With All Our Might...Elevating Child Health Policy

Health Reform Takes Center Stage

by guest blogger, Christopher Dawes, CEO & President of Lucile Packard Children's Hospital

Last week in Washington I had the honor of speaking to about 300 of America’s health care opinion leaders for The Atlantic magazine’s national forum. There were two panels, both of which focused on how providers, hospitals and patients will experience the implementation of the new health care laws.

These forums provided an important opportunity for me to:

• Express my personal support for and appreciation of the Obama administration and the House and Senate leadership for holding strong through a long process to success, from introduction of the bill to the signing ceremony. While the new law is imperfect, it includes many immediate and critical benefits for children, such as the bans on pre-existing conditions and annual and lifetime caps, the extension of dependent coverage through age 26, provisions to improve quality, and the first national Medicaid payment standard that should help to improve access.

• Explain that coverage does not equal access. Pediatrics and its subspecialties pay less than other specialties, and Medicaid reimbursement rates are much lower than Medicare. Together these add up to disincentives for young physicians to enter pediatrics. But even among practicing pediatricians, only 50 percent—according to the American Academy of Pediatrics—will see patients covered by Medicaid. The new laws intend to reverse this shortage by requiring that for two years Medicaid pay for evaluation and maintenance visits at Medicare rates. The laws also include a provision for a $30 million loan forgiveness program for physicians who choose to become pediatric subspecialists. Until these providers are trained and available appointments increased, children may still have to wait as long as six months to see a pediatric specialist.

• Disseminate knowledge about the difficulties of sustainability. As state budgets are shrinking at historic rates, children’s hospitals face significant cuts. This challenge will be exacerbated by the new law’s reduction of disproportionate share hospital (DSH) payments to those hospitals serving large populations of patients insured by Medicaid by a total of $14 billion through 2019. To this shrinking budget, the law adds a potential 16 million new Medicaid enrollees. Yet, many children’s hospitals already provided care to these patients when they were uninsured. Going forward, creating a sustainable model for universal health care will require deeper assessment of and adjustments to the new laws.

• Explore solutions that could resolve many of these challenges. These include bending the cost curve by supporting quality initiatives that work, such as the prevention of catheter-associated blood stream infections through a research collaborative created by NACHRI.

Like many people, our moderator, The Atlantic’s senior editor, Clive Crook, was genuinely shocked to learn that Medicaid varies so much from state to state and that patients cannot predict their eligibility status from one state to the next. In addition, as many providers in one state may accept Medicaid, there may be far fewer who do so in the next state, drastically reducing even an insured child’s access to needed care. Mr. Crook, like many of us, plans to follow these developments in the future.

The panel that I was on featured noted health care leaders, and health economists along with a fresh perspective from DeAnn Friedholm of the Consumer’s Union. Friedholm argued persuasively that the best part of the new law is its expansion of transparency to help patients and caregivers make vital decisions, a point of view we have long embraced throughout Lucile Packard Children’s Hospital.

At the end of the morning, Rep. Henry Waxman (D-CA), veteran of many past health care battles, spoke about his belief that health reform will need continuous tweaking in the coming years to fix the parts that need improvement and strengthen the parts that do the most good, provide the most savings and improve outcomes for the most patients. I was pleased and honored to hear Rep. Waxman echo my message of “coverage does not equal access” in his responses to questions. It is a terribly important message to convey.

The Atlantic magazine’s national health care forum raised my hopes that we may in fact be getting on the right track, at last, for the destination we all want: a health care system that works and provides the best outcomes for our patients. But there is still a long road ahead. Reform may be the law of the land now, but we must ensure this reform effort works to improve the health of every child.

Photograph courtsey of Sam Kittner.

SpeakNowforKids.org Leads the People’s Voice Award

For those of you that have been following SpeakNowforKids.org’s recent nomination for the coveted Webby Award and the Webby’s People’s Voice Award, the website is in the lead in the association category of the People’s Voice Award. The People’s Voice is selected by people like you that are part of the global online community.

While winning may give us an amazing ego boast, the exposure that we would receive could bring renewed interest in Speak Now for Kids and the amazing the stories that have been uploaded to the site. With health care implementation under way, it’s important to remind the public of why we needed health reform in the first place and how it could change the lives of children for the better.

If you have not voted yet, you have until Thursday, April 29, to cast your vote and bring attention to the incredible stories fromSpeakNowforKids.org.

Continuing the Discussion on Childhood Obesity

By guest blogger, Karen Seaver Hill, Director, Child Advocacy, NACHRI

Recently Katherine Christoffel, MD, MPH from Children’s Memorial Research Center blogged on her participation in a multi-disciplinary forum on childhood obesity sponsored by the White House and the Presidential Task Force on Childhood Obesity. While the forum could afford limited participation, in the weeks leading up to it a Request for Information issued by Secretaries Duncan, Sebelius and Vilsack cast a wide net for public comment.

Many children’s hospitals and health care providers employed by children’s hospitals took the time to comment and lend shape to the charge before the Task Force. What follows are some sample comments extrapolated from letters submitted by our colleagues, responding to RFI questions:

Q: What important factors should be considered that do not easily fit under one of the four objectives?

As a children’s hospital, we want to highlight the critical role of health care professionals –- both those treating children and those treating adults/parents in the effort to combat childhood obesity. Physicians and other health care providers are viewed as the experts on addressing health issues -– for the most part, people listen to their doctors.

Global system change is required to address issues with lack of adequate education and training, and, in particular, lack of reimbursement for obesity prevention and treatment. Health care professionals are on the front line of the obesity epidemic and need to be equipped to address the issue proactively. 
--Children’s Healthcare of Atlanta

Q. What goals should we set within each objective to ensure that we meet our overall goal of solving the problem of childhood obesity in this Nation in a generation?

While action on any specific nutrition, activity, or education objective can be quantified and tracked alongside targeted goals (such as the number of new fresh produce outlets available in inner cities, or proportion of food outlets providing nutrition labels) that may be achievable within a generation, the problem of childhood obesity itself will arguably take much longer. Obesity is a metabolic condition that has roots that extend over several generations, seeded in genetic and epigenetic modifications that may predispose children to accelerated weight gain before they are even born. "Solving the problem of childhood obesity" in one generation will not therefore be the same thing as reversing obesity. If the ambitious goals set forth in this initiative are achieved however, we may, quite realistically, improve the fitness of all children in one generation and begin to scale back the proportion classified as obese and overweight in that same time frame.
--Children’s National Medical Center, Washington, DC

Q: What are the key benchmarks by which we should measure progress toward achieving those goals?

Along with ensuring that there is adequate training of health providers to educate parents and children about better food choices and physical activity needed to maintain a healthy body, it is important that there are mechanisms in place to evaluate the effectiveness of these strategies/trainings or programs. Specifically, outcomes effectiveness research must be supported and contain real measurement variables such as weight of a child/adult over his/her lifetime, blood pressure, cardiovascular health, etc. Longitudinal studies of specific populations (i.e. infants, toddlers, adolescents and adults by ethnicity, geography, education and culture) should be considered. Obesity prevention research can only be enhanced through fundamental behavior research. For example, currently there is limited knowledge on why children make certain food choices; choose certain portion sizes; or why they choose to engage in differing styles and levels of physical activity. We need fundamental behavior research to gain knowledge on how children develop certain behaviors and how best to alter those behaviors.
 --Texas Children’s Hospital, Houston, TX

Q: What are the key unanswered research questions that need to be answered with regard to solving childhood obesity and how should the Federal government, academia, and other research organization target their scarce resources on these areas of research?

In recognition of the fragmented demographics in the country, prevention and treatment approaches must be evidenced-based but also must be highly contextualized for the different populations. Treatment and prevention approaches must be identified that are appropriate and effective for populations that vary in factors such as socio-economic status, race, ethnicity and physical environment.
--Rainbow Babies and Children’s Hospital, Cleveland, OH

Additional Comments
We must have strong medical community participation. The only way to ensure medical community participation requires nutrition training for physicians and other medical providers as part of their medical certification.  In 1990, the United States (U.S.) Congress passed the National Nutrition Monitoring Related Research Act, which stated that "students enrolled in U.S. medical schools and physicians practicing in the U.S. should have access to training in the field of nutrition". Unfortunately, less than 25% of US medical schools require instruction in nutrition. That low number may be reflective of a larger dilemma that begins with the NIH.

Since 1990 there has been an unfunded mandate to train all physicians in nutrition. Training in nutrition is indirectly funded by Congress through the NIH fellowship programs and Graduate Medical Education funding for Medical Schools. Funding needs to be expanded to equip primary care physicians with knowledge and skills to counsel families regarding nutrition.
--The Children’s Hospital, Aurora, CO

Likewise, N.A.C.H. took the time to comment to the Task Force on Childhood Obesity.  You can see our comments at Key Issue: Childhood Obesity. We welcome a continued dialogue on these and other questions posed in the Request for Information through this blog.

A Web of Success

With All Our Might may be four months young, but we at N.A.C.H. are seasoned veterans of social media having launched our first major venture, SpeakNowforKids.org, one year ago in May 2009. SpeakNowforKids.org is the Web site for Speak Now for Kids in Health Reform, a national campaign implemented by N.A.C.H. to give voice to children’s needs in health care reform legislation. The Web site, developed for N.A.C.H. by Adfero Group, captured personal stories from families, health care providers, advocates and policy leaders through video, photos and written word to encourage Congress to consider children’s health care needs in health reform legislation.

The Web site kicked-off our efforts to draw attention to children’s health care needs amid the health reform discussion that was often focused on the needs of adults. Little did we know that the road to reform would take so long or be so contentious. Yet nearly a year to our launch of SpeaknowforKids.org, reform is here. We credit SpeakNowforKids.org and the compelling stories that were collected through the site in part with the success we had in elevating children’s health care needs.

This week we learned that SpeakNowforKids.org has been recognized with a Webby nomination for Best Association Web Site. Hailed as the "Internet's highest honor" by the New York Times, the Webby Awards is the leading international award honoring excellence on the Internet. Nominations are selected by a 650-person judging academy whose members include Internet co-inventor Vinton Cerf, R/GA's Chief Bob Greenberg, "Simpson's" creator Matt Groening, Arianna Huffington, and Harvey Weinstein — not the typical group of people that policy wonks like me hang out with.

As a nominee, SpeakNowforKids.org is eligible to win a Webby People's Voice Award, which is voted online by the global Web community. From now until April 29, SpeakNowforKids.org fans can cast their votes in The Webby People's Voice Awards. We encourage you to cast your vote for us. We also encourage you to visit SpeakNowforKids.org and review the stories that helped advance health reforms that work for kids.

State-Federal Tug of War on Maintenance of Effort?

By guest blogger, Melissa James, Associate Director, Policy Analysis

In my last blog, I talked about some controversy surrounding a change in the new health reform law that would prohibit insurance companies from denying coverage to children based on pre-existing conditions. Today I am writing about another provision of the new law that is effective immediately, and that goes to the very heart of the federal-state partnership on Medicaid and CHIP.

The new law includes what is known as a “maintenance of effort” provision. This means that states cannot make any changes to their Medicaid or CHIP eligibility policies or procedures that would result in someone losing coverage who would have been eligible on March 23, 2010, when the health reform bill was enacted. So states cannot lower their eligibility thresholds or implement barriers to enrollment in Medicaid or CHIP; this requirement applies for children until October 1, 2019 and for adults until a state’s health insurance exchange is fully operational. The stakes for violating the maintenance of effort requirement are high: states that do so may lose all federal funding for Medicaid.

Given the dismal fiscal situation that states are facing, the maintenance of effort provision may set up a showdown between states and the federal government.  Medicaid accounts for one of the largest shares of state expenditures, and is a primary target for state policymakers trying to balance their budgets.  The maintenance of effort provision ties their hands to some extent by limiting where they are able to cut: many states have already made large cuts to Medicaid programs, including provider reimbursement, and are running out of options for deeper cuts.  For providers who care for a significant number of children on Medicaid, which children's hospitals do, the maintenance of effort is important because it safeguards coverage for children, but it may result in additional cuts on provider payments which could reduce access to needed services.

The first state to test the new maintenance of effort provision may be Arizona. On March 18, Gov. Janice Brewer (R) signed a package of state budget bills that, among other cuts, eliminated the state’s Children’s Health Insurance Program, KidsCare, beginning in FY 2011. This move is expected to save the state $18 million per year by eliminating health care coverage for 47,000 children. However, legal counsel for the Arizona Health Care Cost Containment System, which oversees Medicaid and CHIP, analyzed the maintenance of effort requirement and concluded that the state must restore KidsCare or risk losing federal Medicaid funds. Gov. Brewer has announced that the state will join other states that are filing suit to challenge the constitutionality of the new health reform law; whether the state will take steps to comply with the maintenance of effort requirement remains to be seen.

This will be an important issue for children’s hospitals and other child health advocates to watch closely. California Gov. Arnold Schwarzenegger (R) has previously proposed elimination of the state’s CHIP program to deal with state budget issues. Others states, wrestling with huge deficits and few options to fill them, may consider similar options. It isn’t a stretch to think that state policymakers, desperate to find ways to balance their budgets, could decide to press the issue and initiate a game of “who blinks first” with the federal government. Although winning such a showdown could help states relieve some of their fiscal pressure, it’s an outcome in which children only stand to lose.

Obesity is the Epidemic of the 21st Century

By guest blogger Katherine Kaufer Christoffel, MD, MPH
Director, Center on Obesity Management and Prevention, Children's Memorial Research Center

I was at a White House meeting on April 9, one of a handful of physicians among 100 people from all walks of life. The topic was childhood obesity. Michelle Obama has made this her cause, and the President has created a multi-Departmental Federal Task Force to develop and implement solutions. The meeting included brief presentations by Mrs. Obama, the Secretaries of Education and Interior, the Surgeon General, and leaders in the Department of Agriculture and the White House office that led the health reform effort. They promised a May delivery of a draft plan to combat childhood obesity, and asked those assembled to help guide it.

This is why they—and we—were all there.
The last quarter of the 20th century gradually fattened us. As a result, obesity is the epidemic of the 21st century. Obesity in adults contributes to diabetes, cardiovascular disease, and some cancers; it contributes to early death. Obesity and its complications reduce productivity at work and consume huge amounts of medical care resources.

As in every epidemic, children are not spared. In the United States, about one third of children are overweight or obese (as defined by BMI percentiles). Every age group of children is affected, from infants to teens. The earlier the onset of excess weight and the longer it persists, the more likely it is that it will endure into adult life. During childhood, obesity is linked to medical problems that include sleep apnea, skin disorders, orthopedic disorders, insulin resistance and type 2 diabetes, hypertension, and depression. Obese girls go on to become obese mothers, whose children are at increased risk for obesity.
Because obesity is so prevalent, pediatric primary healthcare providers now routinely see many obese children. Because it contributes to so many co-morbidities, specialists are dealing with it every day as well. Obesity is now a common issue in routine pediatric surgeries.

This epidemic will be with us for a long time. Though rates of childhood obesity are leveling off, this is happening at historically high levels. At best, the healthcare system will be taking care of a generation of people who acquired obesity in childhood and suffer the consequences for life. At worst, a third of pediatric patients will keep going down this same road (or more, if the leveling off stops).

Over the last decade, some pediatricians across the country have been working to find ways to deal with this epidemic. Research has identified risk factors for obesity at every stage of child development, including prenatal ones (e.g., maternal pre-pregnancy weight and pregnancy weight gain, maternal gestational diabetes, low birth weight), early infancy ones (e.g., rapid weight gain in the first months of life), and on through adolescence. We have also learned how important social context is in fostering obesity: healthy lifestyles are hard to achieve in communities with no available fresh food and no safe places for activity; schools without PE and that serve unhealthy food make matters worse; many families are now led by second or third generation non-cookers; poverty encourages consumption of high-caloric-density junk food.

Thus obesity is not only prevalent, it is complicated. To reduce its toll, changes will be needed in every sector of society. The food distribution system will need to deliver more healthy products and get them out to more places and at affordable prices. Safe and affordable access will need to be provided to physical activity in schools and in the community, in ways that are engaging and fun. Schools will need to build in health promotion in varied ways. Parents need to be supported to help their children grow in a healthy fashion and learn healthy habits. These four realms are the ones that the government is focusing on.
 
The White House meeting was full of enthusiasm, which grew over the afternoon. There was a clear commitment from the current administration to undertaking, at a minimum, regulatory action to implement a plan of action. The networking among the attendees was energetic. The organizers indicated that the plan is to keep in touch with us.

As a pediatric community, we can take heart that this national effort is going on. It will provide an opportunity for our ongoing input, and can support the work we do. And work we must: despite many obstacles and also to overcome the obstacles.

The current funding environment and long-established practice make it very hard to care for obese children in 2010. Reimbursement is poor, and services—like the intensive nutrition and physical activity programs recommended by the US Preventive Services Task Force—are generally unavailable and not reimbursable. The care of obese children with multiple co-morbidities is not well coordinated. Clinical practice settings are not effectively linked to community based services (e.g., nutrition education, park district programming). There are not yet well proven primary care-based interventions to slow and reverse excessive weight gain.

NACHRI and its members can be leaders in this work. I jumped at the chance to represent children’s hospitals and be a pediatric voice at the 4/9 White House event. I also welcomed the chance to join with other pediatricians and government relations colleagues in providing guidance to N.A.C.H. on comments and recommendations related to proposed anti-obesity policy . I’ll continue to look for opportunities to be involved in this important work and encourage my colleagues, growing numbers of whom are doing so too.

The Health Reform Legislation is Done…Now Let’s Get Started!

By guest blogger, Melissa James, Associate Director, Policy Analysis

The massive health reform legislation we’ve worked on for over a year has been signed into law. Whew! Time to take a break, right? I think sunny Mexico is calling my name…or Paris is nice in the spring time…

Not so fast! Getting legislation passed was only the first step in the long process of reforming the health care system. Next we turn our attention to monitoring and helping shape implementation of the new law. Luckily, this will be a more deliberative and structured process than the sometimes frantic pace we experienced while Congress was crafting the legislation, and most of the new law’s provisions will not take effect for a few years. However, the new law will have some immediate effects — some unforeseen —  and federal regulatory agencies and states will quickly begin preparing to implement the new law. So while we won’t have to postpone any vacation plans, it is important that we take this time to fully understand what the new law says and prepare for how it may be implemented.

Already a few issues have popped up that we will want to monitor going forward. One that has gotten much media attention is the issue of coverage for children with pre-existing conditions. During the bill signing ceremony on March 23, President Obama praised the new health reform law for preventing insurance companies from denying coverage to children with pre-existing conditions, starting this year. However, the ink had barely dried on the new law before insurance companies began to question whether this is, in fact, the case. A close read of the legislative language clearly indicates that insurance companies, beginning in September, will not be able to insure a child but refuse to cover treatment for a pre-existing condition. For example, if a child has asthma, his insurance company will not be able to offer a coverage plan that excludes treatment for asthma. However, it is less clear that the legislative language itself prohibits insurance companies from refusing to cover children with pre-existing conditions before 2014, when insurance companies will no longer be able to deny coverage to any individual with a pre-existing condition.

Once this issue was raised publicly, Health and Human Services (HHS) Secretary Kathleen Sebelius announced that HHS will issue regulations to clarify that the ban applies to both refusal to cover benefits for a child’s pre-existing condition and refusal to cover a child on his or her parent’s plan due to a pre-existing condition. The chairmen of the three House committees with jurisdiction over health care also issued a statement that made clear that this was their understanding of the new law. Finally, Sebelius issued a strongly worded letter to the head of America’s Health Insurance Plans (AHIP), the trade association that represents insurance companies, that urges AHIP’s members not to look for loopholes to avoid the more expansive interpretation of the law.

The controversy seems to have been laid to bed by AHIP’s assurance to Sebelius that its members will comply with the rules HHS will issue to clarify the issue. For children with serious health conditions, this provision can make the difference in getting them the treatment they need. However, AHIP has warned that compliance might force it to raise premiums to cover the costs of insuring these more expensive cases. So it will be an important issue for child health advocates to continue to watch.

 

So Many Blogs, So Little Time

I have to apologize. I have been a little bit remiss about blogging this week. You are probably wondering why after health reform passed there was a dearth of new blogs. I am afraid that the passage of health reform legislation has quickly moved into a frantic effort on all of our parts to get a handle on all of the provisions that will impact children, children’s hospitals and other pediatric providers. While I continue to focus on developing a detailed summary to highlight these provisions for children’s hospitals across the country, I wanted to bring to your attention some good blogs on the subject of health reform.

The two blogs below highlight the importance of the passage of health reform, but also what we still need to do to ensure children realize the promise of health reform:

• Dr. Judith Palfrey, President, American Academy of Pediatrics provides her thoughts on health reform.

• Dr. Steve Allen, CEO, Nationwide Children’s Hospital, Columbus, OH (member of NACHRI and on N.A.C.H.’s Public Policy Council) shares why we need to build on what was passed in health reform to ensure children have real access to health care services.

As I have said in my blogs before, I am new to the blogging world, but there are a couple blogs I follow on a regular basis. One because it does have a laser focus on children’s issues and the other because of its broader nature that makes me think about how what we are working on fits into the bigger health policy/domestic policy arena.

• Georgetown University’s Center for Children and Families Say Ahhh – A Children’s Health Policy Blog. Recently, CCF has done a number of blogs on health reform and the potential impact.

• Ezra Klein’s blog on The Washington Post. Mr. Klein recently blogged on the “other” provider payment fix that is needed. In the blog, a guest blogger outlined the inadequate reimbursement provided by Medicaid and the impact this can have on access.

Let me know if there are any recent blogs you would recommend and any blogs that I and others in the children’s health care community should follow. I will include links to any recommended blogs in future posts.

Happy blogging!