SCHIP

HEALTH REFORM: Obama Signs SCHIP Reauthorization

Paul Testa — Wed, 04 Feb 2009 21:49:00 -0500

Just hours after receiving final approval in the House by a margin of 145 votes, legislation reauthorizing the State Children's Health Insurance Program has been signed into law by President Obama. He made clear that expanding coverage for low-income kids is the first, but by no means the last, step his administration plans to take toward his goal of making sure all Americans have health coverage.

H.R. 2 provides the program with an additional $32.8 billion, preserving coverage for about seven million low-income children currently enrolled and extending coverage to an additional four million previously uninsured kids.

During a signing ceremony in the East Room of the White House, President Obama asserted the importance of the program saying no child should be "receiving their primary care in the emergency room in the middle of the night. "

"In a decent society, there are certain obligations not subject to trade offs or negotiations," Obama said. "Health care for our children is one of them."

Flanked by a bipartisan group of Congressional leaders, Obama said that coverage to 11 million children "is a down payment on my commitment to cover every single American," and that the legislation was "just one component of a much broader effort to finally bring our health care system into the 21st century."

That broader reform, Obama acknowledged, won't be easy, and it won't happen all at once. But reauthorizing and expanding SCHIP, he said, "is a critical first step."

COVERAGE: House Gives Final Approval to SCHIP Reauthorization

Paul Testa — Wed, 04 Feb 2009 16:41:00 -0500

By a margin of 290–135, the House gave final approval today to legislation reauthorizing the State Children's Health Insurance Program through Fiscal Year 2013. The bill now heads to the White House, where President Obama has scheduled a signing ceremony for 4:30 pm in the East room of the White House.

The final version of the H.R. 2—passed in the Senate last week by a margin of 66–32, with nine Republican Senators voting in favor of the bill—provides an additional $32.8 billion in funding, extending coverage to four million more uninsured children and bringing total enrollment in the program to 11 million. The spending is funded by a 62-cent increase on the tobacco tax.

COVERAGE: Details, Details, Details

Paul Testa — Fri, 23 Jan 2009 19:44:00 -0500

The devil, we're told, is in the details. We would have said Prada, but if you asked where the details matter most, we think you can make a strong argument for the programs of Medicaid and SCHIP.

First, there's the combination of state and federal funding that makes budgeting Byzantine. Add an array of eligibility, enrollment, and verification requirements. The result is a labyrinth fit for a Minotaur, yet often overwhelming to the populations these programs are intended to serve.

Which is why at a Kaiser Family Foundation briefing Friday on Children's Health Coverage: What's Next, we felt a little like Anne Hathaway, post makeover, in the Devil Wears Prada, suddenly seeing the real impact of details and policies on these programs.

KFF's Julia Paradise (slides) began the day reviewing work from the foundation on the impact of health coverage on low and middle income families. Some quick facts:

Three-quarters of low-income working families with an uninsured child had no access to employer-sponsored health insurance (ESI). Of those low-income respondents with access to ESI, but not enrolled, 81 percent said they could not afford it.
Uninsured, low-income children have less access to care than their insured peers, and were five times more likely to delay or skip care due to cost. The rates were similar for middle-income children (200-299 percent of FPL) without insurance.
Compared to those covered by private insurance, low-income children covered by public programs like SCHIP and Medicaid received essentially equal access to care--such as having a usual source of care or receiving well-child visit.

Having established the importance of Medicaid and SCHIP in providing coverage to an underserved population, Donna Cohen Ross of CBPP and Caryn Marks of KFF, presented an update on the status of the programs' enrollment and eligibility polices in all 50 states for 2009 (slides).

The whole report is worth a read, and next week we'll talk about some state efforts to simplify the enrollment, eligibility, and administration process. For right now, here's a nice summary of changes in policies regarding access to Medicaid and SCHIP over the past year:

The rest of the event provided a series of real world perspectives from individuals directly involved with Medicaid and SCHIP.

John Folkemer, the Maryland State Medicaid director, spoke about his state's efforts to expand coverage to adults and improve outreach in general. The variety of funding tMaryland pulled together to finance the expansion was impressive, although the current fiscal crisis has put further implementation on hold.
Jay E. Berkelhamer, MD, a past president of the American Academy of Pediatrics, provided a physician perspective, noting that CHIP has been extremely successful and that it should be reauthorized quickly. He also urged us to do more to ensure that all children are covered and receive the care they need. (slides)
Susan Johnson, Director of the King Country Health Action plan, offered a perspective from the West coast, describing Washington state efforts to streamline the enrollment and renewal process through administrative simplification, technological investments, and public outreach.

HEALTH REFORM: In the Beginning...

Joanne Kenen — Wed, 21 Jan 2009 18:32:00 -0500

Welcome back.

Yes we noticed that President Barack Obama mentioned health care in his inaugural address. We were pleased, but not surprised. He's made clear that health reform is a priority.

We see there's a new look at www.Whitehouse.gov. We didn't see much new on the health care agenda portion of the site—looks like it's what we heard during the campaign and transition. But it's nice that it has found a new home.

In the near term, the SCHIP and economic stimulus bills should help low-income individuals and the newly uninsured. Amy Goldstein at the Washington Post summed that up nicely over the weekend, including some insights into how this could alter government role in health care. We're hearing that the big push on comprehensive health reform won't come until March, but that's still early enough to enjoy momentum from the new presidency. And momentum is important with an initiative this large and complex. The Wall Street Journal says to expect a White House event involving the administration, members of Congress and interest groups in a "working session of sorts" to launch the effort.

HEALTH REFORM: Free Lunches and Filled Doughnuts

Joanne Kenen — Fri, 16 Jan 2009 12:19:00 -0500

Americans want health reform. They want coverage expansion and insurance reform. As long as they can keep the health plan they have now, save money, and finance it all by taxing an upper income smoker. You know, like that guy on the Monopoly board.

They also want to fill the Medicare drug benefit doughnut hole, cover kids, and provide more care to our veterans. By taxing that same rich smoker.

OK, we're exaggerating. The Kaiser Family Foundation did its traditional poll on the health care agenda for the new president and Congress. There was definitely some good news for those hoping for comprehensive health reform this year. A solid majority of Americans (61 percent) believe that during our economic meltdown "it is more important than ever to take on health reform now."

But the poll also highlighted serious obstacles that reformers need to keep in mind. That includes deep partisanship and a huge amount of economic anxiety, according to analysis offered at a Kaiser forum with three of our favorite health policy experts, Kaiser CEO Drew Altman, the foundation's public opinion research director Mollyann Brodie and Harvard professor Robert Blendon, who is an expert on health reform politics and public opinion. (webcast here, transcript in a few days)

Blendon stressed — and we mean stressed, he said it forcefully and repeatedly — that it's hard to underestimate how worried people are about money in what he called a "near Depression." They are scared to death about paying their bills, and not just their health care bills. Raising their taxes to pay for health care isn't a solution for them (and, yes, they will notice if you start taxing their employer-sponsored health benefits). "Middle income people in something close to a Depression don't want to pay a lot of new taxes," he said.

Altman believes that, obstacles notwithstanding, we do have a real shot at enacting health reform this year. As he wrote in a recent essay:

Beginning this Spring, between expected approval of an economic stimulus package and the start of campaigning for the midterm election, there will be a rare window of opportunity for passage of major health reform legislation. History suggests that momentum can be lost if policymakers do not move quickly to seize these rare openings when they occur. There is an opportunity now because the nation has a popular new president with political capital to burn who is making health reform a priority. Democratic leaders in control in the Congress want to deliver on health care. And a historic recession has transformed health care into a bread and butter economic issue of real salience to working people and the middle class, who are worried about paying their health care bills and about losing their jobs and their families' health coverage.

But Altman has spent some time studying (not to mention living through) past health reform debates. The longer they last, the harder they fall. The public is fickle; ideas they embrace at the outset of an administration become tarnished if they hang out there long enough under attack by interest groups and opponents. Lots of things are different this time around. The public is engaged and truly does think of health care reform as an investment in economic recovery. The pro-reform groups are organized and have begun what Drew called the "rah-rah" phase. And President-elect Obama and his team are determined to learn from the mistakes of the past, particularly the 1993-94 failures. (See the charts with Altman's essay, linked above, on public opinion trends during the Truman and Clinton administrations)

But ask just about any question about health care policy, or more specifically probe a little bit about the tradeoffs necessary for reform, and you'll quickly find partisan divides, Brodie said. Even on the relatively noncontroversial aspects of health policy, that schism looms. For instance, 62 percent of the Democrats but only 29 percent of the Republicans want more spending on SCHIP, the insurance program for children of the working poor.

(For those of you deep into this topic, the poll had a lot of detail on how the public views such things as comparative effectiveness, capping the tax exclusion, medical underwriting, and insurance profits)

Two final stray thoughts..First, the Kaiser poll found that 2 percent of those surveyed thought improving the country's economic situation is "not that important." Who are these people?

Lastly Max Fine (I think that's how he spells it), who identified himself as the sole survivor of President Kennedy's task force on Medicare, was in the audience at Kaiser and he shared some really interesting lessons from the past. I'll pull out his comments and post them if there's a transcript available next week.

HEALTH REFORM: House Backs SCHIP Expansion

Paul Testa — Wed, 14 Jan 2009 22:03:00 -0500

Legislation that would reauthorize SCHIP over the next 4 ½ years passed the House of Representatives by a margin of 289 to 139 votes today (Wednesday). HR 2 would provide an additional $32.3 billion in funding to the program, increasing enrollment from 6.7 million to nearly 11 million children.

The Senate Finance Committee will consider similar legislation in a hearing tomorrow at 11:15 am.

Early action on SCHIP seems likely for a number of reasons. First the program's temporary reauthorization expires March 31. Second, as the Washington Post notes, the economic crisis has left many parents struggling to find insurance for their children. As our colleague Joanne Kenen noted in a post earlier today, this increased need has comes at a time when states are already struggling to meet or pulling back on existing commitments. Finally as some pundits have pointed out, passing SCHIP reauthorization would provide an early victory for the new Obama administration, serving as a down payment on further health reform.

Check back for future updates.

COST: Cutbacks for the Poor Coming Fast and Furious

Joanne Kenen — Wed, 14 Jan 2009 17:17:00 -0500

If the headlines aren’t depressing enough for you, here’s more glum news. States are slashing health services to poor people at such rapid rates that even a federal rescue package might not be able to restore services, the LA Times reports. And the faltering economy “has all but killed trailblazing state campaigns to expand coverage for the working poor—once seen as hopeful signs for national healthcare reform.”

In Illinois nursing homes facing bankruptcy because of slow state payments may have to relocate old and frail patients.

South Carolina has cut treatment for poor women under age 40 with breast or cervical cancer, and stopped providing nutritional supplements for kidney failure patients.

In Nevada some cancer patients, are struggling to get their chemotherapy after the largest public hospital stopped outpatient cancer services. They’ve been dubbed “medical refugees.” And the list goes on to other states, across the country.

The federal stimulus program is likely to have up to $100 million in Medicaid money for the states, and the House and the Senate hope to quickly expand the SCHIP program for low income children. But according to the Center for Budget and Policy Priorities, at least 44 states face budget shortfalls over the next two years totaling more than $350 billion. (See chart bellow)

“Red” and “Blue” states are both affected, so maybe that will spur both speed and bipartisanship on Capitol Hill as lawmakers work on both the emergency health care needs in the stimulus bill and the major repairs to our health care system that can’t come a moment too soon.

IN THE STATES: How Soon is Now?

Health Policy — Mon, 17 Nov 2008 17:06:00 -0500

We asked Leif Wellington Haase, director of New America's California Program, and Micah Weinberg, a research fellow in the California program, to fill us in on the latest developments on health care in California, particularly the possible cuts to funding the state’s Healthy Family Program for low income kids.

This blog has documented the flurry of activity in health reform in Washington in recent weeks. Senator Max Baucus has floated major new proposal to overhaul the delivery and funding of care and Sen. Edward Kennedy is working on a related initiative. Former Senate Majority Leader Bill Frist has urged Republicans to work with Obama to make helping the uninsured an “immediate” priority.

But will immediately be soon enough?

In California, the state faces a staggering budget deficit estimated at between $25 and $30 billion over the course of the next 20 months. In the fourth “extraordinary budget session” of the year, Governor Schwarzenegger has proposed drastic cuts to state health care funding. These cuts include freezing enrollment in the California’s “Healthy Families Program” which provides medical, dental, and vision care to children from families that earn too much to qualify for Medi-Cal (the state’s Medicaid program) but not enough to purchase their own insurance. Other states around the nation have likewise curtailed their health care spending. Hawaii, for instance, recently ended a program to cover uninsured children.

These cuts come exactly when families experiencing layoffs or salary reductions most need the protection of the public safety net and when the country can least afford to have health care pullbacks drive struggling families into debt. As New America Foundation President Steve Coll warns that, “The accumulating failures in the country's health-care system are a cause of profound weakness in the American economy; unaddressed, this weakness will exacerbate the coming recession and crimp its aftermath.”

Against this backdrop, California’s state lawmakers are putting on a brave face. Incoming President Pro Tem of the California Senate, Darrell Steinberg said that “despite the state budget crisis, children’s health care should be a top priority” and noted that “Barack Obama has ... signaled he wants to increase spending for the State Children’s Health Insurance Program.”

Arguments this time will probably turn on the limited resources of a federal government that is still conducting two wars and funding hundreds of billions of dollars in industry bailouts. This series of bailouts may eventually include billions for the states, much of which may in turn go towards continuing funding for health care. These proposals, however, are still in their nascent phases.

In the meantime, decisions are being made at the state level that will affect hundreds of thousands of children and their families. California’s Managed Risk Medical Insurance Board meets on December 17 to vote on whether to freeze enrollments to the Healthy Families program. As the state’s unemployment continues to spike, policy advocates estimate that 162,000 children may be denied coverage in the first six months of next year if these changes to the program take effect.

Lawmakers at the state level will have to make tough choices to protect health care funding in their state budgets. And they will need help. To come to the states’ assistance, the federal government could raise the Medicaid match rate (FMAP) and do so immediately as a part of the bailout. These federal funds should come with requirements that the states must use these funds to expand coverage to assist those families at risk of falling into poverty. The disadvantage of such immediate approaches is that the government may not have time to put in place sensible conditions for the use of these funds. Further, immediate authorization of additional billions of dollars may exacerbate the rising health care costs that contribute to states’ budget crunches.

Alternately, the federal government could wait until next year to address health care funding in a comprehensive manner. Renewing SCHIP is a priority of the incoming Obama Administration. This reauthorization could allow states to cover all children in need of insurance helping to shore up programs such as Healthy Families in California. However, by the time that these decisions are made, many hundreds of thousands of children may have been denied health care.

Whichever strategy they pursue, governments must act boldly. Rather than slashing health care funding for poor and working families—or merely holding the line—states must expand coverage and access. The economic costs of the failure to do so are as high as are the human costs.

IN THE STATES: Chutes and Ladders, Ballot Edition

Paul Testa — Thu, 06 Nov 2008 19:30:00 -0500

Tuesday's election brought a series of health care initiatives to state ballots. Some, like Prop 101, blocking the state of Arizona from enacting universal coverage, are still too close to call. Others, like Michigan's Prop 1 on medical marijuana, aren't our bag (we swear officer). And still others, like measures passed in Montana and Maine, remind us that health reform at the state level can sometimes seem like a game of Chutes and Ladders.

For the more than 30,000 children in Montana without health insurance, the passage of ballot initiative I-155, "The Healthy Montana Kids" plan represents a major step forward. The measure expands the eligibility for Medicaid and SCHIP to uninsured children, whose family income is below 250 percent of the federal poverty level (previously only those in Montana with incomes below 175 percent of FPL were eligible). The plan is expected to cost around $22 million annually and will cover most of the state's uninsured children. It will be paid for with existing revenues from an insurance premium tax.

As we noted earlier this week, expanding SCHIP may be one of the first items on the to-do list for Congress and the next administration. Why? Well, in addition to being cute, children tend to be pretty cheap to cover, making for good politics and publicity.

Malt beverages are also pretty cheap, and the citizens of Maine voted to keep them that way. In voting yes on Question One, ("The People's Veto") voters in Maine rejected recent legislation that would have funded the state's DirigoChoice health program, with a beverage tax on beer (included under the Malt Beverage category in Maine statute), wine and soda, as well as a 1.8 percent surcharge on paid insurance claims. For proponents of Dirigo, the results were a step back, as the plan is currently funded under an unpopular and unpredictable Savings Offset Program (SOP) which taxes insurers based on estimated savings from the State's insurance programs. The SOP has also been challenged in a lawsuit filed two weeks ago by the Maine State Chamber of Commerce.

Like Chutes and Ladders, health reform isn't easy. You take a few steps forward but constantly worry you'll go slip-sliding back toward square one. States in particular have a hard time, given the budget constraints in this weak economy. In every case, whether it's Maine, Montana or Massachusetts, the federal government has had an important part to play if the states want to keep climbing the health care ladder.

HEALTH REFORM: Kids as the Starting Point for a New Agenda

Joanne Kenen — Wed, 05 Nov 2008 17:02:00 -0500

With so much buzz about how Rahm Emanuel may become President-elect Obama's White House chief of staff, we thought it would be useful to share this glimpse of how he saw the priorities of the new administration. It comes from a New York Magazine piece that ran shortly before the election:

"My view is that we gotta be the party of reform," Emanuel begins when I reach him on his cell phone. "There are four reforms. There's financial-regulatory reform, tax reform, health-care reform, and energy. Regulatory will kinda come down the chute fast. Tax reform will take a little longer, because it's not until 2010 that Bush's tax cuts expire. Energy, you can do some things immediately. And with health care, you've got the children's health insurance as the first piece of a series of things you gotta do."

Emanuel's reform agenda is helpful because it's clarifying-in terms of timing, in terms of priorities, and in terms of suggesting where Obama's plans and the appetites (and political tolerances) of congressional Democrats intersect.

So health care is in there, part of the Big Four. How quickly Obama moves ahead, whether SCHIP expansion will include any other health cost, quality or coverage elements, isn't yet clear. We at New America of course believe that we should—and can—do more than expand SCHIP, and we know that a lot of people on the Hill are already hard at work figuring out how to get there and the election results will only make them work harder. But even if the hard-charging Emanuel sees a more gradual approach, it's reassuring to know that he recognizes there are a lot of things "you gotta do."