How Are Children Faring in Health Reform?

November 2009 Legislative Update

November 20, 2009

On November 18th, Senate Leadership released its much anticipated health reform bill.  The Patient Protection and Affordable Care Act is a merged version of the health reform bills approved earlier by the Senate Finance and HELP Committees.  The act incorporates some important health insurance reforms for children that were in the Committee bills.  But it could still leave millions of children worse off.  While the House bill repeals the Children’s Health Insurance Program (CHIP) in 2013, the Senate Leadership bill keeps CHIP in place until 2019 (thanks to the leadership of Senator John D. Rockefeller IV in the Senate Finance Committee), but does not fully fund CHIP after 2013.  This means that CHIP coverage for millions of children could be threatened in 2013, when some of these children could be shifted into a new untested Exchange before it is able to offer comparable benefits and cost-sharing protections – and many of these children could end up worse off.   

 

Fortunately, Senator Bob Casey from Pennsylvania has indicated he will offer a Children’s CHIP Amendment when the health reform debate begins in the Senate.  This amendment will preserve, fund and strengthen CHIP to 2019, so children will be ensured health coverage that is comprehensive, accessible and affordable.     

 

The Senate is expected to vote over the weekend on the procedural motions that are necessary to begin the health reform debate.  Opening statements are expected to begin the Monday after Thanksgiving, and debate over amendments will follow.  The debate on the Senate health reform bill is expected to take three to four weeks.  So please stay tuned!

 

November 9, 2009

Late on Saturday, November 7, the House of Representatives passed the Affordable Health Care for Americans Act of 2009 (H.R. 3962) by a vote of 220-215, with all of the Republicans but one, and 39 Democrats voting against the bill.  The passage of this bill is an important step forward towards achieving national health reform.  Although the House bill would end the Children's Health Insurance Program (CHIP) and move most of the children in CHIP into a new, untested and more expensive Health Insurance Exchange, the bill also includes a number of provisions that will lead to an expansion of affordable coverage to millions of children and families.  It makes it impossible for insurance companies to deny coverage based on pre-existing conditions and eliminates lifetime caps on benefits—improving coverage options for millions, including children with disabilities and chronic illnesses.  The unprecedented expansion of Medicaid to persons with incomes at or below 150 percent of poverty will bring millions of low-income adults, including millions of parents, affordable coverage and move about 2.3 million children from CHIP programs into Medicaid where they'll be guaranteed a more comprehensive set of benefits and protected from high out-of-pocket costs.  In terminating the CHIP program, however, the House bill seriously threatens the health coverage of the millions of children who are projected to be enrolled in CHIP when the bill terminates the program in 2013.  We must work to continue to ensure that a final health reform bill will not leave any children worse off than they are today. 

Our focus now turns back to the Senate, where a final bill should be released very soon and then moved to the floor for debate, which could take three weeks.  Last week, Senator Casey made a firm public commitment to offer an amendment to the Senate bill that would ensure affordable, comprehensive coverage in a simple and seamless system for all children.  Senator Rockefeller also issued a statement last week indicating that he'll continue to fight to strengthen children's health coverage as the debate continues.  President Obama has repeatedly spoken about building upon what works—we can do this by building upon the current CHIP program so that all children will be better off after health reform.  

October 2009 Legislative Update

October 30, 2009

Yesterday, the House Leadership unveiled The Affordable Health Care for Americans Act of 2009 – its merged health reform bill.  While this bill made some important changes from the previous version, but did not go far enough in ensuring children will be better off after health reform. 

One of the most notable improvements is the expansion of Medicaid for all individuals up to 150% of poverty (compared to 133% of poverty as proposed in the earlier bills).  This is not only a huge gain for low-income adults, but also the approximately 2.3 million children who will now be eligible for the comprehensive Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits to which all children in Medicaid are entitled. 

But even with this – and other improvements – the House bill that will go to the floor next week could still leave millions of children worse off after health reform than they are now.  The bill proposes to terminate the Children's Health Insurance Program (CHIP) in 2013 (when it would otherwise be up for reauthorization) and move children who had been receiving coverage in CHIP into the untested health insurance exchange without any real assurance that children will be guaranteed comparable or better comprehensive benefits and good cost-sharing protections that they now have in CHIP – the things that make coverage what children need and affordable for their families.  This transition from a program that is working to something new should not be made until it can be shown to provide coverage that is at least as good as what children have now – but preferably better.

The bill protects the more than a million children who are receiving coverage in the states that operate their CHIP programs as "Medicaid expansion programs," enabling them to remain eligible to for coverage through Medicaid (and therefore, the strong guaranteed Medicaid EPSDT benefit package and cost-sharing protections) after the CHIP program is terminated in 2013.  However, it does not ensure that children in other state CHIP programs have the same comprehensive benefits that children in Medicaid have – or that when CHIP is terminated children will be entitled to those benefits through the exchange.  This means that all children everywhere will remain subject to the "lottery of geography" that protects children in some states but not others. 

Finally, the House bill does little to address the state-imposed administrative barriers that now keep two out of every three of the more than 8 million uninsured children who are eligible for Medicaid and CHIP from getting coverage.  Health reform will be a hollow promise for children if they can’t get the coverage for which they are eligible!      

October 28, 2009

While Members of Congress are working behind closed doors this week to merge the various Committees' bills, child advocates continue the drum beat, working to ensure children are included in those discussions and that the bills we're likely to see on the House and Senate floors in the coming weeks will make children better – not worse – off after health reform.    

In the meantime, we wanted to share with you a couple of interesting new findings that highlight why we must not only keep the Children's Health Insurance Program (CHIP), but strengthen it until coverage in the exchange can be shown to be equal or better.  Recently our friends at First Focus commissioned a study to compare the affordability of CHIP to coverage for children in the exchange plans, as offered in both the House and the Senate proposals respectively.  They found that depending on family income, families with children enrolled in CHIP are only responsible for 0-2 percent of their child’s medical expenses compared to the exchange plans that would require families to pay anywhere from 5-35 percent of the cost.  Moving these children into the exchange would leave many low-income children worse off – paying more for fewer benefits.

The Director of the Congressional Budget Office (CBO), Doug Elmendorf, confirmed these findings in a blog post over the weekend.  Director Elmendorf asserts that by keeping children in CHIP rather than moving them into the exchange, the number of uninsured children would actually be reduced! Like the House bill does, the Senate Finance Committee’s original mark would have terminated the CHIP program when it was up for reauthorization in 2013 and moved children in CHIP into an untested health insurance exchange.  However, Senator Rockefeller’s amendment to maintain the CHIP program until 2019 passed with bipartisan support in Committee, potentially affecting 14 million children who are expected to be enrolled in 2013.

October 13, 2009

The Senate Finance Committee has just approved the America’s Healthy Futures Act of 2009 and it is now in the process of being merged with the Senate Health, Education, Labor and Pensions Committee's bill for consideration by the full Senate. Thanks to the leadership of Senator John D. Rockefeller (D-WV) the Senate Finance Committee bill keeps the Children's Health Insurance Program (CHIP) intact, rather than ending it and moving children to an unproven health "Exchange."  However, the bill still does not ensure all children the comprehensive, affordable and simple coverage they need to survive and thrive.

Health care reform is complicated, but ensuring that children can get and keep the health and mental health care they need to grow up healthy is not. Three elements must be included in any final health care reform bill to ensure that all eligible children can easily enroll in affordable coverage and get the comprehensive care they need.  Until child health coverage in the Exchange can be guaranteed to provide children with benefits and cost-sharing protections as good as or preferably better than they have today, we must keep CHIP and also make it better:

Coverage must be affordable. All children up to 300 percent of the federal poverty level (about $66,000 for a family of four) must be made eligible for CHIP so they can benefit from its cost sharing protections.

• The CHIP program is projected to cover more than 14 million children by 2013. Children who are able to enroll in CHIP and keep CHIP coverage will maintain the benefits and cost sharing protections they have now. However, health care reform is our opportunity not just to maintain the status quo, but to improve access to care for children. CHIP must be made mandatory and funded so that all eligible children will be covered. Under the Senate Finance Committee bill, when the CHIP money runs out for a state, children will be eligible for a tax credit for the Exchange, but will not be guaranteed the same benefits at the same price they would have gotten through CHIP. States also must receive new federal funds to create a national eligibility floor in CHIP of 300 percent of poverty and then guarantee coverage for all eligible children.

Benefits must be comprehensive. Real child health reform must guarantee all children access to the health and mental health services they need to maximize their health and development.

• Under the Senate Finance Committee bill, a million children will be newly eligible for Medicaid, where they will be entitled to receive the regular and periodic screenings and assessments and the full range of health and mental health services and treatment they need. Children who are in CHIP programs with comparable benefits will not lose them. That's good news. However, there are millions of children in CHIP who don't yet get the same comprehensive benefits they need to survive and thrive. Most children in the Exchange are eligible for some basic benefits, but would be denied the full range of benefits they can get in Medicaid or CHIP.

The health system must be simple and seamless. A streamlined application and enrollment process is critical to make it easy for children to get and stay enrolled. State bureaucratic barriers now keep about two-thirds of the more than eight million uninsured children who are eligible for CHIP or Medicaid from getting health coverage.

• Thanks to an amendment offered by Senator Jeff Bingaman (D-NM), the Senate Finance Committee bill now requires states to adopt a "no wrong door" policy to streamline enrollment processes to determine eligibility for Medicaid, CHIP and tax credits—a sort of one-stop shopping. This will prevent the multiple subsidy programs from creating pointless red-tape for families, high administrative costs and erroneous eligibility decisions, resulting in reduced program participation. However, the bill still does not require states to implement many other simplification measures, such as 12-month continuous eligibility, presumptive eligibility upon request for medical services, or automatic renewal, which have proven successful in enrolling eligible children in Medicaid and CHIP. Unless states are required to eliminate barriers to enrollment and recertification, health reform will be a hollow promise for millions of children who will remain uninsured even though they are eligible for coverage.

October 6, 2009

Today, members of the Congressional Black Caucus sent a letter to Speaker of the House Nancy Pelosi expressing their committment to ensuring all children are better off—not worse off—after health reform than they are now.

October 2, 2009

Last night, two amendments passed the Senate Finance Committee that serve as important steps forward to ensure all children will be better off after health reform, but more action is needed to ensure that all children have affordable, comprehensive, simple health coverage.  Senator Rockefeller (D-WV), a longtime champion for children, offered an amendment approved with bi-partisan support that would extend the Children's Health Insurance Program (CHIP) program through 2019, so the coverage gains achieved through CHIP reauthorization will not be lost in health care reform. By 2013, CHIP is projected to cover more than 14 million children.  Under this amendment, children will be able to keep their CHIP coverage and not be forced to enroll in the untested and unknown Health Insurance Exchange where benefits are expected to be worse, while cost-sharing could be 10-20 times higher. View a video of the discussion of this amendment and the vote. 

Also accepted last night was an amendment offered by Senator Bingaman (D-NM) which would provide a “No Wrong Door” policy to streamline enrollment processes to determine eligibility for Medicaid, tax credits and CHIP—a sort of one-stop-shopping. For example, a mother with two children could have one child eligible for CHIP and another child eligible for Medicaid, and she herself might only be eligible for tax credits. Under this amendment, this mother could fill out one application in one place for all of the family members to enroll in each of the different programs.  This is intended to prevent multiple subsidy programs from creating pointless red-tape for families, high administrative costs for government, erroneous eligibility decisions and reduced program participation.

While both of these amendments are critical steps forward for children, much work still lies ahead in the coming weeks as we work to build on the success of CHIP and strengthen the program to make certain that children are better off—not worse off—under health reform, with coverage that is affordable, comprehensive and simple to get and keep.

September 2009 Legislative Update

September 29, 2009

The Senate Finance Committee has resumed its markup of Chairman Baucus’ proposal for health reform and this week we expect the Committee to vote on a number of amendments that would improve the Committee’s bill for children.  Most notable is Senator Jay Rockefeller’s (D-WV) CHIP Amendment. The Rockefeller Amendment (#202) would improve the successful Children’s Health Insurance Program (CHIP) and extend it until 2019.  It would help eliminate the lottery of geography by requiring all states to cover children up to 300% of poverty in CHIP by 2013.  Senator Rockefeller’s Amendment will also simplify the process by which children get enrolled and stay enrolled in CHIP and Medicaid.  This amendment is a critical step forward to ensuring real child health reform that leaves children better – not worse – off than they are now.

Since Chairman Baucus released his proposal on September 16, several amendments have been added that would improve coverage for children and low income families.  The Committee has voted to accept several children’s amendments. They include: Senator Menendez’s amendment to allow children to qualify for child-only health insurance plans in the exchange when their parents may not be eligible; and Senator Stabenow’s amendment to ensure that states can cover therapeutic foster care for children in out-of-home placements.

Momentum is building, but much work still lies ahead. Any final health reform bill must make it simple for more children to enroll in affordable, head-to-toe health coverage. We must guarantee real child health reform for all children this year!

September 16, 2009

How Senate Finance Committee Chairman Max Baucus’ Proposal Could Leave Millions of Children Worse Off

On September 16, 2009, Senate Finance Committee Chairman Max Baucus (D-MT) released his "Chairman’s Mark of America’s Healthy Future Act of 2009"—a proposal which will be considered by the Committee. While the Chairman’s Mark will expand and improve coverage to some children, the proposal does not ensure the comprehensive, affordable and simple coverage that all children need. Millions of children could be left worse off after health reform than they are now, facing higher costs for fewer benefits.

Health care reform is complicated, but ensuring that children can get and keep the health and mental health care they need to grow up healthy is not. Three provisions must be added to the proposal that would allow eligible children to easily enroll in affordable coverage and get the comprehensive care they need: 

1. The health system must be simple and seamless. A streamlined application and enrollment process is critical to make it easy for children to get and stay enrolled. State bureaucratic barriers now keep about two-thirds of the more than 8 million uninsured children who are eligible for CHIP or Medicaid from getting covered.

The Chairman’s proposal misses the mark for children.

• None of the simplification measures, such as 12-month continuous eligibility, presumptive eligibility upon request for medical services, joint verification for eligibility with other federal programs, or automatic renewal, which have proven to be successful in enrolling eligible children in Medicaid and CHIP, are included. Unless states are required to eliminate barriers to enrollment and recertification, millions of children will remain uninsured after health reform, making it a hollow promise.

2. Benefits must be comprehensive. Real child health reform must guarantee all children access to all the health and mental health services they need to maximize their health and development.

The Chairman’s proposal misses the mark for children.

• The proposal recognizes the value of assuring children receive comprehensive health and mental health care as children in Medicaid do today, but it does not require these benefits for all children in the exchanges. The importance of guaranteeing children of all ages regular and periodic screenings and assessments at various intervals and the full range of health and mental health services and treatment they need is well known.
  
  Under the Chairman’s proposal, the CHIP program would end in 2013, at which time all enrolled children would be moved to health insurance exchanges.  Since then, this provision has been amended to make moving children to the exchanges contingent upon certification that coverage offered in the exchanges is at least comprable to The proposal contains a provision that would give all children in families with incomes below 250 percent of poverty ($55,125 a year for a family of four) who have health coverage through exchanges comprehensive benefits through an additional health insurance package provided by the state, known as an "EPSDT wrap around." However, this complicated "wrap around" mechanism has not been shown to truly get eligible children the services they need, and could prove to be a new bureaucratic barrier and hollow promise. Additionally, children in families enrolled in the exchanges with incomes above 250 percent of poverty who have been receiving the EPSDT benefit package in CHIP will not be eligible for the same benefits or cost-sharing they have today. Twenty-two states now cover children at 250 percent of poverty or higher under CHIP. This means that in at least 22 states, children could be worse off under health reform than they are now

3. Coverage must be affordable. All children up to 300 percent of the federal poverty level (about $66,000 for a family of four) need cost sharing protections consistent with current out-of-pocket limits in Medicaid.

The Chairman’s proposal misses the mark for children.

• Children in families up to 250% of poverty will receive the cost sharing protections consistent with current out-of-pocket limits in Medicaid when they are moved into the exchanges.  This provision is critical, but it does not go far enough: children in families with incomes above 250 percent of poverty will likely pay far more for premiums and cost sharing for services under the Chairman’s proposal than they do today, even if their incomes are below 300 percent of poverty and they qualify for subsidies.  This means lower income families will be paying for more, but will get less under heath reform unless the CHIP income protections are extended.

---

August 2009 Legislative Update

With Congress wrapping up their August recess work back home, health reform continues to take shape in a way that could make millions of children worse – rather than better – off at the same time insurance companies and drug companies will profit.  Millions of children could face higher costs for fewer benefits. For children to be better off, changes are needed to make it simple for them to enroll in comprehensive and affordable health coverage.  Amendments and agreements supported by Representatives Bobby Scott (VA) and Bobby Rush (IL) will do that. They worked hard to do the right thing for children and we need to ensure it continues.

Resource: Side-by-side summary from Georgetown's Center on Children and Families on how children fare in the proposals.

Amendments and Agreements to Make Health Coverage for Children Affordable, Comprehensive and Simple

Amendment to H.R. 3200 Proposed by Rep. Bobby Scott (Approved by the Committee on Education and Labor):

Comprehensive Benefits – It guarantees the right to all medically necessary health and mental health care for all children who receive coverage through the new health Exchange.  The amendment only addresses children in the Exchange because the Education and Labor Committee does not have jurisdiction over the Children’s Health Insurance Program (CHIP).

Amendments to H.R. 3200 Proposed by Rep. Bobby Rush (Discussed in colloquy with Energy and Commerce Committee Chairman Henry Waxman and withdrawn):

Comprehensive Benefits – These amendments would ensure that all children in CHIP now (and in CHIP until it expires in 2013 or at a later time) will benefit from the same right to all medically necessary health and mental health care that children receive under Medicaid.  They also would provide comprehensive health and mental health care for all children in the Exchange in families up to 300 percent of the federal poverty line. Some states already provide these comprehensive benefits to children in CHIP.

Simplification – By October 1, 2013, all states must have in place each of the following simplification measures (which states are now eligible for federal incentives to do under CHIP):

• 12-month continuous eligibility
• “Express lane” eligibility process
• Presumptive eligibility upon request for medical services
• By mail, phone or online verification of income
• Joint verification for CHIP eligibility with other federal programs (such as food stamps)
• Automatic renewal

In addition, the eligibility, enrollment and recertification process for children in public coverage may be no more difficult than the process for children covered under the new health insurance Exchange described in H.R. 3200.

Affordability and Cost-Sharing – This amendment would help ensure that children will not be worse off under health reform than they are today.  In 2013, millions of children could be moved from CHIP into the Exchange, where they could be subject to higher cost sharing limits than under CHIP.  These protections will guarantee cost-sharing that is no higher than what children pay now in Medicaid.