Extended Interview: Dr. Nancy Cobb
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SUSAN DENTZER: Let’s go back to, roughly speaking, 1997-1998. Congress has enacted the CHIP program, left it up to the States to decide whether they’re going to do a Medicaid expansion, whether it will be a state assigned program, or a combination of both. What happened here in Indiana after that point?
NANCY COBB: The governor very quickly appointed a 21-member panel that was widely representative of a consumer, a health insurance company, executive, school superintendent – a broad group of people who really dedicated themselves to this task. They felt the importance of this very early on. They met one full day each month in order to try to develop a plan for how this ought to work.
However, we wanted to be able to be sure that we covered as many children as quickly as we could, so early on there was a Medicaid expansion up to 150 percent of the federal poverty level. This was important because there were – because we had different eligibility levels for different ages, there might be one child in a family who would be covered, there would be two children who wouldn’t be covered.
So we expanded up to 150 percent of the federal poverty level, and then we began to plan. That expansion was to sunset in July 1998 when the plan was to become effective, however, while there was much disagreement over whether this should be a Medicaid expansion permanently or not, as this group worked over the year, they began to see how Medicaid had some very important infrastructure issues that could be used very efficiently and effectively to reach the new population. And in addition, we did a whole lot of things to choose the system to make it more user friendly, and to make it more like health insurance.
So as the year wore on, we had public hearings around the state, we had subcommittees with 250 people involved in those with experts from all kinds of areas where there were people interested in this, and they then made recommendations to the governor and to the legislature, and the legislature – we had four legislators who were very involved in this group. And then when we then took the plan to the legislature, the plan was to go ahead and keep the expansion up to 150 percent of the federal poverty level, and then to have a separate state designed program from 150 percent to 200 percent of the federal poverty level. And to give you some idea of what that is, at 200 percent, it’s about $34,100 dollars for a family of four, and that would probably be a family that might have two parents working. It might be someone, a husband who’s working while the wife stays home and maybe cares for aged parents, something like that. So it’s probably families working where there are no benefits available, so it has benefits available.
So the expansion then took effect in July 1st – I’m sorry, the second expansion up to 200 percent of the federal poverty level took effect January 1, 2000. So already we have 1,100 children enrolled in that.
SUSAN DENTZER: Now, of course, the states were given the option, as you implied, of going to 150 percent, or going all the way up to 200 percent, and there was a lot of debate in many states about whether to go that extra mile to those higher income limits that you just referred to. What was the thinking in Indiana? Was there a lot of debate about whether to go that second mile?
NANCY COBB: The real debate occurred around how many children can we actually cover, and how many children are eligible. And so the panel all along wanted to be sure that we covered as many children as we could, and so when it got down to the final decision, it was really how many children could we cover with the amount of funds available?
SUSAN DENTZER: And you decided that you could go all the way to 200 percent.
NANCY COBB: Yes, not realizing at the time that we would have the kind of enrollment that we currently have, which we’re going to have to work very hard to be able to cover all of those children.
SUSAN DENTZER: Well, just on that point, at the time that you were thinking you would have these two phases, first the Medicaid expansion, then the new program, you were thinking how many children would be enrolled?
NANCY COBB: That’s right, and we looked at what every state looked at, which was the CPS data, and for Indiana, because it’s a small state, the data aren’t very helpful for us, as we have come to find out. So we have, at the point where the program started in 1998, the prediction was that we had 55,000 children eligible for Medicaid but not enrolled, and that there would be 36,000 who would be eligible for the first expansion within CHIP up to 150 percent.
At this point, we’ve already enrolled over – or about 115,000 children and we know that 100,000 of those did not – were not formerly insured, and none of those that were formerly insured are in the children’s health insurance program, so we know we’re not substituting four insured children, so the data just aren’t there for us.
We will be conducting – we are, in fact, now conducting a survey, a 10,000 household survey to try to get a real picture of just how many children we do have and how many families we have who need insurance.
SUSAN DENTZER: So in effect you were expecting roughly 90,000 children in both components of the program.
NANCY COBB: Yes.
SUSAN DENTZER: Already you have 115,000, so 20,000 more than you were expecting. And there could be many more because the second phase has just begun.
NANCY COBB: That’s right. That’s right. So we are going to have to really look at this carefully, and we hope the federal government will look at these numbers carefully, too.
SUSAN DENTZER: Now, in a way you’re victims of your own success here in terms of outreach and some of the other things that were done to get as many people enrolled as possible. Let’s talk about those. What is decided to do in order to really address the longstanding problem of having programs that people are eligible for, that they’re not enrolled in, so you want to reach out and bring them in.
NANCY COBB: It was one of the situations where you need to do everything at once. We needed to help families feel that this is an honorable thing to do to get insurance for their children. We needed to make the process simple. These families not only don’t have disposable income, they don’t have disposable time, so we needed to make it simple, we needed to make it very easy to do so that they don’t have to go someplace and stand in line to become involved. We needed to have lots and lots of people involved so that the awareness of the whole issue becomes important to people and they start thinking about it as insurance, not as medical – or not as social services.
SUSAN DENTZER: Or welfare.
NANCY COBB: Or welfare. We just had a whole lot of things that we needed to do at once, and we wanted to either do something as simple as change the card from something that said Medicaid and other public services or something to that effect, to something that looks like a commercial card, and so that these people, when they do access care, do not have to feel that this is something less than what they need to be doing for their children.
SUSAN DENTZER: so you have developed, among other things, a very simple application form.
NANCY COBB: Yes. It’s a two page – one page, two sides application form. It’s user friendly. We fortunately were able to look at what some other states were doing, and we worked with that. But I guess the important thing for us was that – and for the panel and for the legislature was to be sure that we didn’t end up with a two-tiered system, so that we have some kids in Medicaid, some kids in CHIP, and some kids in the new CHIP program.
Instead we call it all Hoosier Healthwise, and the kids that are in the first phase are in Package A, and the kids that are in the second phase are in Package C. The kids in the second phase have a slightly less rich benefit package, and the parents have to pay premiums. That’s how we want people to feel about this. This is insurance.
We think this is not only that the families have to understand that this is health insurance, not social service. What we have to do is help policy makers and all of the program people also understand that this is health insurance. This is a very basic need that families have that are trying to work, and trying to do what they know and what they want to do as being the right thing.
SUSAN DENTZER: You wanted to eliminate the stigma -
NANCY COBB: Yes.
SUSAN DENTZER: Of welfare.
NANCY COBB: Yes. We – there were many different ways that we tried to do this. One of those was the outreach at the local level, the – our DFC director gave each local DFC office a target of the number of folks that they should enroll based on what used to be our data that we were using, and they each had to design the plan, they had to submit a plan to him for that enrollment, and this had to be community based. They had to have lots of people involved.
So as this all happened, we hoped that that also helped those who were helping to enroll those children, have a different attitude about the enrollment and to – all of a sudden these were people that they wanted to get into the system where maybe before it was trying to be very careful that we not let anybody in who shouldn’t be in. And we still have our eligibility requirements, and they’re very careful to meet those, but we want to have a new attitude about welcoming them into the system, inviting them in, in fact.
SUSAN DENTZER: In addition, you also created a lot of enrollment centers and outreach centers around the state.
NANCY COBB: Yes. We have about 500 enrollment centers. Some of those are more effective than others, but we’ve tried to support those and help those as much as we can. But those have been done without additional funding. Those folks have assumed the responsibility for this, and that’s been a very important aspect of this. Not only have we done that, but we have a mailing unit where families can mail in the application and they can have their interview over the phone. And so we think we have – we hope we have simplified that for families where health is disposable time that we talked about earlier.
SUSAN DENTZER: So what kinds of places now can a parent go to enroll?
NANCY COBB: Depending on their community, because all of these plans were defined by the local community, and so it might be a community health center, it might be a head start center. We tried to put them in places where families already go. It might be a child care center. So we tried to have the community enrollment centers in places where families would already have a reason to be there.
SUSAN DENTZER: In schools too.
NANCY COBB: In schools, yes. Yes. A variety of places, depending on the community.
SUSAN DENTZER: Now, as we mentioned, with the enrollment targets having been met and indeed exceeded, there was a budgetary impact that went along with this. The Medicaid budget alone is about a third higher now than it was in fiscal 1998. What kinds of concerns or lot has this created?
NANCY COBB: Well, our policy members and legislators, especially the ways and means folks, are always very interested in what this means to the budget. It’s been surprising the acceptance of this, and there has been very little actually controversy about the increase once they understood that that was because we are serving more children, and it has been a very pleasant surprise actually to have not met the kind of resistance we thought might be there.
SUSAN DENTZER: What about the phase two expansion, and the budget implications of that?
NANCY COBB: Well, because this is a capped amount, we will have – the more children we serve in package A, the fewer we will be able to serve in package C, so that does present something that we will be working at, and we will have to follow closely to see if they might to lower the benefit package, to see what kinds of options might be available so that we could serve as many of these children as possible. So we have a plan for monitoring that.
SUSAN DENTZER: At this point, how much could be expended on phase two, say, in the current fiscal year . . . . The other important part I want to make sure that we come back and stress is that when you enrolled a lot of these children, it turned out they were, indeed, children who were not only eligible for an expanded Medicaid program, they were eligible for the old Medicaid program
NANCY COBB: That’s right.
SUSAN DENTZER: so in effect what you were doing was picking up a lot of children who should have been allowed on Medicaid long ago.
NANCY COBB: Yes. Yes. In fact, for the total program we have 50 percent more than we had when we – 55 percent more than we had when we began in 1998. So we know that an awful lot of those children were needing care, and simply weren’t enrolled. We weren’t reaching out, we weren’t actively seeking them, and now we are.
SUSAN DENTZER: Another important issue has been how all this has existed – co-existed with welfare reform. And as we convert it to the new temporary – not so new anymore, but the temporary assistance to needy families program, severed the old link to Medicaid that had existed with the AFDC. There has been a concern that families would fall off the Medicaid rolls, or even that they have been transitioned off welfare, would not necessarily avail themselves with the coverage opportunities that were available. What’s happened here in Indiana on that score?
NANCY COBB: Well, we have not exceeded the pre-welfare reform rolls for Medicaid, so we feel like we have come back and picked up a lot of those through this new effort that we have had.
SUSAN DENTZER: so it doesn’t necessarily appear to be the case that a lot of people fell through the cracks here because of welfare reform.
NANCY COBB: No. We feel that we have been able to, partly through the targets that the local offices had to beat, we feel that it became important for folks to be – caseworkers to be sure that families did get care. And so we feel very good about that.
Welfare reform actually occurred very early in Indiana. We started in 1995. Welfare reform in Indiana is essentially over. We have fewer than 20,000 adults on welfare, on cash assistance right now.
SUSAN DENTZER: That’s a very low number.
NANCY COBB: So we know that the families that we’re serving, for the most part, are working families, and they deserve this, the children deserve this care, and they deserve to have this for their children.
SUSAN DENTZER: So once again, you did not see this falling through the cracks in large numbers that other states appear to have seen.
NANCY COBB: We saw it somewhat before the new effort began, but we feel that we have picked those back up and that we’re doing very well in that area.
SUSAN DENTZER: And that, in fact, as you said, more people now are covered than had been previously.
NANCY COBB: Yes. Yes, there are more enrolled now than before, before welfare reform.
SUSAN DENTZER: Given the degree to which you’ve exceeded the enrollment targets, obviously much is going right here. We have heard some comment about things not going quite right, obstacles that continued to remain in enrollment. One of the complaints that we’ve heard about from individuals is, in effect, caseworker overload. The caseworkers aren’t able to process a lot of the applications as quickly as – particularly some of the outreach workers would like.
SUSAN DENTZER: So . . . you have caseworker overload. How serious a problem is it?
NANCY COBB: We don’t really know, and we do understand that we have had this influx of work for them because of the enrollment that we might not have anticipated. But that is something that we will continue to monitor. I don’t know that there are any magic bullets on that, but we will be working with that and monitoring that.
SUSAN DENTZER: We’ve heard a lot also about case worker turnover, people starting to work with one caseworker who is gone a month or two later.
NANCY COBB: Yes. That continues to be something that we are working with. The State and federal government don’t always pay at the same salaries as other folks. We do have benefits. And so we need to work with those folks to try to increase the stability of the system, and that will be something we will also monitor again as we – as we move forward, we have a lot of things that we have to work with since we have had this influx.
SUSAN DENTZER: What does a typical caseworker earn in a job like that?
NANCY COBB: I guess it would be about 20,000 but I’m not sure. That’s a guess.
SUSAN DENTZER: We’ll come back and pin that one down. We’ve heard, again not surprisingly, about the degree of knowledge among caseworkers, as one would expect with all this turnover, and not all the caseworkers seem to understand what benefits are covered under the program, what documents are or are not required for an application to be processed, etc.
SUSAN DENTZER: We have had extensive training that we’ve been implementing to try to rectify this. With the turnover that continues to be a challenge, because since we do have some turnover, then trying to get each person trained as quickly as we would like is a challenge. But we will continue that kind of training, and working with them, and updating all of our information for the local offices so that they have materials that they can work from, too, that are current.
SUSAN DENTZER: Let’s talk a bit about the delivery of health services under this program and the fact that basically a two-track kind of system was developed – a managed care type orientation on the one hand, and a primary care based referral system, I gather a tracking system on another. How well is that working?
NANCY COBB: We have tracked the satisfaction of the members, and we have a very high rating. I believe it’s 85-95 percent satisfaction of good or very good ratings. So we think that that is working pretty well. The providers are over 50 percent have a good rating of their satisfaction, in their satisfaction survey. So we really have a ways to go there, but we feel that we’re doing a pretty good job serving folks. That isn’t to say we don’t have some things we would like to improve.
SUSAN DENTZER: Does that mean that when the mothers are asked to rate the doctors, they only give them a 50 percent satisfaction rating, or is that for the providers -
NANCY COBB: They are about 55 percent satisfied, the providers themselves.
SUSAN DENTZER: And one of the issues for them, obviously, is payment.
NANCY COBB: yes. Yes. They have asked for an increase, they have asked for an increase in their reimbursement rate. We did work with the dentists. We had a very low provider participation rate with dentists, and we did work with them, and their rate has been raised, and the dentists provider – the dental providers are coming back to the system.
We have not yet made that rate increase for the medical providers; however, we think that that’s being given a lot of consideration at all levels of government, and that is something that is definitely on the table for discussion in ____ deliberation, so we continue to work with them on that. We do think that there are some ways that they can raise their rates even now, and that’s by being very careful to charge the appropriate charge for EPSDT visits which are the preventive health kind of visits, and they can get a higher rate of reimbursement for those, and it also helps us with our data. Then we know how many children have had their lead screenings, and have had their immunizations if they do report that way. So that’s a win-win for us.
Another cost to the physician is the paperwork. And so we are also looking at ways that we might be able to decrease that paperwork and therefore decrease the cost to them, and increase what they might see then as their actual reimbursement.
SUSAN DENTZER: Overall, how many – or perhaps in percentage terms, how many doctors in Indiana are participating in these two pieces of the program?
NANCY COBB: Oh, boy. I have that number. I have it right here in my desk. I looked at it yesterday. Can’t tell you right now.
SUSAN DENTZER: We’ll come back to that as well. So there’s a prospect that the payment issue would be addressed, payment rates somewhat. There’s a prospect that some of these other concerns will be dealt with. Those also have healthy budget impacts as well.
NANCY COBB: Yes, they do. However, it is pretty clear that there is a strong commitment in this state to the health of the children, and both from the legislature and from the governor. So we – I understand that this will not be totally painless as far as the budget is concerned, but we will continue to raise the issues with the legislature and with the governor, and we have every hope that they will find an appropriate response to the issues.
SUSAN DENTZER: One of the remaining issues in this state, as the case nationwide is now that the children have been covered, or at least these programs have been structured to cover children up to 200 percent of poverty, what about their parents, because frequently their parents still end up uninsured.
NANCY COBB: That’s right, and we know that children are more likely to get care if their parents are also insured. So that’s a very important issue for the state, and the legislation actually calls for us to look into expanding coverage to the parents of these children. There is a committee that has been established to look at that. Again, this involves the chamber of commerce, the Manufacturers Association, the hospitals, the providers. It’s a broad-based group and we are looking very carefully at how we – the options that we might have to expand coverage to families, and also, of course, looking at what that kind of – what the options – what kind of budget impact the options might have.
SUSAN DENTZER: what are the options?
NANCY COBB: Well, we don’t know what they all are yet, but we’re looking at various things like HIPCs, Health Insurance Purchasing Cooperatives. We’re looking at a partner sponsored coverage . . ., the children’s health insurance program, though the federal restrictions on that make it very difficult for families to qualify for that. But we will be looking at that. So we will be looking at whatever options we can find that might be helpful, and we hope we can adapt them to – again, to the population here in our state.
SUSAN DENTZER: would that also include public subsidies toward private coverage?
NANCY COBB: That’s certainly one of the options, and we would – that’s part of what would happen with employer-sponsored coverage would be the subsidies. And there are two ways that that can happen. The direct subsidy to the employer or a subsidy to the family to pay the premium.
There is also the issue of whether there might be tax credits, and of course, we’re also going to be watching very closely at the federal level to see what kinds of options they are looking at to assist states.
We do hope that at the federal level that they help us build on what we already have, so that we don’t build a more fragmented system. This is very important for the families, as well as the administration of that. But mostly for the families, and for the providers, that we just have adopted – we have been able to use a single enrollment form for a family for the programs. The families don’t need to know who funds their insurance. They only need to know that they have insurance.
And so we hope that the federal government will help us build on what we already have if they do decide to proceed from here, and we certainly hope they will.
SUSAN DENTZER: Which would include such options as a federal commitment to expand CHIP coverage for families.
NANCY COBB: That’s right. That’s right. That would be a very useful Indiana – I can’t speak for the state and tell you which way we would go, but that would be certainly very helpful to have that option.
SUSAN DENTZER: What about working people who are childless, single adults? What kinds of programs might be created for them, and is there a desire to reach out to that part of the population as well that lacks health insurance?
NANCY COBB: I don’t think we have tackled that issue yet, but that will certainly be a part of what we look at. I think all of us have children and grandchildren who might be in that position, and we certainly understand the importance of that. So it will be part of what we look at in the future.
SUSAN DENTZER: And another growing area of concern is the influx of undocumented workers and new immigrants, many of whom – we spoke to a number who have ended up uninsured, obviously, treated here at Wisherd, covered under Wisherd advantage, but not legally covered under Wisherd advantage. How big a problem is this?
NANCY COBB: That is a growing problem, even here in Indiana, and the federal legislation, of course, does not permit us to work with most of those families . . . with those families except in a very limited way.
So I think that that is something that the country is going – the country as a whole is going to have to come to grips with. These are the people who serve us our food, who care for our children, who have an . . . in their lives, so even if we only looked at this from a self-serving standpoint, the country is going to have to see – to figure out some way of dealing with the health issues that these people face.
SUSAN DENTZER: and in the interim also, what about Indiana?
NANCY COBB: I don’t think that we have a plan on the table at this time, and part of that is because it’s just now raising to our awareness that we have a considerable number of these people in our state. And I think as the census numbers come out and if they’re counted, the various surveys that we do when we can find out just what – where we can quantify the numbers of folks we have, then we’ll have some idea of what we – what the problem is and where we need to go with that. But that, again, is – there’s a lot to be done.
SUSAN DENTZER: Let’s say I handed you a magic wand and said NANCY COBB:, as the person directing the CHIP program here, you are now empowered to fix all the problems in the system and go beyond that, make it even more perfect a program of health coverage than it now is, what would you do? What are your biggest concerns?
NANCY COBB: The biggest concerns are to be sure that everyone has access to care, has access to insurance, and then has access to care, and then that they actually take advantage of that, and that it becomes in everyone’s mind something that is important for all of us. We all benefit when all of us are healthy, and we benefit economically, we benefit in our quality of life in all kinds of ways when we do have health care for everyone who needs it.
And so the magic wand, I can’t tell you programmatically what that can look like. I can tell you that what it would mean would be everyone would have access to care.
SUSAN DENTZER: Everyone who currently lacks it, whatever their circumstances.
NANCY COBB: that’s right.
SUSAN DENTZER: whatever their citizenship or nationality.
NANCY COBB: that’s right. That’s right. Their disease is nearly specter of income, or any other eligibility guidelines we might have, and disease has to be treated or people suffer, and the suffering is then translated into lots of things. It’s translated into school failure, it’s translated in not being able to be at work all the time. It’s translated in lots of ways that affect all of us.
SUSAN DENTZER: Is the rest of the state with you on that?
NANCY COBB: There is a lot of support in this state for understanding the needs of the working poor. There was a commission for the working poor that met for three years. Their final report was issued just before the CHIP legislation passed by the federal government, so that did a great deal to raise awareness among a group of policy makers and legislators. And then with the CHIP program and all of the public support that that generated, and all of the public aware ness of the issues that that generated, I think that there is a surprising amount of support for being sure that people have health care.