Shriver Center: November 2005

Perspective: All Kids Program Is An Important Improvement

2008-01-08T15:49:16Z

In an impressive display of just how much government can accomplish quickly when the powers that be are all on the same page, –Governor Blagojevich announced the All Kids program of universal health insurance for Illinois children on October 16, 2005. Just a few weeks later the General Assembly passed implementing legislation (HB 806) in a matter of two and a half days.

The Governor announced that All Kids would be paid for through savings accomplished by shifting the entire caseload of Medicaid and related programs to a new service delivery model known as "primary care case management" ("PCCM"), effective July 1, 2006. All Kids and PCCM are best understood as separate programs -- they are not really linked other than that the savings realized by PCCM will make is possible for the state to afford All Kids. Under PCCM, all covered families and individuals (including the elderly and disabled), with some exceptions, will choose a doctor to be their main coordinator of care. All other services from specialists or hospitals (again with some exceptions) will have to be authorized by that doctor.

Both All Kids and PCCM are good concepts and have potential to be important improvements to the current system. Both programs, especially PCCM, require thoughtful design of the details in the rulemaking process over the next months and then careful implementation. The success of PCCM, in particular, will depend heavily on smart exceptions in the program, attention to matching people up with doctors, and maximization of recipient choice in doctors. In concept, however, both programs can be clear winners, for these reasons:

All Kids

All Kids enables the covered children to have access to preventive and maintenance care. While uninsured kids can usually get care for emergencies, health insurance means access to a "medical home" and to the type of care that prevents crises. This promotes strong child development and maximizes children’s life chances in many ways.

Thus, All Kids also will save money over time. One of the long-term strategies that is essential to gain a handle on overall health care inflation is to enable children to receive good preventive and maintenance care. Many expensive health issues are minimized or never encountered.

As designed by the Governor and authorized in HB806, All Kids is really for all kids. Children are treated the same, regardless of family income. No child is “too rich” or “too poor”. A sliding scale of affordable premiums and co-payment obligations recognizes family responsibility while keeping the program accessible.

All Kids will result in fewer cases of hospitals providing care to children without reimbursement. Because of this "uncompensated care" for uninsured children under the current system, hospitals have to charge every insured person more money in order to cover their overall costs. The insurance companies charge higher premiums to cover these bills -- an insured family pays over $1000 a year more in premiums than they would otherwise. By paying hospitals for treating children, All Kids reduces pressure on everyone’s insurance premiums.

Yet, as an insurance program, All Kids is not expensive. The per child per month insurance burden is about $80. The overall cost of the program is small (about $25 million in the first year) compared to the overall Medicaid program (at least $8 billion).

All Kids builds smoothly onto KidCare, a program that is already well understood. It has an effective waiting period of up to 12 months to prevent a massive switch to the program of children currently covered by private insurance.

All Kids is a breakthrough in children's health coverage that is important across all income groups. Polling has shown that, regardless of the ebb and flow of public budgets, health care for children is a core national priority for most people. As politicians all over the country neglect this problem and many of them go about figuring out how to provide less health care, Governor Blagojevich has shown important leadership.

Primary Care Case Management (PCCM)

In concept, PCCM promises both better and more efficient care while preserving core principles of choice for covered individuals. The patient chooses the doctor who will be the care coordinator. For patients with chronic illnesses (e.g., asthma, HIV), the specialist for that illness can be the coordinator. If the patient so chooses, the coordinator can be a community clinic or an HMO. PCCM, however, is not HMO-style managed care. All the doctors and other providers will be paid the same way as they are now.

The theory of PCCM is that better patient outcomes and cost savings come from the establishment of a "medical home" and a consistent source of health care management. This produces avoidance of unnecessary or duplicative medical care and services, proper management of chronic conditions, improved primary care, early detection and treatment of health conditions, better prevention, and avoidance of unnecessary hospitalizations and institutionalizations.

PCCM is a care delivery model that has a substantial track record. It is not a new or untested idea. The cost savings and patient outcomes that the Administration projects appear to be reasonably based on the performance of the PCCM model in other states.

PCCM can dramatically improve the connection of patients to a "medical home". These “medical home” aspects of PCCM will benefit from and build on well-child initiatives that the Administration already has underway (see related article in this issue of IWN). These well-child initiatives will increase the number of doctors participating in pediatric care under Medicaid by raising pediatric and dental rates, shortening the payment cycle, and improving the matching up of children with participating doctors willing to be their primary care coordinator.

PCCM must be implemented carefully, because it can have a messy and unproductive outcome if it is not. The Administration appears to have a credible plan for implementation, including open formal and informal access to the process, designation of he Medicaid Advisory Council as a formal public forum, and promises of a "constant improvement" implementation mindset. People concerned with all populations covered by Medicaid must be vigilant during the rulemaking and implementation processes.

Implementing legislation (HB806) easily passed both the Senate and the House with bipartisan majorities, and the Governor will sign All Kids in early in November. What we know of the details of the program is described elsewhere in this issue of Illinois Welfare News. The Department of Healthcare and Family Services (HFS) will work out the details through the rulemaking process, and the program will take effect on July 1, 2006 . HFS is off to a good start and given its good track record in implementing FamilyCare and other recent health care programs, it deserves a "benefit of the doubt" as the process begins.

Task Force Hearings Reveal How Lack of Quality Health Care Adds Insult to Injury

2008-01-08T15:49:16Z

“I have no insurance.” The words sent a chill through the crowd gathered for the first public hearing of the Illinois Adequate Health Care Task Force in Chicago . The speaker was quoting a neighbor, who was recently diagnosed with breast cancer and who, like many of her neighbors on Chicago ’s southeast side, had lost health coverage due to plant closings and company bankruptcies. The speaker went on to testify that her neighbor did not get treatment for the cancer because doing so would bankrupt her family and deprive her elderly mother of a place to live.

Real people, real lives, real struggles, and real losses—that’s what the task force members are hearing about as they visit communities throughout the state. At the first five of some 20 public hearings the task force has set through April 2006, task force members heard from hundreds of ordinary Illinoisans, health care providers, and health policy experts about the realities of Illinois’s fragmented health care system, or “nonsystem” as some called it. Individuals described the nitty gritty of being uninsured or underinsured. Many have put off care, gone without needed prescription medicine, and waited too long for free or reduced cost care. Often ashamed of their past-due medical bills, some would skip follow-up care rather than endure the shame. Still others become stressed out from dealing with collection agencies and facing bankruptcy. Other individuals described shortcomings in the health care system even for those with insurance—for example, the restrictions on mental and behavioral health services, the lack of dental care coverage, and the bias toward institutional care over home care for seniors and people with disabilities.

Medical providers told the same stories through a different lens. Hospital administrators testified to their frustration, dismay, and sadness at people’s putting off care and coming to emergency rooms as very sick people. Earlier care would have made them much healthier and their treatment much less expensive. Primary care clinic staff told of juggling, begging, and pleading to find specialized care and scrounging for free medication for their patients. Safety-net providers in Cook County described their struggle to care for increasing numbers of sick patients where the waiting times verged on the surreal. One doctor said that a patient with symptoms of colorectal growths waited 22 months for a colonoscopy.

Each public hearing is a forum for the people and medical providers of that area to instruct the task force on what the health care system is like and how it needs to be changed. Task force members also are listening and learning at their monthly and specially scheduled meetings. For example, in October they heard presentations from the Illinois Division of Insurance on the insurance landscape in the state. In early November nationally known health policy experts advised them about the potential for Medicaid expansion, the universal coverage initiatives in other states, and the economics of health care.

In November and December the task force will hold public hearings in Bourbonnais , Naperville , and Aurora . Information about the dates, times, and places for the hearings and meetings is posted on the Illinois Department of Public Health website under “Health Care Justice Act,” www.idph.state.il.us, and the Campaign for Better Health Care’s website, www.cbhconline.org.

For more information, contact Margaret Stapleton at the Sargent Shriver National Center on Poverty Law, 312.368.3327.

Adequate Health Care Task Force Meetings

The Illinois Adequate Health Care Task Force began conducting public hearings this month to develop a plan for Illinois residents to have access to a full range of preventive, acute, and long-term health care services. Mandated by the Health Care Justice Act and appointed by Gov. Rod Blagojevich and Illinois General Assembly leaders, the task force is holding public hearings in each of Illinois ’s 19 congressional districts between now and April 2006 and will submit its plan to the General Assembly in the fall of 2006. The dates and general locations of the public hearings are:

November 16—11th Congressional District, Bourbonnais
December 6—13th Congressional District, Naperville
December 7—14th Congressional District, Aurora
January 4—5th Congressional District, Franklin Park
January 11—6th Congressional District, Elk Grove Village
January 18—9th Congressional District, Skokie
February 1—18th Congressional District, Peoria
February 8—19th Congressional District, Mt. Vernon
February 15—15th Congressional District, Champaign
March 8—12th Congressional District, Carbondale
March 15—17th Congressional District, Quad Cities
March 22—16th Congressional District, Rockford
April 4—10th Congressional District, Deerfield
April 5—8th Congressional District, Hoffman Estates
April 18—19th Congressional District, Collinsville
April 19— Springfield

Will Hurricane Katrina Force the Bush Administration to Rethink Its Housing Policies?

2008-01-08T15:49:16Z

For the last several years, the federal Housing Choice Voucher, or Section 8, program faced a barrage of fiscal and programmatic attacks from the Bush administration. What could not be accomplished legislatively was carried out by its administering agency, the U.S. Department of Housing and Urban Development (HUD). The new officials at HUD, however, do not seem to believe in subsidized housing for very low-income families or the basic concept of government stepping up to serve as a safety net for those in need.

Then Hurricane Katrina hit, rendering more than a half million people homeless, and millions without access to employment, health care, cash assistance, or other aid. While there are ongoing debates as to how comprehensively to rebuild communities and lives, many, including conservative ideologues such as Newt Gingrich, agree that the most effective form of housing assistance for displaced families is the Housing Choice Voucher program.

The Bush administration’s plan will in part concede the program’s effectiveness. The Katrina Disaster Housing Assistance Program will provide Housing Choice Vouchers covering three months’ rent to evacuees who were receiving public housing assistance, had Housing Choice Vouchers, and were homeless before the hurricane or otherwise ineligible for other FEMA (Federal Emergency Management Agency) assistance.

Eligible homeowners and renters will receive three months of rental assistanc e payments totaling $2,334 per household. Other families who were not a part of a federal low-income housing program may be housed in travel trailers, mobile homes, hotels, or cruise ships.

But does the Bush administration need to create a new type of temp orary voucher program, or can it rely upon the existing attributes of the Housing Choice Voucher program? Under the administration’s plan, existing voucher holders will be shifted temporarily into the Katrina Disaster Housing Assistance Program, rather tha n accessing the portability features—the ability to move at least theoretically anywhere in the United States with your voucher—of the regular voucher program. Rather than ramping up a new program, enrolling families, and disbanding the program several mon ths later, the existing program could temporarily suspend certain eligibility requirements (i.e., paying 30 percent of your income toward rent).

Many advocates and journalists note that the government has a history of successfully housing thousands of peo ple with regular Housing Choice Vouchers in the wake of other natural disasters. The federal government responded to the 1994 Northridge, California, earthquake that rendered thousands homeless by quickly tapping the program to house over 11,000 people in private rental apartments. Why was this initiative a success? Because the government accessed a government program around since the mid-1970s, there was no “trial and error” period typically part of any new bureaucratic venture. More important, the program provided permanent relocation assistance, not temporary trailer cities or cruise ships, and allowed the displaced families to decide where they wanted to restart their lives.

The housing dilemmas caused by Katrina also underscore the importance of maintai ning the voucher program in its current form, although with the funding levels in place before 2003. A program block granted to the states or run exclusively by local housing authorities without federal oversight will cause the same headaches played out wi th other block-granted aid programs post-Katrina.

The Bush administration may find it difficult to admit that a federal housing program they are determined to destroy actually works. But if they want to provide effective assistance to the victims of Hurri cane Katrina, the administration may just have to recognize that.

Illinois Is Ensuring Equal Access to Preventive Care for Children

2008-01-08T15:49:16Z

A new children’s health care initiative addresses deep problems that surfaced in a court decision called Memisovski v. Maram. The State of Illinois’s initiative aims to improve preventive health care for children on Medicaid. Beginning January 1, 2006, the Department of Healthcare and Family Services will inform families better about services, encourage families to seek preventive health care, increase the availability of doctors and dentists, and encourage health care provider participation.

Federal law requires that children on Medicaid receive pediatric care and services comparable to the general population, but this was not the case for an overwhelming majority of enrolled kids. Of the 600,000 children on Medicaid in Cook County, almost two-thirds did not receive sufficient, timely well-child health care, and one-third did not receive any well-child care at all. Instead of receiving preventive care in a medical home, children were more likely to get care in the emergency room when their health problems could no longer be ignored, and the children suffered poor health outcomes as a result.

According to the Memisovski v. Maram consent decree, the primary reason for insufficient preventive health care is the scarcity of doctors and dentists accepting Medicaid. Parents spoke of the difficulties they encountered in trying to find a doctor for their children on Medicaid compared to the relative ease of finding a doctor for a child covered by private insurance. In fact, payment rates are so low that practices cannot accommodate all Medicaid patients and remain open. Studies show that payment rates are the main factor in deciding whether to participate in Medicaid. Not surprisingly, with rates set at half of Medicare rates and much lower than private insurance rates, there are not enough doctors and dentists to give children the services they need.

The new initiative aims to increase the number of children receiving preventive health services and improve health outcomes by informing families, encouraging families, encouraging providers, and increasing provider availability.

Informing Families. Beginning on July 1, 2006, the Department of Healthcare and Family Services will inform families better about the preventive health care services available to children in the Medicaid program. These early stages of outreach involve contacting families to communicate the importance of preventive care services covered by Medicaid.

Encouraging Families. The department will send informational welcome letters and yearly materials about well-child care and medical transportation and will give every family a KidCare manual in the appropriate language. The department will hire a reading specialist to ensure that materials are readable at a sixth-grade level. By July 1, 2007, the department will begin sending notices to families to let them know when a child is due for a well-child screen, a dental screen, or an immunization. By July 1, 2008, service providers working directly with the target population will be involved in the outreach. The department will train the staff of KidCare application agencies, managed care entities, Family Case Management, and the Illinois Department of Human Services’ Family Resource Community Center to promote preventive health care and refer families to doctors and dentists.

Encouraging Providers. The Department of Healthcare and Family Services will use financial incentives and streamlined procedures to make it easier to accept Medicaid. As of January 1, 2006, payment rates for preventive services will increase, bringing them closer to Medicare payment rates and nearly tripling the rates for certain services. Doctors will no longer be denied payment for providing multiple specialty services on the same day. In the second quarter of 2007, a $30 bonus will go to doctors enrolled in the Maternal and Child Health program for each year that a patient aged 0 to 5 receives the full number of recommended office visits.

Increasing Availability. By January 1, 2006, the Department of Healthcare and Family Services will increase its use of electronic communication methods, making it easier to share information about available providers among the department, agency offices, and doctors’ offices. Then by July 1, 2007, the department will hire a contractor to create a new information, recruitment, and referral program to increase doctor and family participation as well as improve communications and procedures.

The state’s plan will be finalized on November 18 at 9:30 a.m. at a final settlement hearing in federal district court, Room 1925. This will bring to a close a case that was filed in 1992. These new initiatives offer an opportunity to improve children’s health outcomes. The Sargent Shriver National Center on Poverty Law is organizing an effort to inform families and their service providers about the importance of preventive health care.

To join in these outreach efforts, or for more information or to report any anecdotal evidence related to preventive health care or specialty care, contact Melissa Buenger, Shriver Center, at 312.368.1005.

The Shriver Center, Health and Disability Advocates, and the Chicago law firm of Goldberg, Kohn, represent the plaintiffs in Memisovski v. Maram.

Federal Housing Bill Would Silence Voter Advocacy Efforts

2008-01-08T15:49:16Z

A U.S. House of Representatives bill, H.R. 1461, the Federal Housing Finance Reform Act of 2005, would restrict the ability of nonprofit organizations to engage in voter registration or other get-out-the-vote activities.

Housing groups participating in nonpartisan voting activities 12 months before the application date and during the funding period would be ineligible for Affordable Housing Fund grants. Agencies would be prohibited from using other dollars to fund their civic engagement activities or even affiliating with an organization involved in such activities.

Affordable Housing Fund grants support the production and preservation of very low-income housing. For the next two years, funding prio rity will be given to efforts to rebuild housing in areas devastated by Hurricane Katrina.

Advocates argued that the proposed restrictions ran afoul of existing federal and state law. The National Voter Registration Act of 1993 requires nonprofit organizat ions receiving public dollars to provide clients with the opportunity to apply to register to vote and to assist clients on their applications.

A coalition of organizations, the National Organizations Opposed to Voter Restrictions in H.R. 1461, led by the National Low-Income Housing Coalition, is opposing the restrictions.

In an October 19, 2005, letter to Speaker Dennis Hastert, the coalition called the provisions “blatantly undemocratic” and intended “for no other purpose than to reduce access to voting b y low-income people.” The coalition noted that for-profit companies, which are also eligible for the grants, were exempt from these restrictions.

For more information, contact Kate Walz, Sargent Shriver National Center on Poverty Law, at 312.263.3830 ext. 232.

All Kids Offers Comprehensive Health Coverage to All Illinois Children

2008-01-08T15:49:16Z

Recognizing the importance of staying healthy to be happy and succeed in school, Gov. Rod Blagojevich’s new All Kids program extends comprehensive health coverage at low cost to all children in Illinois. The first comprehensive health coverage program of its kind in the country, All Kids covers half of the 253,000 uninsured children in Illinois.

While nearly half of the uninsured children in Illinois are eligible for Medicaid, the other half are typically from working and middle-class families. These families do not qualify for public health programs; nor can they afford the high cost of private insurance. They make anywhere from $40,000 to $80,000 a year, live all over the state, and lack health coverage for their children. A majority of these children do not receive preventive health care, and many do not regularly visit a doctor. They are six times as likely to go without treatment for serious medical issues and are nine times more likely to be hospitalized for a preventable problem.

When an uninsured child is hospitalized and the bills go unpaid, those costs are eventually taken on by the insured. Families USA estimates that this form of cost shifting will likely cause an estimated $1,059 increase in family premiums this year. Families who participate in All Kids pay monthly premiums that range from $15 or $30 for families with incomes of $0 to $40,000 to over $150 for families with incomes over $100,000. Affordable copays for doctor visits and prescriptions are charged.

Current estimates project that the state’s first year costs will total $45 million. The program will be funded by nearly $56 million in savings from implementing the primary case management model used in 29 other states. In this managed care model, enrollees choose a primary physician for preventive care and disease management to help avoid unnecessary hospital visits.

All Kids has the support of the Sargent Shriver National Center on Poverty Law, House Speaker Mike Madigan, State Senate President Emil Jones, and hundreds of community organizations, churches, and medical provider groups. All Kids takes effect on July 1, 2006. For more information, visit www.allkidscovered.com.

Huge Cuts in Safety Net Programs Averted: More Calls Needed This Week

2008-01-08T15:49:16Z

Advocates for human needs were victorious in Congress last week. Lacking the votes to pass the budget reconciliation bill that would have saved more than $50 billion over five years by cutting programs serving low-income people, House leaders pulled the bill from consideration. Programs that would have been cut include Medicaid, food stamps, child support enforcement, foster care, student aid, and Supplemental Security Income.

The Washington , D.C. , offices of moderate Republican members of Congress were barraged with calls from human rights advocates urging them to reject the policy of cutting programs for low-income people to finance tax cuts for the wealthy.

Another major call-in effort may be necessary this week as the House leadership plans to bring budget reconciliation back to the floor as soon as Wednesday, November 16. They hope to obtain passage by the end of the week before Congress goes on a two-week recess. If this effort fails, budget reconciliation is dead for the year and the cuts will not happen.

Advocates urge the public to keep those calls going, especially to the three moderate Illinois Republicans who are swing votes on budget reconciliation: Reps. Tim Johnson, Judy Biggert, and Mark Kirk. Call the toll-free number 800.426.8073 to be connected to the Capitol switchboard and to any member of Congress.

The House leadership failed to muster the votes needed to pass budget reconciliation despite making last-minute concessions to moderate Republicans on drilling for oil in the Alaskan national reserve (Arctic National Wildlife Refuge) and very slightly softening and postponing the full impact of a proposal to cut food stamps for legal immigrants.

House leaders will continue to make concessions to the moderates, but the leadership can go only so far without losing support from the other side. Pressured across the country by advocates for human needs, Republican moderates are stiffening in their resolve that the American people do not support cutting programs for low-income people to finance tax cuts for the wealthy.

The Bush agenda of tax cuts for the wealthy and spending cuts in programs for low-income people also suffered a major setback in the U.S. Senate on the same day last week. Sen. Olympia Snowe, a Republican moderate from Maine , refused to support a tax reconciliation bill extending Bush’s 2003 cut in the tax rates on capital gains and corporate dividends. She said that she could not support a tax cut that primarily benefited the rich at the same time that Congress was trying to cut programs for the poor. Consideration of the tax measure by the Senate Finance Committee was cancelled because, without Senator Snowe’s support, the bill could not be passed. The Senate had earlier approved a budget reconciliation measure with spending cuts of $35 billion that, unlike the House budget reconciliation bill, was not targeted on low-income program beneficiaries.

For more information, contact Dan Lesser of the Sargent Shriver National Center on Poverty Law. Call the toll-free number 800.426.8073 to be connected to the Capitol switchboard and to any member of Congress.