With All Our Might...Elevating Child Health Policy

Access to Care Highlighted at Congressional Briefing

 

By guest blogger Camie Corrigan, assistant director of federal legislative affairs, N.A.C.H.

The President’s State of the Union address on Wed. Jan. 27 followed several important remarks made on Capitol Hill earlier that morning. The Partnership for Medicaid, a national coalition of health care, local government, and labor organizations all dedicated to improving Medicaid hosted a Congressional briefing that morning to educate Hill staff on the state of America’s safety net and urged Congress not to delay in addressing the problems facing this vital program.  Through our work and other partners on the coalition, we were able to shine a spotlight on improving access to care for children while also addressing the important challenges facing the Medicaid program overall. 

Despite the recent turn of events in the health reform debate, The Partnership for Medicaid’s briefing provided Members of Congress and their staff an opportunity to hear from a panel of providers and consumers who rely on Medicaid as well as longstanding advocates of Medicaid from various associations.  Three Members of Congress also attended the briefing to share their comments on the state of America’s safety net.

Dr. Rhonique Harris from Children’s National Medical Center in Washington, DC spoke on behalf of N.A.C.H. and articulated her deep concerns for the patients she serves who rely on Medicaid as they face insufficient access to care from pediatric specialists in District of Columbia. A problem children’s hospitals across the country know is not unique to the DC area. Dr. Harris said that many of her patients will use emergency departments for their care because in some cases children have faced delays of nearly three months to be seen by a pediatric specialist. 

Just as Dr. Harris was wrapping up her passionate plea to strengthen Medicaid for our nation’s most vulnerable population, Congressman Chris Murphy (D-CT) entered the room to address the audience. Rep. Murphy agreed with Dr. Harris’ remarks and stated that a focus must be placed on access to care for the American’s who rely on Medicaid and urged that his colleagues in Congress ensure that these patients have access to a strong provider network, especially for pediatric specialists.

Another panelist - Tomlyn Farley who is a parent of child with special health care needs enrolled in Medicaid -- outlined her worries about her daughter falling through the cracks of the current health care system. Ms. Farley and her family are grateful for the coverage and services provided through their Medicaid benefits, but she admits frustration with the program in many ways that impact the care her daughter receives. As her child transitions into adulthood, Ms. Farley urged Congress to fix the broken health care system immediately and strengthen Medicaid to provide access to the best care for her daughter.

Congresswoman DeGette (D-CO) spoke to the audience about her efforts in the current health reform debate to enact auto-enrollment for newborns into Medicaid so that they may receive EPSDT benefits from day one. She highlighted the important role Congress must play in making provider’s reimbursement rates more competitive to encourage access to care for patients covered through Medicaid and she would like to see Medicaid’s benefits expanded to more Americans. Rep. DeGette remains hopeful that Congress will address health reform this year and will continue to champion for these improvements.

Rep. Sarbanes (D-MD) followed his colleague’s remarks about the need to fairly compensate providers who care for American’s relying on Medicaid and asked that all of the organizations fighting to improve Medicaid continue their advocacy in the days ahead.

Congressional briefings offer a unique opportunity to educate staff on complex policy issues and their impact on children’s health care while engaging policymakers in the discussion. The Partnership for Medicaid briefing was an excellent opportunity for our panelist Dr. Harris to continue advocating for improved access to care for children who rely on Medicaid. No matter what happens with health reform moving forward, the focus of Congress needs to be on improving children’s access to the right care, at the right time, in the right medical setting.

 

Dare We Hope for Movement on Health Reform?

The last couple of weeks have been a little depressing around the office since we got word that movement on health reform was stalling.  My eight year old who always thought ensuring all children have quality accessible health care was a small feat was so confused when I told him that what Mommy had been working on for more than a year may not come to fruition.  The disappointment of those who would benefit from reform must be so much stronger.  Not to mention all of my friends and family who are so tired of me talking about health reform all the time!

Yesterday produced two glimmers of hope.  Although not a main tenet of his speech, President Obama did spend some time on health care and did include a strong plea to move ahead.   The President encouraged Congress not to “walk away from reform.”

On another positive note, House Speaker Nancy Pelosi made a commitment to getting health care done.  The idea of making some key changes through the budget reconciliation process and then passing the Senate bill in the House seems to be getting some traction.  And the Speaker is promoting this path and working with House members to garner support.

I am not saying that these glimmers of hope mean we are on our way, but they are positive movements in a debate that has quieted in the past week. As an association, we want keep the debate on health reform moving forward to make sure that it works for children. We have worked to include key provisions for children over the past year in health reform legislation and we don’t want to lose now. Health reform would move us in the right direction to ensure that our nation’s children will be able to access the right care at the right time. 

When I get discouraged about our progress, I remember the President’s words not from the state of the union address but his health care address to Congress in September, “I still believe we can act even when it's hard.  I still believe we can replace acrimony with civility, and gridlock with progress.  I still believe we can do great things, and that here and now we will meet history's test.”  We need to make sure that the President and Congress meet this test for our nation’s children. 

Recent Survey of Children’s Hospitals Shows Serious Struggles in the States

With the news of the likely defeat or significant scale back of health reform, I turned my attention to the other part of my job — what is happening in states on Medicaid, CHIP and other issues of interest to children’s hospitals — hoping to find some good news. What I found instead is serious challenges facing children’s hospitals.

In December, we did a survey of children’s hospitals asking what they expected in their 2010 state legislative sessions, many of which start later this month or early next month. The results show that policy priorities for children’s hospitals are more clearly focused on state budget issues. With extreme budget pressures at the state level, states are faced with limited options on how to balance their budgets. Medicaid is often a target because it is one of the largest budget items in many states. Within Medicaid, reimbursement for providers is usually one of the first choices for cuts. From what we have heard from children’s hospitals this has continued in 2009 and more significant cuts are expected in 2010.

According to respondents from 25 children’s hospitals in 18 states, the top three policy issues for children’s hospitals in 2010 are:

• Cuts to Medicaid and CHIP in the state budget: Hospitals in 14 states and D.C. In many cases these are additional cuts since many states have already cut reimbursement to hospitals in the past two years to fill budget shortfalls.

• Provider Taxes: Hospitals in eight states. Many states and hospitals are exploring instituting a provider tax, in many cases it would be a hospital tax, in order to raise the state share for Medicaid and receive more federal funding. This strategy for increasing funding for Medicaid has garnered additional support in the last year due to the federal share increase enacted in the American Recovery and Reinvestment Act.

• Cuts to disproportionate share hospital payments: Hospitals in four states and the District of Columbia. Disproportionate share payments are critical to children’s hospitals because they treat a large number of children covered by Medicaid and Medicaid reimbursement does not cover the cost of care. Loss of this funding would have a significant impact on children’s hospitals.

As you can see from these results, if health reform does not move forward at the federal level, the problem does not go away. In this serious budget crisis how will states be able to continue to support their Medicaid programs to ensure that the children covered are able to access needed health care services. It seems to me discussions in the states this year will necessarily focus on the cost containment strategies needed to balance budgets and not serious discussions of how best to provide health care for children. I hope I am wrong.

The Game Change in Health Care Reform

By guest blogger Jim Kaufman, vice president for public policy, N.A.C.H. 

The 1990s failed effort to enact health care reform has played prominently in what President Obama and Congressional leaders did, and did not do in their effort to enact sweeping health care reform legislation this year. When this process began last January, there were so many things that could have derailed their efforts, even with significant majorities in both chambers, but Congressional leaders were able to overcome these challenges to stand on the brink of passing sweeping reform. 

However, the failure to move quickly and now the loss of Senator Kennedy’s seat to Republican State Senator Scott Brown has cost the Democrats their 60 vote majority in the Senate.  The loss of the Massachusetts seat means that if House and Senate leaders are able to hammer out the difference between the two bills, the compromise package would need to go back to the House and Senate for final approval.  Therefore, assuming both parties vote en bloc as was seen on previous floor votes related to these bills, health care reform would die under the threat of a Senate filibuster.

As a result, President Obama and Congressional leaders are forced to develop Plan B to enact reform.  As been reported by the media, while there are options besides going back to the Senate for another vote, each of these options has pitfalls.

Option #1: House simply accepts the Senate bill.  Since the Senate’s reform package was amended to a previously passed House bill, procedurally the House can simply accept the Senate’s amended bill, as is, and send the final package to the President for signature. However, while this is probably the best option from a procedural standpoint, it will be difficult for Speaker Pelosi to convince House Democrats to accept the Senate bill. Key House members have already expressed concerns over the Senate’s structure for the Exchanges and the failure to improve access to care for enrollees in Medicaid, making it very difficult for them to accept this package. 

Option #2: Budget reconciliation. The benefit of reconciliation is that you only need 51 votes in the Senate compared to the traditional 60 votes. However, it is expected that the reform bill would need to be stripped down because the rules governing budget reconciliation limits the provisions to those that directly impact federal revenues and expenditures. Under these rules, the most powerful person in the country related to health care reform may be the Senate Parliamentarian. The Parliamentarian will decide if a provision is germane to reconciliation. For example, he will decide if insurance reforms that are the cornerstone of the overall package directly impact federal expenditures and can be included in a reconciliation bill.

Option #3: A third option is a combination of both – moving the Senate bill alongside a budget reconciliation bill.  Under this option, the House accepts the Senate’s bill, but the provisions they want changed are moved through reconciliation, again only requiring 51 votes.  The major obstacle with this option is whether the outstanding issues that the House wants addressed pass the germaness test of the Senate Parliamentarian?

Option #4: A final option to enact reform, the one that is least palatable to Democrat leaders who have invested tremendous political capital in a large, sweeping reform bill is moving a much smaller, scaled down package. If one assumes that the Massachusetts voters sent a message to Washington on the direction of reform, a scaled bill may only include steps towards insurance reform and smaller Medicaid expansions. However, this scaled down approach would require at least one Republican, maybe Senator Olympia Snowe who voted for the reform efforts in committee, to support the bill

The bottom line is, after the loss of Senator Kennedy’s seat, President Obama and Congressional leaders need to find a new path to enact health care reform. They must choose a path that avoids the need for another 60-partisan vote in the Senate or a path that can attract bi-partisan support - the one Republican vote needed to enact a final health care reform package.  The saga continues…

Wall Street Journal Article Resonates, Raises Questions Too

By guest blogger Larry McAndrews, president and CEO, NACHRI 

A January 12 article in the Wall Street Journal by Laura Landro on the national shortage of pediatric subspecialists has generated a lot of buzz in the medical community. It effectively summarizes why some families experience barriers when trying to access specialty care for their children, and highlights what policy makers might consider right now to address these barriers through final health reform legislation.

Most of the feedback we’ve received validates what the article reports. However, questions have been raised about a data graphic in the article that indicates some states lack at least one pediatric subspecialist in one or more of 13 subspecialties.

The data that NACHRI provided for the chart was gathered by the American Board of Pediatrics (ABP). As with any data set, there are limitations – outlined below. In providing the data to the Wall Street Journal, we did not clearly articulate these limitations and we regret this inadvertent oversight. The data set includes:

• pediatric subspecialists who have been certified by ABP

• pediatric subspecialists under the age of 66 years (if the age of the subspecialist was not available, it was treated as missing data)

• pediatric subspecialists with a known address on record as of 12/31/2008

A data research check indicates that there are two pediatric rheumatologists in Georgia and one pediatric rheumatologist in New Hampshire. NACHRI apologizes for missing these errors. Also, based on the limitations of the data, there may be board-certified physicians in specific pediatric subspecialties who are indeed currently practicing in states that were listed in the article as lacking subspecialists. (While no physician database is 100 percent complete, the ABP database provides the most robust data available on the number of ABP-certified pediatric subspecialists.)

Yet the data limitations do not negate what families across the country are experiencing when they confront long wait times for specialty appointments or are required to travel long distances to see a subspecialist. The barriers to accessing care are real. In fact, children’s hospitals responding to a December 2009 NACHRI survey report significant shortages in high-demand pediatric subspecialties and long wait times for families seeking appointments. These findings together with alarming pediatric subspecialty workforce trends demand a concerted response by the pediatric community, teaching hospitals, state and federal legislators.

We must do everything possible – at the practitioner level, the hospital level and by strengthening federal support for pediatric care – to ensure sure children can get the right care at the right time and in the most appropriate setting.

We Welcome You . . .With All Our Might

Welcome to N.A.C.H.’s new blog, With All Our Might. The title might strike you as odd for a blog that focuses on child health policy, but it sums up the effort that those of us who either work on child health public policy issues, provide medical care to a child or are the parent of child who has been ill or suffers from a chronic condition: we do it with all our might. It takes energy and passion to give voice to the health care needs of children. It’s our hope that we’ll be able to capture that spirit as we write about the latest child health issues.

Unfortunately, discussions on health care often do not have a special focus on children.  As parents, providers, and patients we know that children require unique health care services to keep them healthy and strong.  In this blog we will attempt to highlight important health policy issues to focus on what they mean for children.  We start with our first blog that looks at the critical workforce shortage for children, which is the opposite of workforce challenges for adults. 

Our blog kicks off on the same day as the Wall Street Journal publishes findings from our 2009 Pediatric Specialist Workforce Survey. The article, "For Severely Ill Children, a Dearth of Doctors", written by Laura Landro, makes the case that ongoing shortages in pediatric specialties contribute to the problem that many families face in accessing timely care for their children. The article features interviews with a family from Oregon, originally from Alaska, treated at Cincinnati Children’s Hospital Medical Center and doctors from Children’s Hospital Medical Center of Akron and Children’s Medical Center of Dayton. The article also offers an overview of the legislative solutions to address the shortage in pediatric specialists including equitable Medicaid reimbursement, Children’s Hospitals Graduate Medical Education and loan forgiveness.   Tomorrow we will hold a briefing for Congressional staff on the results of a NACHRI study, which the article references, that show these critical shortage areas. 

We hope the article and the briefing will raise awareness for policy that we believe should be included in the final health care reform bill, specifically provisions that would raise Medicaid reimbursements to Medicare levels. The House takes a step by raising reimbursements of services, such as doctor office visits, coded as Evaluation and Management, under Medicaid to Medicare, but there’s more to be done.

So with all our might, we plan to elevate child health policy issues through this blog and welcome you to join in this ongoing discussion on how to improve access and coverage for children in this country. Lend your voice to our efforts by signing up to be a contributor to the blog or by participating in the conversation with your comment posts.