HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Nuts and Bolts on Medicaid Reform

KAY JOHNSON: So here’s the basic division that I’m calling for us today and we’ve got a very creative, we have too many things up here right now. But we’re going to make the slides go, here we go.

I’m going to talk a little bit about the past and Matt’s going to talk a lot about the present and Neva ’s going to talk about some of the vision of states for the future, so it’ll be three very different perspectives, but I think that they’ll, they really will add considerably to your knowledge about this.

I’m going to talk about some of the things we learn for how children were positioned in terms of politics and policy in past efforts around big Medicaid change. And I think there, I’m just going to say that this based on a research project that I was funded, the Robert Wood Johnson Foundation to do that looked at seven major health policy proposals that took place between 1977 and 1997, so you’re going to see in a moment, I call this from chap to chip, and you’ll see why.

The model that I’m using, and I just want to say a little bit about this theoretical model because I’m going to come back to it and I think it has relevance here, is from a man named John Kingdon, this is taught very often in political science courses and basically Kingdon talks about the fact you need these four things. You need the good problem identification, and a policy remedy, some social context that it fits into the way people are thinking, and then the political will to make change. And I’m going to talk about things that happened in the policy stream, that’s those things on top. That’s a lot about the ideas and then things that happen in the political stream and I think you know what the meaning of that would be. And then Kingdon’s theory that has worked across many, many years is that then you get a window of opportunity for change and I think, unfortunately, that’s where we are right now.

Just a little more about the framing of all of this. In some ways, my perspective on this is going from my work at the Children’s Defense Fund with the button up in the corner there Leave No Child Behind and then down to the campaign button for the Bush/Cheney campaign No Child Left Behind. And moving on, by the way, if you go to the New Yorker, it’s pretty cheap to get permission for these and saying what we’re worried about now is you get to the point where someone says the feds have authorized me to leave your child behind.

So, starting back at the big context. Putting these issues in context, there are two researchers, Jones and Baumgartner looked at one hundred years of public policy making including relationship to health. And what they found was that there was really a significant correlation between the public identification as an important problem and what actually happened. Here you can see particularly around the deliberations, you can see from 1946 basically going through 1999, how often was Congress thinking about health issues. And you could put some of those bars back up again.

And then if you think about Medicare and Medicaid, here are the counts for that. And you can see this very strong period in the 1980’s, a little bit more in the 90’s and if you could see today, you would see those bars back up again in the past three years in particular.

And this really does reflect both inside and outside the beltway what’s going on. So from chap to chip, what was going on with child’s health insurance? I’m going to talk to you about this Child Health Assurance Program, CHAP, Medicaid expansions, the Medicaid Block Grant Child Health Insurance Program, and the Medicaid reform proposals again. And I’m going to tell you you don’t have in your handout a lot of the graphic material. But they do follow the same sequence. And there were three main forces shaping the policy throughout all this. The budget priorities, social values, and public opinion, and then something that political scientists call Policy Learning and Legacies.

In the base period, we had actually in the Carter administration, a whole, a big proposal known as CHAP that submitted, that would have brought in all poor pregnant women and children into the Medicaid program. It failed twice to pass Congress. Democratic president and democratic congress and it failed twice. It failed largely for two reasons. Well, actually, larger for three reasons. One is people were talking about the fact that we shouldn’t go for just kids and pregnant women when we should get health care reform for all or health care for all. And national health insurance was the leading topic.

So the issue of the children was pushed to the back in that conversation. The other biggest factor in all of that was that the, that Medicaid was still financing abortion issues and when these bills came to the floor talking about pregnant women and children, there was a huge battle over, for the pregnant woman, whether or not abortion would be a covered service in this legislation and was part of the reason for the crash.

As a result of that, there was no major child health policy change and we entered the Regan years and major proposals like this were not put up. In thinking about the Medicaid expansion period between 1984 and 1990, in essence what happened was an incremental approach to take those pieces of CHAP and other pieces that emerged and pass them incrementally. And so, you know, there’s a hopeful message in part of this to say what could not pass in the Carter administration, what failed twice, was ultimately signed into law by President Reagan and the first President Bush. Unanticipated consequences. So there was a very sympathetic mood in the public and we’ll talk about why that was.

So here’s the summary of what happened. Coverage of all poor children, proposed in ’73 and ’77, adopted in ’90, not actually enacted fully until 2002. Coverage of all poor pregnant women, again, proposed in the 70’s, adopted in ’86. And creating more of a national pediatric benefit in Medicaid through EPSDT improvements, again proposed in ’73 and ’77, adopted in 1989 and threatened in 95, 96, and 2004, 2005.

If we think about the Clinton Health Reform Plan and there are people in the room who were actively involved with me in the battles that we fought in those years. Basically, there was very much one parallel to what happened in the 70’s, which is once the debate moved back up and people were talking about national health reform, health insurance reform, the children’s issues moved to the back. And in fact we got a letter from the white house when we complained that millions of children with special healthcare needs were going to lose the coverage they had under EPSDT and lose benefits under this Clinton proposal. We got a letter from the White House that said we cannot do everything for everyone. And it’s just too bad. If you want to take this up, go fight with the disabled veterans and AARP for a piece of the long-term care pie. That was our remedy. And we did it, we actually did it.

Now, the whole thing didn’t go anywhere, but we did. We went and sat at those tables. You don’t want to be the person who’s asked the question by the disabled veterans of why children with disabilities ought to be more important than they are. And we sort of had to argue it wasn’t about more important, how about equally important? We would go for that. So we had to really work on figuring out and really scramble and this is something Phyllis and I have been talking about. Had to really scramble for the data that could argue what these children need, what with their finances. We went for actuarial studies, so we could get cost pieces put into this. There were no data. The actuary said we can’t cost that out. We don’t have any data for doing that.

And then there was only one really big vote on health care reform and it was about maternal and child health and it was a pilot test by Senate Majority Leader Mitchell and it failed, as it did everything else in that time period.

The Medicaid Block Grant period of the mid 90’s, with the problem defined by the governors, the politics driven to, to people to shift around in their positions. The child advocates joined with a lot of other poverty advocates and elderly advocates and pushed very hard against this. Many people would argue that it was that pressure, particularly the alliance with seniors groups that pushed finally President Clinton over into a veto, but I would like to remind you that it passed Congress even then. That this Medicaid block grant proposal did. And it further eroded support for the idea that we would have a national benefit for children under EPSTD, defined as a pediatric standard.

And then when we got to the child health insurance program, people were looking at incremental reform, people were looking at ways to do things, there was still this group of children who were uncovered, there was bi-partisan support for it, but there was bi-partisan support for what? There was bipartisan support to resurrect the idea of a block grant for kids. And we added millions of additional children, but it embodied the block grant approach and it created a two-tier system for kids.

So we have some positives in countering conventional wisdom. The child health reforms of the Carter administration adopted in Reagan and Bush I. That we had Senator Chaffey and Representative Gingrich be the people who pushed to pass the protection in the Medicaid Block Grant that was passed by Congress for poor pregnant women and babies. We only had poor pregnant women and babies. We didn’t get all the kids, even. Even all the poor kids. It was just pregnant women and babies.

And then in CHIP, President Clinton sent over a bill, which people thought was a good high-water mark, and Congress tripled the funding. So those were all happy problems that we had to figure out how to deal with. Who were the people doing this? I think there is such a tendency to be partisan in today’s debates. It is very easy to forget this. If you look on the left, it’s a hundred point scale from conservative to liberal. And this is on a broad set of ratings done across a wide array of issues. But as you can see, these were all individuals who were directly active in securing benefits and eligibility for children in the 1980’s and they go all the way across the spectrum. I’m not sure we’re doing as good a job with securing that kind of support and remembering the opportunity to do so.

There are also huge changes in the policy community that in the 1980’s whole array of people on this list were very active in this. And I do not think that that whole array of organizations and individuals today could be mobilized for kids. And we’re in charge of making that happen.

So, framing. We were framing in the 1980’s as social investment. Children aren’t to blame, we can save more by prevention today, and we can invest in the future work force. Between Reagan and Gingrich, the whole frame got flipped around. It got framed into an anti-welfare frame. Social investment was no longer a viable thing. People did not buy into it. It wasn’t the driving force. A good family was a working family and there was a shift in sort of all the thinking both of the public and the Congress. Does it take a village or does it just take a good family? And big government doing everything versus each family taking responsibility. And this affects the mood of the public and affects what we are able to do.

I’m going to skip over this one in the interest of time. But to say that it wasn’t just conservative republicans who were taking those positions so you have on the top the Republican Minority Chapter in the National Commission of Children saying as important as it is to finance health care issues, we believe that the weakening of the structure of the American family may be an even greater threat to the health of children. And at the same time, in advancing the CHIP legislation, even Senator Kennedy, arguably our most liberal progressive member of the Senate at that time and today, would say, here’s how I introduce my bill. Their parents work hard, but all their hard work doesn’t buy their children the protection they deserve. The legislation imposes no new governmental mandates, it does not substitute for family values. If we aren’t helping to frame what we’re talking about in the family values frames, in the personal responsibility frame, we are not on the right bandwagon.

So what does all this mean for the future? We have a policy legacy of the Medicaid Block Grant that both the tradeoffs and the EPSTD benefits list. The social learning about what happened after the Clinton plan, what was salient. You could do things incrementally that state experiences were fooling the process. And again, EPSTD benefits at risk. And then the policy legacy of CHIP with a lost vision for a standard of care for all children.

I’m going to skip over this one because I think Matt’s going to talk a little more about this, but if you look on the left, just the big pieces of what are in current Medicaid savings proposals. And I think a very good article, if you haven’t read the article by Jean Lambreau of George Washington University that was in the Milbank Quarterly at the beginning of this year. Very good lessons overall about Medicaid Block Grant. Why do people propose block grants? Two issues, the two F’s, I call them, I give it two F’s. Block grants get two F’s from me. Not A’s, not B’s, two F’s, okay. Jim got it, thank you Jim. Federalism, giving control to states, and fiscal control, constraining entitlements. And the evidence shows we get problems with cap funding. We all know that and we should be able to argue it well that you get more uninsured, that the Medicaid waivers had caps and it sort of doesn’t play out over time. That the money, the cap money runs out and that when you get into programs like CHIP and WIC, you get waiting lists, enrollment limits and so on.

Jean has a very nice number of data in her paper showing how Medicaid Block Grants would or would not have constrained the cost and not as much as people project is her main point.

And thinking about how well do we as children’s advocates and people who run children’s programs, understand the recent growth in Medicaid. The big message here is that little bar in the center is children’s benefits. That little gray one right there, that low one. It’s not quite as small as the payments to Medicare, but if you look at the percentage change, which is what we’re showing here, it’s among the lowest of a variety of things that are driving change in growth in Medicaid spending. We know this, we talk about it sometimes in how little children cost, but we’re not fully talking about how little they contribute to the growth in cost.

What are the potential futures? I have to start with the high ground. What’s the chance that we’re going to get universal coverage for all? Not much chance, but even if we did, we can expect that children would be asked to sacrifice for the good of all. Medicaid Block Grant, limited standard benefit packages, CHIP cutbacks, and the erosion of other programs like Title V, all looming issues for us.

I guess my main point in closing about this is my main concern and that’s are we willing to fight for EPSTD and its principles. Because if we’re not willing to really fight for it, we’re going to lose it and there’s a good chance we’re going to lose it at the federal level anyway and then you’re going to have to fight in every state for it. And what do those principles mean to you and how are you going to stay with them? We know that EPSTD makes a difference, we know that Medicaid coverage makes a difference. You can see how those bars work, Jamie Resnick and I, and some other, Chris *Cuss and others have been involved in a project with the Center for Healthcare Strategies and Sarah Rosenbaum and some folks from George Washington University thinking about how we reengineer EPSTD. I just want to foreshadow this a little bit to think about there will be some paper, but you are the people who need to get data ready to make the case. There’s a very good chance that you’ll be called upon to define core benefits and supplemental benefits just as we were in the Clinton plan, just as some of us are doing in our states in the context of waivers.

Are we thinking about how we operationalize the definition of children with special health care needs? The MCHB definition, not our current states limited definition. And how are we going to insure that children have a developmentally appropriate set of benefits, not just the standard adult package of benefits because all of that is at risk and on the table.

I’m not going to go onto the, I just want to say there’s a lot of thinking about EPSTD and Title V interaction and Jamie mentioned that we have a, Jamie mentioned that a website may ultimately emerge from HRSA, we’ll see. When it does, it will look like this, if it does, it will look like this. And it will talk a lot about the ways that EPSTD and Title V can interact and be synergistic with one another. And let’s just make this go back up. I don’t know where I’m going to go here when I go back to this presentation, I got to tell you. I see where I go.

I’m going to close with that and not try to figure out the technology to get to the place where I was. And just saying to you, HRSA is sponsoring a series of technical assistance workshops around EPSTD and Title V leadership. My word on this one is, you probably could use some thinking about that in your state no matter what happens with Medicaid. And if the federal rules all change, you probably really want to talk about what’s going to happen with EPSTD. So, with that, I turn it over to Matt.