CHIP Renewal: Will the Perfect Be the Enemy of the Good?

April 2, 2015

Last week, the House passed a bipartisan (yes, really) bill that would, among other things, extend the Children’s Health Insurance Program for two years, with the higher matching rate that was part of the Affordable Care Act. The Senate will vote on the shortly after members return from their two-week break.

The bill is far from perfect. CHIP supporters and others of progressive leanings will have to decide whether — and at what point — to say it’s good enough.

A Lot at Stake and the Outcome Uncertain

Some Senate Democrats, urged on by lead children’s advocates, have insisted on a four-year CHIP extension. That would, of course, tend to avert another go round in 2017, when we could have a Republican President. And it would enable states to plan for the longer term.

But withholding support for the package could kill it, especially because it’s under fire for reasons that have nothing to do with CHIP, e.g., an offset that would raise Medicare premiums for better-off beneficiaries, the usual ban on using federal funds for abortions, except in certain limited cases. And, of course, some of those self-identified deficit hawks object because the costs aren’t fully offset.

Defeat of the bill would leave not only CHIP imperiled, but also other programs that benefit low-income children, including the Maternal, Infant and Early Childhood Visitation program, the Transitional Medical Assistance program and a provision in the ACA that funds community health centers.

Why the Bipartisan Deal Now?

As I’ve written before, CHIP will receive no more federal funding after September unless Congress extends it. That, however, is not why we’ve got votes on an extension now. There’s an urgent need, as there is virtually every year, to prevent the Sustainable Growth Rate from taking effect.

Congress enacted the SGR nearly 20 years ago in an effort to control Medicare costs. It provided a formula to curb spending on physicians’ services to Medicare beneficiaries.

But physicians claimed — perhaps, in some cases, rightly — that the reimbursements wouldn’t even cover their costs of providing care. So Congress temporarily suspended the SGR, but left the provision otherwise intact.

And it’s done the same ever since, allowing instead very small — or in some years, no — rate increases. The so-called doc fix has become increasingly necessary because, without it, all the annual rate reductions would take effect. Doctors are thus hypothetically facing a rate cut of 21% — hypothetically because, of course, Congress won’t let that happen.

The package now pending in the Senate would, at long last, repeal the SGR, but not the intent because it establishes a new reimbursement rate scheme.

Risks for CHIP

We’ll, of course, have another doc fix if the final package doesn’t pass. But we can’t count on full funding for CHIP — let alone, at the higher matching rate. For one thing, a bill brewing in the Senate would not only repeal that rate, but cut program funding in several other ways.

For another, we’ve now got a House budget plan that would fold CHIP into the same block grant as Medicaid. States would thus have to cope with an ever-greater funding squeeze. And they’d have the “flexibility” to eliminate benefits and/or beneficiaries.

Fund Cut-Off for Home Visiting Programs

Meanwhile, funding for MIECV would remain in limbo. And it expires at the end of this month. The pending bill would extend it until October 2018, at the same funding level it has now.

The program is quite small. It has nevertheless helped agencies establish and expand programs that offer poor and other at-risk pregnant women and parents of young children the opportunity to have trained professionals come to their homes, assess their family’s needs and then provide and/or refer them to a variety of services.

These include, but are by no means limited to health-related services, e.g., advice on infant care and child nutrition, screenings for developmental disabilities.

States reported serving about 115,000 families last year — surely a small fraction of those that could benefit. Hard to believe that as many would be served if Congress lets funding for the home visiting program dry up.

Other Health-Related Programs

The bill would convert two time-limited healthcare law programs that benefit low-income people into permanent law.

One — Transitional Medical Assistance — enables families to temporarily remain in Medicaid after they’ve moved from welfare to work. That move can happen when they’re by no means earning enough to afford other health insurance because state income eligibility thresholds for welfare, i.e., Temporary Assistance for Needy Families, are so low.

TMA doesn’t altogether take care of the problem, especially in states that have refused to expand their Medicaid programs. But it gives parents some additional time to increase their income — or find an employer that offers health insurance they can afford.

The other program provides states with funds to pay for the Medicare Part B premiums of qualifying individuals. Since I’m focusing here on support for children’s health and wellbeing, I’ll refer those interested to a short, clear summary by the Center on Budget and Policy Priorities.

Lastly, the bill would extend the funding for community health centers initiated by the ACA. It’s helped support preventive care and treatment for 21.7 million people, according to the latest (somewhat outdated) figures from the U.S. Department of Health and Human Services. Nearly a third of those people were children.

A Difficult Balancing Act

What all this means, I think, is that advocates for children — and for appropriate, affordable health care generally — have to balance priorities and prospects. They understandably want CHIP funded at the higher matching rate for the full four years the ACA envisions. Backing off now could doom efforts to get that in the Senate.

On the other hand, once Congress has taken care of the SGR problem — permanently or just for another year or two — chances it will renew CHIP at the higher matching rate don’t look good. What will happen to the other programs that benefit low-income children is a question mark.

Recall that both House and Senate Republicans seem set on drastically reducing federal spending (except for defense, of course). Not a good time to leave some many healthcare programs for vulnerable people wide open.

 

 

 

 


Budget Bill Fails on Unemployment Benefits, But Will Renew Health Insurance Help for Low-Income People

December 16, 2013

As I’m sure you know, the budget deal we’ve been reading so much about didn’t fold in an extension of the Emergency Unemployment Compensation program. And it’s highly doubtful Senate Democrats will upset the apple cart by adding it as an amendment to the bill the House passed.

The omission will, at the very least, make for a tough January for 1.3 million jobless workers and their families, who’ve got rent and other bills to pay. More harms to millions more if Congress actually lets the program die — not a foregone conclusion.

On a cheerier note, the budget legislation the House passed did fold in, via an amendment, extensions of two programs that benefit low-income individuals and families. Both, in different ways, help ensure that they can continue to get affordable health care.

They weren’t familiar to me. Perhaps aren’t to some of you either. So here are brief summaries, plus a bit of policy perspective.

The Transitional Medical Assistance program allows some low-income families to get up to a year of Medicaid benefits when they’d otherwise lose them because their incomes boost them over their state’s eligibility threshold — typically just 61% of the federal poverty line, but far lower in about a dozen states.

TMA temporarily averts an unintended penalty to parents in the Temporary Assistance for Needy Families program who move from welfare to low-wage work — one of those so-called “cliffs” that works against a primary TANF goal.

Those whose income rises because they get a raise or an increase in hours can qualify, as can those who come to the end of a partial income disregard that some states and the District of Columbia provide so that earnings from work increase family income, rather than merely replace cash assistance.

The Affordable Care Act initially would have enabled the lowest earners to remain in Medicaid until they made enough to lift their families above 133% of the FPL — effectively 138%, for technical reasons.

Now that 25 states haven’t expanded their Medicaid programs — a choice the Supreme Court’s ACA ruling allows — TMA remains an important, though time-limited protection.

The program also affords some months of protection for very low-income parents when their child support payments rise — or for that matter, when the absent parent merely starts paying them. Here again, it’s diminishing a conflict between two government priorities.

The Qualifying Individuals program provides federal funding to states so that they can pay Medicare Part B premiums for seniors with incomes between 120% and 135% of the FPL. Younger people who receive SSDI (Social Security Disability Insurance) benefits also qualify.

The QI program is that last tier of premium assistance for low-income Medicare enrollees — unless, in some cases, they are disabled and working.

Part B, as you probably know, covers most of the costs of outpatient care, lab tests, “medically necessary” equipment like a walker or a blood sugar monitor and certain in-home, health-related services.

For most people, the Part B premium will cost slightly less than $1,260 in the upcoming year — a real bargain, but a strain on the budget of someone who’s total income may be about $13,790.*

No one in the Senate — except maybe a few of those “wacko birds” — will oppose the amendment that extends these programs, since it also includes the annual “doc fix,” i.e. a measure to forestall what, by this time, would be a 24.4% cut in Medicare reimbursements to physicians.

Senate Minority Leader Mitch McConnell reportedly objects to the whole budget deal, as do several other Republican Senators who are looking nervously — or hopefully — at their Tea Party constituents. But they can’t stop it from passing, even if they vote against it.

So two worthy programs will live for another year — both small, but important to those who benefit and to bipartisan interests in promoting work and controlling health care costs.

Not enough to make us stand up and cheer for a bill that could, in many ways, have been better — and not only because it leaves jobless workers in the lurch.

But if you look at Congressman Ryan’s latest budget plan, you can see that we could easily have been heading toward another government shutdown — and even greater pressures on programs that serve low-income people’s needs.

* This is 120% of the 2013 federal poverty line for a single person, rounded up.