Federal Child Health Issues: Looking Forward, Looking Backward

1. Federal Child Health Issues:Looking Forward, Looking Backward Jocelyn Guyer Center for Children and Families Colleen Chapman Spitfire Strategies

2. WHAT HAPPENED? SCHIP Reauthorization

3. 2007: Wave of Support for SCHIP Reauthorization

4. Americans Support Covering Children 91% July 23, 2007 Source:Poll conducted by Lake Research Partners and American Viewpoint, national survey of 1,002 American voters from June 26 - July 1, 2007 for the Center for Children and Families

5. Over 400 Positive Editorials and Headlines “This Health Program is Too Important to Let Die” - Sacramento Bee, July 31, 2007 “Lawmakers Must OK Health Coverage for Kids” - Arizona Daily Star, July 30, 2007 “Children are Worth It” - New Orleans Times Picayune, July 24, 2007 “Insuring All Children: The People Want It” - Seattle Post-Intelligencer, July 20, 2007 “Health Care: Yes, For the Children” - Milwaukee Journal Sentinel, July 20, 2007 “Are Healthy Children a Danger?” - Boston Globe, July 12, 2007 “Child Health Care Funding is Vital” - Denver Post, July 19, 2007

6. Final SCHIP Bill • Coverage for an additional 4 million uninsured children • $35 billion in funding over 5 years • Major new initiatives to reach already eligible but uninsured Medicaid children • New child health quality initiative BUT • No new option to cover legal immigrant children and pregnant women • New limitations on covering moderate-income children • Phasing out of adult coverage • Improvements for citizenship documentation requirements, but also applied to SCHIP

7. Two Perspectives from Republicans in Iowa Representative Steve King (R-Iowa) on the House Floor, 10/18/07

8. Two Perspectives from Republicans in Iowa (continued) “This is a bipartisan compromise. It has broad support from Republicans and Democrats. It will help as many as 4 million low income uninsured children…It puts the lowest income children first in line… Here's what it's not: It's not a government takeover of the health system. It does not undermine immigration policy. It's not expanding the program to cover high income kids.” — Senator Charles Grassley (R-Iowa) on the Senate Floor, 9/27/07

9. A Large Majority of Congress Supported The Reauthorization Bill(Vote on first major SCHIP reauthorization bill) Source: Roll No. 906 in the House of Representatives (September 25, 2007) and Record Vote No. 353 in the Senate (September 27, 2007) which sent H.R. 976, the Children's Health Insurance Program Reauthorization Act of 2007, to President Bush who vetoed it on October 3, 2007.

10. Bush - Why I Vetoed Children’s Health Care

11. August 17th Directive • Issued August 17th, 2007 without notice • In effect, makes it difficult or impossible for states to cover more moderate-income children • 95% coverage rate • Minimal decline in employer-based coverage • Major shift in longstanding SCHIP policy and quickly a target for litigation

12. SCHIP Extension - S. 2499 • Extended SCHIP through March 31, 2009 • Significant new funding for many states • Did not address the August 17th directive

13. WHERE ARE WE NOW?

14. Federal Child Health Issues in 2008 • SCHIP reauthorization likely on the back burner until the fall • Administration using administrative strategies to cut Medicaid and SCHIP • Medicaid regulations • August 17th SCHIP directive • 6 of the 7 Medicaid regulations have been stopped, but the directive remains in effect

15. Update on the Directive May 7th Clarifying Letter Medicaid expansion states are not subject to the directive A moratorium on the directive was included in the Labor, HHS Appropriations bill, but not likely to pass until after August

16. Update on the Directive (continued) On May 9, 2008, Rhode Island became the first state to meet the requirements of the August 17th directive Serious questions have arisen about Rhode Island’s data “adjustments”

17. Update on the Directive (continued) “We said they moved the goal-line for RI (by shifting from a 95% enrollment of eligibles to 95% insurance coverage). Now, we see they ignored a fumble, overturned an interception, gave them two extra downs - and still had to move the goalposts!” - State official from another state commenting on Rhode Island’s approval

18. At Least 22 States Are Affected by the “August 17th” CMS Directive WA NH VT MT ME ND OR MN MA ID WI SD NY WY MI RI CT IA PA NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC AK MS AL GA TX LA HI FL States already negatively impacted (8 states) Expansion states with 2008 implementation dates (3 states) States with approved plans that must comply by August 2008 (12 states) States deemed by CMS to meet the directive requirements (1 state - RI) Note: DC covers children above 250% FPL, but because they are a Medicaid expansion state, they are not affected by the directive. Ohio is also a Medicaid expansion state, but they delayed implementation of their eligibility expansion due to the directive. Source: Center for Children and Families, July 2008.

19. LOOKING AHEAD

20. Key Questions for the Future How will SCHIP reauthorization get done? Will we have national health reform? What administrative actions might a new Administration take to quickly improve coverage for children?

21. Under an Obama Administration Options for SCHIP Push for quick reauthorization of SCHIP; pursue more ambitious children’s agenda in health reform Hold SCHIP for the larger health reform debate

22. Under a McCain Administration Options for SCHIP Push for quick action on SCHIP Shoot for a more ambitious SCHIP bill given broader reform is unlikely

23. Obama on SCHIP “If there’s one thing all of us should be able to agree on, no matter what our political views, it’s that our children should get the treatment they need when they need it. And when I’m president, they will.” Source: Barack Obama’s comments on Bush’s veto of SCHIP, October 3, 2007.

24. McCain on SCHIP

25. Talking Points on SCHIP Reauthorization: Background Considerations Serious harm to children if reauthorization drags on SCHIP reauthorization is a first step, not a final step, for children’s coverage. Despite fears to the contrary, SCHIP reauthorization can help pave the way for broader reform Reauthorization should be as strong as possible but overreaching is a risk

26. The Imperative for Quick Action on SCHIP Given that SCHIP will expire early in the term of the new President, quick, decisive action on reauthorization will be critical. A strong, reauthorization is needed to continue coverage for millions of low-income children, especially because it will take some time for broader health reform to be acted upon and implemented

27. The Imperative for Quick Action on SCHIP Given that SCHIP will expire early in the term of the new President, quick, decisive action on reauthorization will be critical. An early win on SCHIP will show that the new Congress and new Administration can start to break the gridlock of the Bush years.

28. The Imperative for Quick Action on SCHIP Given that SCHIP will expire early in the term of the new President, quick, decisive action on reauthorization will be critical. By taking action on common sense, bi-partisan legislation, the new Congress and Administration can start a working relationship that will pave the way for broader reform.

29. The Imperative for Quick Action on SCHIP A series of short-term SCHIP extensions would wreak havoc with children’s coverage States will be paralyzed in their efforts to move forward With the economic downturn causing more families than ever to need affordable coverage for their children, it is exactly the wrong time to introduce massive uncertainty into the future of SCHIP A series of extensions will drain time and energy away from other initiatives, such as broader health reform

30. Even after SCHIP reauthorization, the job will not be finished. As part of broader reform: All children in America should have coverage. All children should have access to the care they need to grow and develop. The Imperative for Quick Action on SCHIP

31. Broader Health Reform –What Do Children Need? • Access to affordable coverage for all children • Stronger financing structure • Shortcomings of Medicaid’s financing structure • Capped funding in SCHIP • A benefit package designed for children and their unique developmental needs • High quality care with access to needed providers • Family-based coverage

32. Broader Health Reform – Risk Points for Children • Elimination of SCHIP/Medicaid without an adequate replacement • Failure to acknowledge and address the unique needs of children • Politicians using mandates to claim victory on enrollment issues • Poor coordination between existing programs and new initiatives • Fracturing of coverage within families

33. Administrative Actions to Quickly Help Children August 17th Directive Medicaid Regulations Revamping Waiver/ Deficit Reduction Act State Plan Amendment Process