With All Our Might...Elevating Child Health Policy

Reflections of a Historic Day

By guest blogger, Larry McAndrews, N.A.C.H. President & CEO

Standing in line to enter the auditorium at the Department of Interior to hear President Obama on the signing of the health care reform bill, I stood among those that had interrupted their normal schedule to be a part of this historic occasion. In line with me were the former State Senate Majority Leader from North Carolina Anthony Rand and the Connecticut Speaker of the House Christopher Donovan. We recalled where we were and what we were doing when health reform failed under the Clinton administration. We speculated on what the next steps were and the challenges facing the country to pay for the new guarantees of health care. As I looked around, I saw fellow association executives and hill staffers that were also working on health reform in 1992 when I came to Washington to be a part of the reform debate. I appreciated the many people who for many years had worked hard to bring about where we were today.

Inside the auditorium there were warm up speeches from Secretary of Labor Hilda Solis and Secretary of Agriculture Tom Vilsack in anticipation of the President and his entourage. When Vice President Biden finally introduced the President in very historic terms, those in attendance were rewarded for their years of work and dedication as they witnessed the President officially enacting the bill. The thoughts of all those present, no doubt, reflected on their good fortune to have had some part in the long journey. Success has many fathers and mothers, and I am sure each of us were claiming some little piece, recognizing in our hearts that we were supported by many in our own organizations who were not present but in truth should have been.

The President spoke to hopes and aspirations, and the boundlessness of the country’s creative power. Vice President Biden spoke to erecting the final girder in the structure of support for the least among us. My thoughts were, yes, it is good that we commit to health care for all our citizens but my focus was on to the next chapter: pay for the entitlements promised; promote a vibrant economy; improve productivity; and leave to our children a sound and prospering country. Perhaps it is true that the final girder has been put in place. As a nation we now strive to balance all of our competing priorities. While our imagination may be limitless, we will nevertheless be in a race with the limits of our resources.

As I left, looking for a taxi, I saw Rep. John Dingell (D-MI), on the street corner, with a small following. At 83 years of age, having served for 53 years, after following in the footsteps of his father, Rep. Dingell introduced health care reform legislation continuously year after year. Even on crutches, as he signed autographs, his persistence shined through. Is it not wonderful? Is not America great? Can we not succeed?

Making Positive Strides for Kids

During one of the most crucial weeks for action on health reform, I am spending the week at the home I grew up in with my Dad and my 4-year-old-son. Between lots of game show watching, work in the yard and doctor’s appointments for my Dad, I have not had tons of time to think about health reform. However, being with my Dad and my son has opened my eyes again to the complexity of reforming our health care system.  The different health care needs of just the three generations represented around my parent’s table illustrates why health reform is not an easy endeavor. 

Thankfully, my colleagues back at the office are reading and analyzing the recent House package (Senate bill and “side car”) to see what it will mean for children. I am happy to say that the House package has many positive provisions for children. The bill prohibits insurers from denying coverage to children with pre-existing conditions; extends the authority and funding of the Children’s Health Insurance Program (CHIP) and provides a $30 million loan forgiveness program for pediatric specialists.

The bill also would increase Medicaid reimbursement to primary care physicians for evaluation and management codes to Medicare levels for two years. Our association, working with children’s hospitals across the country, has supported this provision to establish a federal standard for Medicaid reimbursement for these services. There is more to be done in this area to ensure that children have access to needed specialty services as well, but this is a significant step in the right direction. As we have argued for many months now, coverage does not equal access. This seems to have been heard by the President and Congressional leaders. 

N.A.C.H. supports the expansion of coverage for the 30 million uninsured Americans and insurance reforms as outlined in The Patient Protection and Affordable Care Act. The positive provisions outlined above were the direct result of our collective effort to make health reform work for children. I will be watching the historic health reform vote this weekend (if my Dad let’s me change the channel away from the UCONN women’s basketball game) and crossing my fingers that together we can continue making positive improvements for children.

Globe Article on the Cost of Care at Children’s

by James Mandell, MD, CEO

A Boston Globe article this morning brought the cost of care here at Children’s Hospital Boston into question, saying, among other things, that “Children’s charges the highest fees for both outpatient and inpatient care.” It’s based on data by Harvard Pilgrim Health Care (HPHC) that we don’t feel accurately reflects the care that we provide.

While the writer, Liz Kowalczyk, did say that because about 30 percent of our patients are on Medicaid, we have to “make up the lost revenue from private insurers,” I don’t think she went far enough in explaining why our costs tend to be higher than other hospitals in the state.

First and most important, Children’s is the only freestanding children’s hospital on the Globe’s list, so comparing the care we deliver to that of hospitals that primarily care for adults puts us at an automatic disadvantage. Why? Because, fortunately, children get sick much less often than adults, but when they do get sick, it costs much more to care for them.

And when they get very sick or critically injured, they nearly always come to Children’s, which provides the highest level of trauma and neonatal intensive care in the state. The costs associated with this are far from insignificant, given that we treat an amazing 90 percent of the state’s most complex pediatric patients. The HPHC data didn’t distinguish between the care of high-acuity and low-acuity patients, which we refer to as case mix.

I realize that health care organizations like Children’s are -- and should be -- under the microscope regarding the cost of our care. And I applaud the Globe and other media outlets for making sure that all sides in the health care reform debate are accountable to the public. Children’s has worked hard in recent years to control our costs, build greater efficiencies into the way we do business and collaborate with the state’s insurers to ensure that we’re providing the best care at the best prices -- even going so far as volunteering to cut our payment rates in FY2010.

But I think it’s critically important that the health care debate take into account the real differences between the care provided at adult hospitals vs. pediatric hospitals, and that the health care system should take a long-term view of “value.” Early and comprehensive intervention in childhood diseases, like asthma, autism and diabetes, is the best societal investment we can make, but one that is often overlooked in the health care cost debate.

This post originally appeared in Children's Hospital Boston's blog, Thrive on March 16, 2010.

Medicaid Access Issues in the News Again

For those who have not seen it, The New York Times highlighted the serious access issues for Medicaid beneficiaries in yesterday’s paper. Kevin Sack did a great job of sharing some of the struggles beneficiaries, including children, are facing getting health care. He explains that low reimbursement is forcing many physicians to limit or stop taking patients on Medicaid. They are doing this because the low reimbursement is threatening the financial viability of their practices. The challenge in finding and keeping a physician when you are on Medicaid can be devastating, as Sack outlines in his article. This is a big issue for children because Medicaid is the single largest insurer for children and provides coverage for one out of every four children in our country.

The good news is that this just may be an issue that has bipartisan support. The Republican leaders have highlighted it as an issue to be addressed and now President Obama included it in a list of changes he would like to see as part of health reform. The House version of the health reform bill included an increase in Medicaid reimbursement for certain evaluation and management codes to Medicare levels.  This increase could help bring Medicaid in line with Medicare for many services. We hope to see this provision included in the package that is expected to be voted on this week. This would, indeed, be a step in the right direction.

Recent Blog Highlights Access to Care Issues

I am relatively new to the blogging world, but I already have some favorite blogs. The Georgetown University Center for Children and Families’ Child Health Policy Blog is one of them.  Last week, Joan Alker did a great post that highlights the access issues with Medicaid that the children’s hospital community has worked so hard to raise in the health reform debate.  The blog rightly highlights the access issues that need to be addressed in health reform to ensure that coverage equals access for children.   

N.A.C.H. and children’s hospitals across the country have been working to ensure that health reform provides coverage for health care for more children, but also that the coverage provided results in children being able to get the right care at the right time at the right place. Today, physicians and hospitals that provide care to children receive inadequate reimbursement for their services, threatening the financial viability of the safety net for our nation’s children. Currently, Medicaid payments do not cover the cost of care, forcing many providers to limit the number of children that they see insured by Medicaid. A recent survey of children’s hospitals (which house the greatest concentration of pediatric specialists) shows tremendous delays in scheduling specialist visits, resulting in delayed care and increased emergency room visits.

Recent cuts to Medicaid at the state level will affect the future supply of pediatric specialists. Lower Medicaid reimbursements add an additional barrier for physicians choosing a field, resulting in long wait times for our most vulnerable children accessing needed services. States are in a bind, with low revenues and the requirement to balance their budgets. They do not want to do any harm, but their options for filling budget gaps are extremely limited after consecutive years of budget pressures. Congress and the administration need to make a federal investment in children’s health care that will result in better access to needed services. We are in a crucial week for health reform passage.  Real health care reform needs to be enacted that works for children and improves their ability to access needed health care services at the right time in the right place.

Experts Address Key Health Reform Questions

For those of you who are still interested in the talk about town on health reform, I attended a Congressional Quarterly briefing earlier this week that included many different experts (Hill staffers, lobbyists, health plan representatives, providers, advocates and pollsters) opining on the topic.  Much of the substance you all have heard before but it did give me a new perspective on some key questions:

What if health reform does not happen?

Many of the panelists agreed that if the current health reform package does not pass, there is no plan B.  The focus of Congress will turn to jobs and those on the panels thought there would not be the political will to even attempt “health reform light.” As I have said in past blogs, many of the speakers felt that doing nothing does not fix the problem.  Costs will continue to rise, employers will be less able to afford health insurance for their workers, the number of uninsured will continue to increase, uncompensated health care costs will grow and the incentives in the system that encourage providing more care not better care will remain. 

Will the current health reform package (Senate bill with possible changes suggested by the President) bend the cost curve?

Although presenters acknowledged key questions in this area: are the Medicare cuts sustainable?; will the demonstrations and pilots in the legislation bear fruit?; and  what will be the impact of the new excise tax on certain insurance policies?  Some of the speakers believed that the new structure included in the current legislation would provide a platform for further cost controls.  If left alone, health care costs will crowd out every other national priority.  It was predicted that there will not be one “crisis” moment for the health care system, but gradual erosion overtime.   

Why not take an incremental approach? 

Many of the speakers thought that health care is so interconnected, which makes it very hard to take one piece in isolation.  One piece of reform will not work without the other pieces.  For example, the insurance reforms do not work without the mandate that all Americans have health insurance coverage.
All agreed that the next few weeks will determine if health reform will pass or not. 

Although children were not a focus of the meeting, it was interesting to hear about the possible fate of health reform because it most certainly will impact children and their providers.  Stay tuned…

A Front Row Seat to History in the Making

By guest blogger, Larry McAndrews, N.A.C.H. President & CEO

Yesterday, the President accomplished what no other person could do. With less than 24 hours notice, he changed the calendars of 250 very important leaders in the health care field to support his initiative in health reform.  I had the privilege of being one of 250 invited at the request of the White House to hear President Obama’s latest appeal for sweeping health reform. Scripted and confident, the President laid out the reasons that the nation could not afford to be passive and called upon Congress to vote up or down for the health reform bill. We, likewise scripted with our talking points, looked for administrative officials to get one last chance in to communicate the needs for children in health reform.  Certainly it was exciting for us to be there, to be a part of the historic effort to fundamentally restructure health care, all of us excited but also anxious that we get this right as a nation for the benefit of those we care for. In the next few weeks we will see how this unfolds.

More Uncertainty after Health Summit

I apologize for my delay in writing about the President’s Health Summit held last week, but I really don’t know what to say. The future of health reform remains uncertain, which is what I have been saying in my blogs since the health reform efforts began early last year.  

If you like political theater, than the seven hour summit was right up your alley. I enjoyed watching the Republicans and Democrats sit down together and discuss health care reform, but I don’t think the two sides are any closer together on the issues than they were a week ago.

Since conclusion of the summit, the pundits in town have been discussing the summit and the uncertain future of health care reform continuously. I watched many of the weekend news shows where they actually had a show of hands on who thought health reform would be enacted and those that didn’t. No clear answer there.

The President will release his thoughts on how to move forward later this week. It seems likely that the House will attempt to pass the Senate health care reform bill and then a budget reconciliation package (or the reconciliation side car as many are calling it) will be passed that will include changes and additions to the Senate health care bill. The budget reconciliation bill would not require 60 votes to pass in the Senate; it would only require 51 votes. The key question is whether the House has the votes to pass the Senate bill. Today, the White House said that they will have the votes in the House, but that is not at all clear.

As those in my personal and professional life know, I don’t like uncertainty and this is really pushing my tolerance to the edge. Maybe the President will provide a clear path forward later this week. For those in the children’s health community, let’s keep our fingers crossed that it results in health reform that works for children.