With All Our Might...Elevating Child Health Policy

The Outcome of State Level Elections Are a Big Deal

By Jan Kaplan, Consultant, N.A.C.H.

Political analysts are now saying what health care policy wonks have been saying ever since Nov. 2. What happened in the state-level elections is a big deal for the future of health care, particularly for those most in need.

Right after the Nov. 2 elections, analysts focused their attention on the Republican gains in Congress and the implications for President Obama’s agenda. When they turned their attention to the other headline of election night – the Republican gains in state legislatures and governors’ offices, they focused on the political implications of that sea of red on the election night maps. The Republican wins warrant attention because they give the party a huge leg up in next year’s redrawing of congressional districts and, potentially, in the 2012 election cycle. But, the political junkies ignored the other big issue of the day. The Republican dominance in the states has definite implications for children’s health care.

First, let’s take a look at what happened on Election Day. The elections on Nov. 2 resulted in a power shift from Democrats to Republicans in the majority of states. Before Nov. 2, there were 26 Democratic and 24 Republican governors. Next year, there will be 29 Republican and 19 Democratic governors, with an Independent governor in Rhode Island. The outcome was similar in the elections for state legislators. Prior to Nov. 2, legislatures were controlled by Democrats in 27 states, by Republicans in 14 states and split in the remaining states. Next year, control flips to the advantage of Republicans. Republicans will control the legislature in 25 states and Democrats will be in control in 16 states. The remaining legislatures will be split. Furthermore, Republicans will control both legislative chambers and governor’s offices in 20 states, up from nine states now. So what does this power shift in the states mean for health care issues of concern to children’s hospitals and the children they serve? 

First, no matter who is in charge in the states, Medicaid cuts can be expected to be on the table as states continue to face huge budget shortfalls. According to the Center on Budget and Policy Priorities, states could experience their largest-ever budget gaps next fiscal year (which begins July 1 in most states). States must, under their constitutions, balance their budgets every year, which means that the primary focus of most governors and state legislators in the coming months will be on ways to fix their fiscal crises. In at least 12 states, tax increases are presumably off the table because their new Republican governors campaigned against tax increases and they will be expected to try to keep their promises. In those states, dramatic spending cuts will be needed to achieve a balanced budget. In other states, cuts should also be expected even if combined with tax increases. Medicaid cuts will be high on the list for most lawmakers who are concerned that the program’s costs are out-of-control. In fact, the governor of Texas, is floating a proposal to opt out of Medicaid completely as a way to deal with the burgeoning costs of the program. His proposal has garnered the attention of several of his fellow Republicans.

States have very little wiggle room when it comes to finding ways to cut Medicaid spending. Provider reimbursement is often high on the target list for cuts and this year will be no exception. Unfortunately, the ongoing attack on reimbursement rates means many children and families who rely on Medicaid will find it more difficult to access the care they need when they need it.

Second, newly-emboldened Republican governors and legislators may use their states’ fiscal crises to strengthen their call for a repeal of health care reform, beginning with the Medicaid expansions in the new law. Republican governors and legislators have consistently decried the law’s Medicaid expansions, even though the expansions come with enhanced federal matching funds. The lawmakers assert that even a 10 percent state matching requirement is too large a burden for a state that faces an economic disaster.

Third, Republican state  lawmakers will do what they can to delay, prevent or modify the implementation of many of the key provisions of health reform as they continue to argue for the law’s repeal. Though they must implement many of the law’s provisions, they have some flexibility in how those provisions are implemented and they may choose to opt out of certain aspects of the law.

The state-level decisions that children’s hospitals will be watching closely relate to the exchanges, as well as changes to Medicaid. The key questions for children’s hospitals include: Will the state decide to operate its own exchange or will it opt out? Will the state apply for or accept federal funds to support activities related to health reform implementation? Will the state explore participation in a Medicaid demonstration project? Will the state decide to implement new options under Medicaid, such as medical homes for individuals with chronic conditions? Will the state seek a waiver from the new law’s Medicaid requirements?

Children’s hospitals cannot take a “wait and see” position on any of these critical questions. They are already gearing up to educate new and returning governors and legislators, regardless of party, about the impact of the outcomes of these decisions on children’s health care. Children’s hospitals will be paying close attention to the actions of their state policymakers and will be at the table as much as possible to ensure that those actions work for the children they serve.

Dr. Becker Goes to Washington

By Adam B. Becker, Ph.D., Executive Director, Consortium to Lower Obesity in Chicago Children

With the recent elections and imminent changes in Congress, this seems like a good time to reflect on my visit to Capitol Hill on September 16.  I was invited by the National Association of Children’s Hospitals and Related Institutions (NACHRI) to serve on a panel to brief Congress about the important role that children’s hospitals play in childhood obesity prevention.  Panelists represented the broad range of roles that hospitals play – from community-based prevention to intensive clinic-based behavior change interventions, to surgical and other specialty care for those children who are in urgent need of treatment.  It was an honor to be among distinguished colleagues from hospitals in Washington, D.C., Maryland, and Washington State.  It was a privilege to hear from a very brave young high-school senior and her equally courageous mother as they described the challenges and the heartbreak that their family faced dealing with childhood obesity. 

Staff members from the offices of more than 30 U.S. Representatives and Senators came to learn about childhood obesity and how hospitals and hospital-based programs are helping.  I believe that the large turnout was due, in part, to the fact that First Lady Michelle Obama took such a public stand on the issue.  I took the opportunity to tell the elected officials and their representatives about the many partners who make up CLOCC – more than 1,000 organizations in Chicago and beyond who are at the “front lines” of obesity prevention.  I told them about our efforts to make sure that kids and families know what the elements of a healthy lifestyle are, understand the risks of not making healthy choices, and have access to environments that make healthy choices easier where they learn, play, and live.  I told the briefing participants that the health care system was an essential component of the battle against obesity but doctors alone cannot solve the problem. 

As I listened to the other panelists talk about how complex and challenging it is for them to find the resources and models they need to treat overweight and obese children, I thought about how much harder it would be without those of us fighting on the prevention side – working to improve nutrition and physical activity to keep children healthy so that they don’t need treatment. 

I was truly humbled to be in one of the very buildings where decisions get made every day that affect children and families.  Decisions about how much money our schools will get to provide food to children.  Decisions about whether our transportation system will accommodate those who want to walk or ride their bikes for at least some portion of their daily commute.  Decisions about how much of the fertile soil across the U.S. will be used to feed people vs. animals vs. vehicles.  Decisions about how many children will have health insurance and what the quality of that insurance will be.  And yes, decisions about reimbursement to health care institutions for the basic and specialized services that are so essential to protecting children when they are overweight or obese.

Congress headed home for vacations or to work on their re-election campaigns before they decided on some of the critical issues facing children and families.  I was frustrated that Congress went home with so much work yet to do, but I continue to be hopeful because so many people showed up that day to hear from us and because so many champions for children and families are working every day in Chicago and across the nation to make sure kids grow up healthy and happy.  I hope that this new Congress will be as concerned as the last and look forward to helping them make the best decisions for the nation’s children.

The Times, They are a Changin’

By John Knapp, Director, Federal Affairs 

Every election brings change, but it is rare when an election brings changes of the magnitude that will result from last Tuesday’s races.   As of the time of this writing, there will be at least 93 new Members of the House of Representatives (a number of races remain officially undecided), of which 84 are Republicans, and 9 Democrats.   That represents just over a fifth of the entire membership of the chamber.  There will be also 16 new Senators (13 Republicans and 3 Democrats).   

This influx of new legislators creates new opportunities for advocates for children’s health care.  Our first mission should be educating new members of Congress on how health care is delivered to children in this country, including the role of public programs, and, of course the indispensible role of children’s hospitals.   To facilitate this, N.A.C.H. has assembled a Post-Election Tool Kit which can be used by children’s hospitals as they reach out to their new Senators and Representatives even before they officially begin their duties.  Ultimately, many of the newly-elected will be in positions to directly affect the delivery of children’s health care. The coming weeks and months provide a chance for children’s health advocates to present a picture of how children’s health care is delivered, what makes children’s hospitals unique, and what are the key issues related to children’s health care going forward. 

Next year will mark a return of divided government where one party does not control the White House and both chambers of Congress, and it remains to be seen how this new dynamic will affect health care issues. With Republicans assuming a majority in the House, an entirely new set of Committee Chairmen will assume power and be setting the legislative agenda in that chamber.   The new Congress, particularly in the House because of the change in party control, can be expected to both pursue new directions in health care, as well as revisit aspects of health care reform. 

Perhaps as never before, budgetary issues are expected to be front and center as concerns over federal spending and the deficit formed the plank of many campaigns in this cycle.  There will be considerable pressure to control costs and hold the line on spending.  In this environment, advocates for children’s health will need to emphasize the cost-effectiveness of children’s health care and how investments made in our children today can reduce future long-term health care costs.  

As the election dust settles, House and Senate Committee rosters are finalized, and more information emerges about the 2011 Congressional agenda advocates for children’s health will have a better idea of what specific challenges and opportunities lie ahead.