music to the ears of the parents of the 145,000 uninsured children in Tennessee who may be eligible for coverage if they are unable to find private health insurance.  The Tennessee Justice Center and other advocates have been urging the Governor to re-open enrollment.  Michele Johnson at the Justice Center blogged about the enrollment freeze on Say Ahhh! last month and credits the blog with helping to focus attention on the issue which led to the Governor's action to re-open CoverKids. 

In announcing the change in policy last night, the Governor was quoted as saying: "Fortunately, we've been able to dig deep and find additional funding to keep this option available to families in need."

Let's hope other Governors and state policymakers are paying attention and will "dig deep" before denying access to affordable coverage to children in need.

 

There has been much discussion about states' ability (and willingness) to help finance health reform, especially as it concerns an expansion of Medicaid. A little background data may help to illuminate the debate.

While significant, Medicaid's role in state budgets is far more modest than the headlines often suggest. Medicaid constitutes 16.2% of state general fund spending, leaving it well behind elementary and secondary education (in fact, as shown below, states spend nearly twice as much of their own money on elementary and secondary education (35.1%) as on Medicaid).

It is often, misleadingly, suggested that Medicaid consumes a larger share of state budgets than any other item. Misleadingly because the numbers cited to make this point include federal Medicaid matching funds states receive. So while this may be true for total state spending (if you include federal funds), it is not the case if you consider Medicaid spending as a share of a state's own general fund (basically just the state's money). In fiscal year 2009, state funds spent on Medicaid actually decreased by 2.2% from fiscal year 2008 due to the increased federal Medicaid support made available by ARRA - the federal stimulus legislation.

As the health reform debate continues, it is important to acknowledge state concerns regarding their dismal fiscal conditions and realize that there are certainly options to adjust the formula in order to make it more equitable across states.

However, it is also vital not to lose sight of the larger point - states are getting a pretty good deal out of health reform: near universal coverage with marginal costs. Yes, their budgets are in disarray and yes the federal government (not to mention their citizens) are expecting a bit more of them. But these requirements are years away, as states would not be expected to contribute to the cost of the newly eligible until 2015 in the House bill and 2017 in the Senate bill.

There's a risk of exaggerating claims without a full understanding of the fiscal implications of health reform (or current Medicaid spending). Everybody would be better served by having an honest debate about the true costs of reform and how best they can be shared.

Each celebration of a new year brings a renewed sense of optimism and 2010 offers tremendous promise in mitigating the chilling impact of the citizenship documentation requirement imposed by the 2005 Deficit Reduction Act (DRA) on Medicaid. The citizenship documentation requirement not only made it more difficult for eligible citizens to enroll in Medicaid but states have also spent millions of dollars in administrative costs to comply with the regulation. The title of a study by the Government Accountability Office says it well: "States Reported that Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens." 

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?

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.

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.