Caring for Children
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ELIZABETH FARNSWORTH: And for more now we turn to Julie Rovner, who covers health policy for Congress Daily and The Lancet, a British medical journal, and Sara Shuptrine, president of the Southern Institute on Children and Families, which conducts research on health and welfare issues for southern states. Thank you both for being with us. Julie Rovner, how big a deal is this?
JULIE ROVNER, Congress Daily: Well, it’s a very big deal. This is the first single piece of legislation we’ve seen to expand access to health insurance really since 1965 when Medicare and Medicaid were first created.
ELIZABETH FARNSWORTH: Who will be covered by this program? Give us a picture of the children who will be covered.
JULIE ROVNER: Basically, these are the children who live in families that are too wealthy to qualify them right now for Medicaid but who still have incomes under around 200 percent of poverty, which is about $32,000 for a family of four. These are almost exclusively children in working families and families with parents who work, which is one of the reasons you’re not eligible for Medicaid. And yet, parents don’t quite make enough money to be able to buy health insurance, or they work in jobs where health insurance isn’t offered, at least for the children.
ELIZABETH FARNSWORTH: And who remains uncovered?
JULIE ROVNER: Well, basically everybody else. There are about 10 million children without insurance. The majority of them have lower incomes, but there are certainly a large number of uninsured children in families with 250/300/400 percent of poverty. Again, if these families live in high-expense areas or if they don’t have any access to health insurance, parents have nothing that they could buy. So there will still be a substantial number of children left uninsured even after the program is fully implemented.
ELIZABETH FARNSWORTH: Sarah Shuptrine, the states have the–the southern states have a large percentage of the children that will be covered under this plan, is that right?
SARAH SHUPTRINE, Southern Institute on Children & Families: We have a disproportionate number of children that are uninsured in the southern region, yes.
ELIZABETH FARNSWORTH: And explain how there are children who would be covered by Medicaid but don’t know about it or their parents haven’t enrolled in it and how this program helps them to–let’s start with the Medicaid aspect a bit.
SARAH SHUPTRINE: Well, up until about the mid 1980′s Medicaid was connected mostly to the welfare program. So in order to have Medicaid coverage your children and you had to be on the welfare system. And that changed in 1986 and states began to expand coverage to children that were not on welfare by giving them simply the Medicaid coverage and not a cash check.
ELIZABETH FARNSWORTH: Well, but now the kids that could be eligible for Medicaid but haven’t known about it, their parents haven’t known, there will be an outreach program under this new bill, right?
SARAH SHUPTRINE: Yes, there is a certain amount of the money that states receive that they can devote to the outreach program, and it is greatly needed.
ELIZABETH FARNSWORTH: Explain that.
SARAH SHUPTRINE: Well, we hope they’re going to be very aggressive about outreach because since that change was made in Congress in the mid 1980′s we’ve done a very poor job of getting word to families that their children don’t have to be on welfare in order to get Medicaid coverage. In fact, we don’t say Medicaid is welfare at all. It is assistance to families that are working, which is going to be a very important service particularly for families that are leaving welfare for work.
ELIZABETH FARNSWORTH: So how do states reach out? What are they doing and what should they do more?
SARAH SHUPTRINE: Well, states can adopt a number of outreach strategies. There’s not a lot going on right now. So I think that they’re going to be a lot of experimenting and development on the outreach side of this. And it’s something that is not going to be a terrifically expensive activity on the part of the state, but it’s going to require commitment, and it’s going to require an attitude on their part that they really do want children insured in order to do active outreach because it will help to enroll many more children as they get out into the community if they do 1-800 lines, if they do some very user-friendly materials and other kinds of public awareness activities, they will begin to get the word out to working families that their children can be eligible for Medicaid.
ELIZABETH FARNSWORTH: Julie Rovner.
SARAH SHUPTRINE: Or a state-only program.
ELIZABETH FARNSWORTH: Okay. We should get one thing clear. The states don’t have to do any of this, do they?
JULIE ROVNER: That’s absolutely correct. It’s a purely voluntary program on the part of the states. There is money out there. Each state will have a set allotment, which is based essentially on the number of low-income children and the number of low-income uninsured children in the state. But the states could theoretically do nothing. Now, that being said, most states are doing something. The federal government was a latecomer to this effort. More than half of the states have already started programs. They’ve either expanded their own Medicaid program–sometimes they’ve had to come to Washington to get permission to go above some of the threshold–or they’ve started some “children only” health insurance programs. And they’ve been putting their own money into it. So now they’ll be able to access some federal money to augment state money.
ELIZABETH FARNSWORTH: Explain what happens. Now, the money becomes available in October from the federal government, right?
JULIE ROVNER: The money–
ELIZABETH FARNSWORTH: What happens then?
JULIE ROVNER: The money becomes available on October 1st. Each state will have a set allotment that it can draw down by putting up some of its own money. Now, most people don’t expect states to start drawing that money really until next year. There are a lot of decisions that they have to make. First, they have to decide if they want to expand Medicaid, or if they want to set up a new program. That’s a big decision, a big political decision, a big substantive decision. Even if they decide which way they’re going to go, they’re going to have to allot new money. States cannot access this money for their existing programs, except by expanding them. Most state legislatures aren’t in session right now, and they won’t be in session until next year. So, in all likelihood, it’s going to be next year before the states can actually get around to allocating the money that will allow them to set up these programs and thereby draw some of their federal allotment.
ELIZABETH FARNSWORTH: Ms. Shuptrine, are the states really scurrying? Are you hearing from a lot of state governments that are trying to figure out how to meet the requirements of this?
SARAH SHUPTRINE: Well, first of all, states have already begun to go beyond the federal mandated levels, and many states have taken actions to provide insurance coverage that does not require a waiver from the federal government.
ELIZABETH FARNSWORTH: Why was this necessary then? Why was it necessary to have federal action?
SARAH SHUPTRINE: What this provides is additional enhanced match for states to pull down some additional funding to assist and maintain for health coverage for children.
ELIZABETH FARNSWORTH: So go ahead. But the states do now have to decide how best to use this, right?
SARAH SHUPTRINE: That’s the first decision. They’re going to have to determine at what level they want to cover children in their state. And I would hope that they will look to some uniformity on that level so that it’s not confusing to the families that are trying to access the program and to the agencies that are trying to administer it, because we could add further complications inadvertently.
ELIZABETH FARNSWORTH: Speaking of those complications, Julie Rovner, what about the question–the criticism that was raised during the discussion, the debates over this that some of these kids are covered because their parents work, but it’s fairly insecure because they don’t always work and so they would go on the federally funded plan in order to have a more secure coverage dropping out of the private pool, which is not necessarily good for private insurance companies, what about that criticism?
JULIE ROVNER: Well, that’s a legitimate criticism. There’s also an even broader criticism that employers will see that the government–the state governments with the federal government’s financial aid is now offering children health insurance they will feel free to drop health insurance for dependents. Now, that I think was more of a concern when this program was in a larger form and went further up the income scale. At this point it really only goes to 200 percent of poverty; I think an employer would be unlikely, they would have to drop coverage for all dependents at all income levels for all of their employees and yet, only some of them would be eligible for this type of insurance. So I think the problem that we call substitution or crowding out, or the idea that now public insurance would replace private insurance will be not so great with this program than with some of the other ones that are under discussion.
ELIZABETH FARNSWORTH: Ms. Shuptrine, explain what will be covered. Will kids be able to go to eye doctors? Will this be very basic, or will there be extras?
SARAH SHUPTRINE: Well, if the states decide to go with the Medicaid program, they will provide a very comprehensive set of services, including preventive services and treatment services that will correct whatever the screening determines the child needs, such as sight and hearing and speech. If a state decides to go with a state insurance program, they have some leeway on there, but there are a number of protections that are in the law to make sure that to the extent possible there is a good scope of coverage, particularly with preventive services.
ELIZABETH FARNSWORTH: What other kinds of questions are states having to answer now?
JULIE ROVNER: Well, I think one of the key questions and one of the reasons this legislation is shaped it’s like giving so much flexibility to the states is that there were some governors who came and were worried, for instance, with Medicaid’s very rich benefit package, that this public insurance would have better benefits than was available to most people with private insurance, and they didn’t want to then be a magnet. So states will have to decide what fits into their package. I think there is certainly an encouragement for states to offer as comprehensive a set of benefits as possible but with a sight towards what is the individual needs of individual states. States may also choose to offer different types of packages in different areas of the state. That’s anticipated as one possibility. The idea is that there is some money here; that we ought to expand the coverage of children who currently don’t have insurance, and that they’re going to let states decide the best way to do that.
ELIZABETH FARNSWORTH: When you call around to the states, when you’re doing your reporting, what are they telling you about what stage they’re in in planning this? This is an enormous undertaking for them.
JULIE ROVNER: It is an enormous undertaking. Right now, they’re having meetings. A lot of this bill was written very late at night, particularly the children’s health package was finished at 2 or 3:30 in the morning, and there are still a lot of unanswered questions. The Department of Health & Human Services still has a lot of its own unanswered questions. States will basically have to file a plan with the federal government to say what they’re going to do. So everybody’s scrambling around, trying to understand exactly what kind of hoops they have to jump through to get this money. And I think there’s going to be a lot of talking before there’s going to be a lot of action.
ELIZABETH FARNSWORTH: Well, thank you both very much for being with us.