Update on Health Reform Key Issues for Kids

Update on Health Reform: Key Issues for Kids Jocelyn Guyer, Joan Alker and Cathy Hope 2009 Finish Line Conference Center for Children and Families http: //ccf. georgetown. edu Say Ahhh! A Children’s Health Policy Blog at http: //www. theccfblog. org July 6, 2009

Importance of Health Reform • Historic opportunity to move towards universal coverage with significant new role for federal government in shaping health policy. • Infusion of $1 trillion federal money into health coverage. • New regulatory framework for private insurance.

Importance of Health Reform to Kids • Coverage for their parents and others who care for them • Much-needed relief for family budgets • Improvements to the health care delivery system • Chance to cover remaining uninsured children and make sure they get the care they need

Schedule for Health Reform

Senate HELP Committee Schedule • Early June, an initial bill was released. • Markup is in process. • Goal is to combine with Senate Finance Committee bill in July.

Senate Finance Committee Schedule • Issued options papers, but no bill as of yet. • Initial mark release postponed after $1. 6 trillion CBO score. • New mark will be available at the end of this week? ? ?

House Tri-Committee Schedule • An initial bill released in mid-June. Revised version imminent. • Markup later this week? ?

The Remaining (Optimist’s) Schedule • House and Senate floor action by the end of July. • Conference in the fall after August recess. • Health Care Reform bill on President Obama’s desk by October.

Contents of The Bills

Build on What Works My view is that reform should be guided by a simple principle: we fix what's broken and build on what works. -President Obama June 11, 2009 Green Bay, WI

Build on What Works; Fix What Doesn’t • Keep employer-based coverage • Expand public programs • Create an “Exchange” • Create a related subsidy program for remaining uninsured • “Shared responsibility” o Individual mandate o Employers offer coverage or help finance subsidy program o Government spends more

Overall Structure Employer-based coverage Medicaid Uninsured people The “Exchange” Note: Relative size of these circles is unclear

Which Children Will Remain Uninsured? • Immigrant children • Children whose parents cannot comply with the mandate for whatever reason o Red-tape barriers to coverage in Medicaid o Affordability issues

Issues for Kids in Health Reform 1. 2. 3. 4. CCF’s Framework for Evaluating Bills Building Affordable Coverage Pathways for All of America’s Children Beyond Insurance – Ensuring Children Get the Care They Need Creating a Family-Friendly, “No Wrong Door” Enrollment and Renewal Process Strengthening Financing for Public Programs

How Do Kids Get Coverage? Finance HELP • Medicaid to 133% FPL gross income • Assumes Medicaid coverage to 150% FPL • Medicaid to 133% FPL net income • If between 100 and 133% FPL, can go into Exchange • “MOE” on Medicaid until health reform begins • Subsidies to 400% FPL • In 2018, Medicaid beneficiaries can go into Exchange under some circumstances (selected childless adults earlier) • No discussion of CHIP House • Few details on CHIP; states may be able to use to provide supplemental coverage to Exchange children up to 275% FPL • Permanent Medicaid “MOE” • Tax credit to purchase coverage up to 300% FPL • Subsidies for families up to 400% FPL • CHIP expires September 2013; children moved into Exchange

What Happens to CHIP? Finance • Few details on CHIP • States may be able to use to provide supplemental coverage to Exchange children up to 275% FPL HELP House • No discussion of CHIP; • CHIP expires September outside the committee’s 2013; children moved into Exchange jurisdiction • Children eligible for CHIP on Day 1 of health reform implementation are deemed eligible for Exchange plans • For purposes of subsidy eligibility determinations, their income is deemed no greater than under CHIP

What kind of coverage will kids get? The Big Punt

What Kind of Coverage? Finance • Plans must cover a broad range of medical benefits, including preventive care and maternity and newborn care HELP House • Plans must cover a package of essential benefits roughly equivalent benefits in value to a typical employer plan • Pediatric services are covered, including well • Benefits include baby and well-child care, “pediatric services” as a • CHIP may play a role in “general category” of what oral health, vision and supplementing Exchange needs to be covered hearing services, coverage equipment, and supplies • Benefits must include preventive care and screenings recommended in “Bright Futures”

How Much Would it Cost to Buy Subsidized Exchange Coverage? Finance HELP Details are missing, but Subsidies would keep we know: premiums at 1% of income for those at • Premiums end at 150% of FPL, rising on a 300% FPL sliding-scale basis to 12. 5% of income for • Coverage will be those at 400% FPL deemed “affordable” if it costs less than 15% of family income House Subsidies would keep premiums at 1% of income for those below 133% of FPL, rising on a sliding-scale basis to 10% of income for those at 400% FPL

What Kind of Out-of-Pocket Costs Will Children in the Exchange Face? Finance Details are missing, but available information suggests: • Little or no costsharing on preventive services HELP House • Minimal cost sharing for preventive services • No cost sharing for preventive services • Subsidies that allow lowincome people buy into “higher tier” plans with better cost-sharing protections (right? ) • Subsidies designed to provide better cost-sharing to lowerincome families (e. g. , , an average population below 133% of the FPL would have to cover 2% of their covered health care costs; one at 400% would have to cover 30% on average) • Subsidies that allow low-income people buy into “higher tier” plans • Plus, an annual out-ofwith better cost-sharing pocket cap set at $11, 900 protections (e. g. , an for families average group of people would have to pick up 10% of their covered health care costs) • Plus, an annual out-of-pocket cap set at $500 for families below 133% of the FPL and increasing on a sliding-scale basis to $10, 000 for a family

What Efforts Are Made to Transform the Delivery System for Children? Finance HELP House • 100% federal funding for higher reimbursement rates for • Investments in workforce primary care in Medicaid • Quality measures from CHIPRA are extended to Medicaid • National strategy to improve the quality of care • Otherwise, delivery system reforms limited largely to Medicare trainings • May address Medicaid reimbursement rates • Promotion of preventive care • Investment in medical homes Children are included in each of these initiatives. • Medical home demonstrations in Medicaid

How Do You Get Signed Up? Finance • Details not yet available HELP • State-based Exchanges will be responsible for enrolling people in coverage • Eligibility will be based on adjusted gross income in prior tax year (verified via federal income tax data when possible with special procedures for non-filers) • State-based exchanges will have some responsibility to facilitate enrollment of people into Medicaid House • National exchange responsible for enrollment • An annual enrollment period each year; information provided via telephone hotline, web site, etc. • Eligibility will be based on adjusted gross income in prior tax year (verified via federal income tax data when possible with special procedures for non-filers) • States may be able to conduct determinations. If so, federal government will reimburse them • Semi-auto enrollment of some people into Medicaid

Strengthening Finance HELP House • 100% federal financing Not addressed in • 100% federal of new expansions on a temporary basis; phase down to regular FMAP over time • May include an automatic countercyclical stabilizer in Medicaid detail due to jurisdictional issues funding indefinitely for new expansions • No countercyclical stabilizer

Messaging

Value For health care reform to be viewed as a success it must ensure everyone has access to quality, reliable coverage – that includes the millions of our children who remain uninsured or do not get the care they need.

Issues Proposals could: • Fall apart entirely; • Risk the stability of the highly-effective Medicaid and CHIP programs; • Fail to address the red-tape barriers to coverage that could make it more complicated for parents to enroll their children in coverage; and • Ignore the unique health care needs of children in efforts to improve the health care delivery system and design benefit packages.

Ask • • Adopt health reform. The country has before it an historical opportunity to provide affordable, high quality -care to everyone and put the nation’s economy on a stronger footing. Do no harm. Before making major changes to existing, successful initiatives, Congress should guarantee that children will receive comparable benefits at an affordable price under any new program. Insure all kids. Eliminating red tape and bureaucracy by simplifying enrollment would be the cheapest, quickest and smartest next step toward getting most of our children covered. Cover Kids from Head to Toe. All children need coverage that meets their unique developmental needs, and provides them with the preventive services, medical care, and oral and mental health benefits needed to launch them on a better trajectory in life.

Vision There are no do-overs for childhood. Let’s make sure Congress gets health reform right the first time. For health reform to be truly successful, it must ensure that everyone – including all of our children -- have high-quality, affordable coverage.