Last week, the Urban Institute released the most in-depth analysis that I’d seen of a state improving its enrollment process for children on Medicaid. The 30-page report showed how Louisiana hit a home run when it became the first state to implement automatic enrollment processes called Express Lane Eligibility. Essentially. the state married technology and policy changes to get more kids insured.

The policy change was simple. The state looked at what families with uninsured kids were getting food stamps, and they sent those parents Medicaid cards for the kids. They told them that all they had to do was use the cards to be enrolled. Here’s where the costs come in. According to the report, Louisiana was spending an average of $116.48 to process a children’s Medicaid application. Through the Express Lane process, the cost dropped to between $12 and $15. Right off the bat, the state saved $1.1 million on enrollment costs during the first year.

Yet, the biggest savings were in renewals. Louisiana said it cost $76 in administrative costs per child for each renewal. By automatically deeming children who were getting food stamps for Medicaid eligibility, the cost dropped to zero, saving the state more than $8 million. Total return on investment for buying the technology necessary: between 15 and 22 to 1 after one year. And get this: procedural terminations now affect less than 1% of children in Medicaid and Louisiana’s CHIP program, LaCHIP. Fewer than 5% lose coverage for any reason. Compare this to the national average — 29% of Medicaid and CHIP children lose coverage at renewal, even though 44% of the terminated children continue to qualify. That means there are gaps in coverage as families fall through administrative cracks.

Now, think about Texas. We’ve got twice the renewal costs because families have to renew every 6 months. In Louisiana, it’s every 12 months. And the administrative costs might also be higher here because we have an asset test, which Louisiana doesn’t have. But aside from costs, here’s the best news: more kids found coverage. “Through these and other measures, Louisiana reduced the proportion of its low-income children without coverage from 25.5% in 1997-1998—the 15th-highest state percentage in the U.S.— to 11.8% in 2009-2010—the 21st-lowest state percentage, according to Census Bureau data. Put differently, the state moved from having one of the country’s highest proportions of uninsured low-income children to better than the national mid-point.”

After these changes, the state conducted focus groups with families. So, when they asked parents what they thought when they received coverage for their children even though they hadn’t applied, here were some of the responses:

“I thought it was a gift from God!”

“I said thank you, God!”

 ”I was jumping for joy.”

Since Louisiana implemented this, other states followed suit: Georgia, Iowa, New Jersey, and Pennsylvania. In addition, Arizona, Colorado, and Massachusetts all have plans to implement Express Lane Eligibility.

Read the entire report here.

Enrollment up in February

Enrollment in children’s Medicaid and CHIP was up in February. For Tarrant County:

• Enrollment in children’s Medicaid was 149,935, up by 1,294 kids over January.
• Enrollment in CHIP was 41,138, up by 413 kids.
• Over the past year, enrollment has grown 6.5%. We continue to outpace state growth, which is up 4.5% over the past year.

I don’t know if this is a blip or not, but the state numbers saw an unusual trend in February. There were more new enrollments in CHIP (4,198) than children’s Medicaid (3,114) . Generally, children’s Medicaid enrollments outnumber CHIP by about 5 to 1.

Maybe all the new dental ads are spurring more working families to get their kids insured. Awareness is good!

Since I work for an accounting firm, I’ve always enjoyed the simplicity of this riddle. And, today is Lincoln’s birthday so it seemed appropriate. So, in Texas, families can apply online for CHIP and Medicaid — but — it’s not a complete application. They still have to mail in income verification. So, what’s the use of doing one thing online and one by mail? Actually, the chances of the application and the paper being separated or lost are multiplied.

Imagine you bought a book on Amazon and then had to mail in a check? It wouldn’t really be an online purchase, would it?

Some states are completely online, though. Our neighbors to the north, for example. In Oklahoma, families fill out an online Medicaid application, and they know immediately whether they’re eligible. In Texas, families wait 45 days. (Obviously, it’s a more labor intensive process here.)

Oklahoma officials say 45% of applications come through the online portal. But what about income verification? Well, Oklahoma uses electronic sources, including the Social Security Administration and the state employment security commission. A lot of this data is available to government; it just has to tap into it. Think how much Texas could save, and make the system simpler for busy families.

If you’d like to hear more, Enroll America is hosting a webinar Wednesday at 2 pm on Verifying Eligibility in the Digital Age. You can register here. Speakers will discuss eligibility systems in Oklahoma and Wisconsin.

True, except in one area:  health insurance.

Last week, the Commonwealth Fund compared premiums for family coverage across the nation.

The US average was $13, 871. Texas was $14,526.

The real rub was the Commonwealth Fund analyzed premiums as a percent of median household income. Texas ranked second highest at 25.9%. Only Mississippi had a higher percentage.

So, if you’re working at a Texas company that doesn’t provide health insurance — and half of employers here don’t — you’re looking at a big chunk of your paycheck going towards healith insurance.

But even if you work at an employer that provides coverage, Texas employers tend to make their workers pay a higher share. Nationally, the average it’s 26.8%. In Texas, workers on average pay 31% of the cost of their coverage — again, one of the highest.

But wait — before you even use that insurance, there’s a deductible.

And the average deductible in Texas for family coverage: $2,283.

Wow. Read the whole report here.

This is why we should be grateful for programs like children’s Medicaid and CHIP that cover kids when their parents can’t afford it.

Or, maybe someone told you about part of it, but you had no idea there was more. Meanwhile, your family is scraping by, living paycheck to paycheck, with little hope of getting ahead.

Sound like a nightmare?

This is reality. Each year, about $8.3 billion in federal benefits for families goes unclaimed in Texas, according to the Texas Health Institute.

But, there’s a solution called The Benefit Bank. This organization trains counsellors to work with families and apply online for:

• Food stamps
• College tuition assistance
• Medicaid
• CHIP
• Income tax credits

And families can apply for all of these benefits at the same time. Free and online.

For example, thousands of families that could qualify for food stamps don’t apply. We know the same is true w/ CHIP and Medicaid. In Tarrant County, only 58% of those eligible are receiving food stamps, according to The Texas Food Bank Network. That amounts to nearly $225 million.

I love this idea because I think it could help more children gain coverage.

The Benefit Bank is already up and running in Arkansas, Florida, Indiana, Kansas, Mississippi, Ohio, North Carolina, Pennsylvania, and South Carolina. For example, in Ohio, the Benefit Bank has returned more than $500 million in benefits. They have counselors in community and faith-based organizations, social service agencies, food pantries, job training programs, and homeless shelters.

Currently, The Benefit Bank is being rolled out in Amarillo. I met with the Benefit Bank team this week, and would love to see this happen in our area.

If you’d like to get involved or hear more, contact the Texas Benefit Bank’s executive director, Diana Maldonado at dmaldonado@texashealthinstitute.org. Or visit http://www.thebenefitbank.org/texas.

Improving economy or re-enrollment snafus?

Hard to know.

 In Tarrant County, 2,961 fewer kids were on children’s Medicaid, but 65 more were on CHIP.

Statewide, 21,109 fewer kids were on children’s Medicaid, and 1,088 fewer were on CHIP.

As a nation, we are a long ways from that. The U.S. is a patchwork of coverage requirements, a fact underlined this week in a new report, Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012.

There’s a lot to digest in this 92-page report, but the one big take-away I get is how very, very different these “United” States are in children’s coverage. For the one-third of kids that depend on Medicaid and CHIP, their access to our nation’s healthcare pie depends entirely on where they live.

Here are just a few examples:

• Cost of a preferred name brand drug: Texas, $25; Utah, 25% of cost, Georgia, free.
• Cost of non-preventive doctor visit: Texas, $12, Maryland, free; Illinois, $5.
• Enrollment fees for CHIP: Texas $35 to $50, depending on income; Kentucky, none; New Jersey, none up to 201% of poverty, then $40.50. But, New Jersey also lets families up to 351% of poverty buy CHIP for $134.50.
• Length of time a child must be uninured befor enrolling in CHIP: Texas, 3 months; Idaho, 6 months; Hawaii, none.

This report lays out probably a hundred or more different variables in the eligibility, enrollment, renewal, and cost-sharing approaches that states can take for Medicaid and CHIP. And, I’ll bet no two states are alike. They’ve each developed their own synchronic concoction — a mixture that they believe will work best for kids — or if you’re cynical, what taxpayers have decided they’ll spend on kids’ health.

But there was one thing ALL 50 states had in common between 2010 and 2012. Even as our nation went through the worst recession in a quarter-century, states did not take draconian measures to cut kids from Medicaid.

Oh, many wanted to. Oh how they wailed! But, it was against the law. The Affordable Care Act, also known as Obamacare, said that if your state receives Medicaid funding, your state must maintain eligibility, enrollment, and renewal policies that were in place as of March 23, 2010 (when the law was enacted).

For that, we should be thankful. It could have been much, much worse.

I’m really interested in this information, and you should be, too. First of all, Texas pays private health plans to manage the care of kids in Medicaid in most urban areas. The state has gone with a managed care strategy as one that contains costs, but also provides a professional coordinator that ensures that kids are getting appropriate care.

Physicians are obviously important partners in children’s care, and so are parents. But only health plans are paid to “manage” that care. Measuring how well they manage care boils down to some widely used national benchmarks. Texas, as it should, has adopted several of these. These benchmarks can be used by state officials and health plans to identify opportunities for improvement. Families also can use these to select the Medicaid health plan that’s right for them.

The report released this week analyzed data from September 2009 to August 2010. To read the entire 101-page report, click here. The report has measurements by plan as well as by county.

I’ve summarized it here.

Primary care access — % who had a visit with a primary care physician

o   12 to 24 months old — 98% in Texas and in Tarrant County.

o   25 months to 6 years old — 95% in Texas, 93% in Tarrant County.

o   7 to 11 years old  — 96% in Texas, 95% in Tarrant County

o   12 to 19 years old. — 95% in Texas, 94% in Tarrant County

This looks pretty good to me. Access is slightly lower, though, in Tarrant County.

Well-child visits

o   Six or more well-child visits in their first 15 months of life — 63% in Texas, 70% in Tarrant County

o   One or more well-child visits in the 3rd, 4th, 5th, and 6th years of life — 80% in Texas, 75% in Tarrant County

o   One or more well-care visits for 12 to 21 years old — 63% in Texas, 57% in Tarrant County

A mixed bag here on Tarrant County performance.

ED visits per 1,000 member months

o   Total — Texas, 59; Tarrant County, 73.

o   Less than 1 year old. — Texas, 108; Tarrant County, 116.

o   1 to 9 years old — Texas, 52; Tarrant County, 61.

o   10 to 19 years old  — Texas, 39; Tarrant County, 51.

Here a low score is preferred. Research shows that at least a third of ER visits could have been handled in a lower cost setting, such as a physician office or clinic. Looks like Tarrant County has some work to do here.  

Inpatient rates per 100,000 members

o   Asthma — National, 124; Texas, 113; Tarrant, 79.

o   Diabetes short-term complications — National, 28; Texas 25; Tarrant, 39.

o   Gastroenteritis — National, 105; Texas, 50; Tarrant, 24.

o   Urinary tract infection — National, 43; Texas, 34; Tarrant, 13.

o   Perforated Appendix — National, 29; Texas, 39; Tarrant, 37.

Here, national benchmarks are also available, and a low score is preferred. No one wants their child to wind up in the hospital. Excellent score on asthma!  Good on the others, too, except diabetes.

Appropriate testing for pharyngitis (sore throat) — National, 62%; Texas 52%; Tarrant, 59%.

Appropriate treatment for upper respiratory infection — National, 86%; Texas 83%; Tarrant, 80%

Use of Appropriate Medications for Asthma

o   5 to 9 years old — Texas, 96%; Tarrant, 94%.

o   10 to 17 years old — Texas, 94%; Tarrant, 92%.

Tarrant County plans underperformed on all of the above.

Mental health

o   Had an initial follow-up visit with a provider within 30 days of beginning an ADHD medication — Texas, 47%; Tarrant, 48%.

o   Remained on an ADHD medication for at least 7 months and had two or more follow-up visits with a provider within 9 months — Texas, 58%; Tarrant, 58%.

o   Readmitted to the Hospital Within 30 Days After an Inpatient Stay for Mental Health — Texas and  Tarrant, both 10%.

Mixed bag.

All in all, most Texas Medicaid health plans are doing a pretty good job.

My beef is it’s hard for families to find this info.

If I have a child with asthma, I’d like to know which health plan has the best track record at taking care of kids with asthma. Same with diabetes or mental health issues.

Hope you’ll let families know. Keeping kids healthy takes a collaborative effort in which everyone works towards improvement.

You wouldn’t know it by reading or listening to the local media, but the East Coast press has had quite a discussion around how much guidance Texas’ population needs to find coverage.

First, the Washington Post broke the story of how Texas was preparing to shut down its Texas Consumer Health Assistance Program (CHAP). It had been the state’s first office dedicated to helping consumers find health insurance. CHAP was federally funded with a $2.8 million grant that was part of the Patient Protection and Affordable Care Act. The funding is running out so they’re closing it down in April.

According to the Post. CHAP had hired nine employees who handled about 6,000 phone calls. The article pointed out that meant the government has spent $466 on each call handled to date.  That may not seem like a good use of tax dollars. (Obviously, the money went for more. Texas CHAP has a nice educational website; click here to view.)

Next, the New York Times weighed in with a column by Princeton University health economist Uwe E. Reinhardt further analyzing Texas’s consumer assistance budget. Reinhardt pointed out that consumers don’t need much help buying insurance in Europe, but they may in Texas. Switzerland, Germany and the Netherlands all have social health insurance in which consumers select from various private carriers — all of which sell standardized packages. But, here in the U.S., it’s a different story.

As Reinhardt so bluntly states; “Choice in the United States is expensive, because it requires prospective enrollees to do near-Talmudic studies of the fine print of each insurer’s offerings — many times multiple distinct offerings per insurer.”

Then, today, the Post published another piece about Texas’ CHAP. In this piece, the Post compares the cost-per-call with what an insurance broker charges, saying its not that much more.

Here’s my reaction to all of this:

• Readers in Washington and New York know a heck of a lot more about Texas CHAP than Texans.
• I’d bet there are far more than 6,000 Texans who are confused about where to get health coverage.
• I wish the media spent as much time on these complex issues as what went wrong with the Cowboys.
• There’s no state where where consumers could possibly need more help with this issue than in Texas where one-fourth of residents are uninsured.

To be eligible for a performance bonus, states had to adopt five of eight specified measures aimed at simplifying Medicaid/CHIP enrollment and renewal for children.

For the third year in a row, Texas didn’t qualify.  Last year, 15 states got more than $200 million in bonuses. In 2009, 10 states got $75 million in bonuses.

Notice how more states got on board with each round?

Is this another Oops moment?

The “5 of 8″ test is designed to determine whether states really want to enroll more children in Medicaid/CHIP. The system actually serves to further separate the “haves” from the “have-nots” by giving more money to states that are more generous to their children. The states that are stingier get less money. Not the fairest system in the world, but it’s designed to influence behavior of the “have-nots,” like Texas

Here are the eight requirements for children’s Medicaid and CHIP:

• 12-month eligibility. (Texas has 12-month eligibility for CHIP, but only 6-month in Medicaid.)
• No asset test, or if there is one, require no documentation (Texas is one of the few states that still has an asset test.)
• Eliminate in-person interview. (Texas OK here.)
• Same application for Medicaid and CHIP. (Texas OK here.)
• Automated renewal process. For example, Virginia has simplified the eligibility renewal process so that children have an easier time keeping their coverage when it’s time to renew.
• Presumptive eligibility. For example, Montana and Connecticut have adopted the “presumptive eligibility” option, which jump-starts enrollment for children who appear eligible and lets them see a doctor or get a prescription while their full eligibility is being determined. In Texas, families must wait until the application is processed, which can be a month or more.
• “Express Lane,” an accelerated process for children who have other government benefits. For example, Georgia is using information from the WIC program to make Medicaid enrollment simpler.
• Premium assistance subsidies. (Texas OK here with the Health Insurance Premium Payment (HIPP) Program)

The formula for calculating these bonuses is really complicated, but I think we can easily figure that Texas has forgone hundreds of millions of dollars so far.

Other implications:

• If Texas had simplified enrollment and made it easier for more families to enroll, it likely would have enrolled even more children and been eligible for an even larger bonus.
• The simplification measures that other states have implemented save the state money in administrative costs. 
• It’s not too late!  The feds will award these through 2015.

Is a world that cares

That all kids get care

Everywhere

Gee, if we could only
have ALL kids get care,
then I could wish you
“Merry Christmas!”

It seems so wonderful to hear

That more kids have found coverage in our state

Gosh, oh gee, how happy I’d be,
with 100% insured rate.

All I want for Christmas

is Medicaid and CHIP

for our kids,

all our kids

Yet, we still have one million uninsured kids,
I hope they don’t get the flu on Christmas.

It seems so sad that I must say,
“Susie, fill out this long application.”
Gosh, oh gee, how confused she’ll be,
she’ll quit in blind frustration.

All I want for Christmas is health equity from sea to sea,

why can’t we agree?

Gee, if we could only have health equity,
then I could wish you
“Merry Christmas!”

It seems so odd that we can spend

Trillions, more than any other nation

Yet, paying for coverage for every child

Gets no collaboration.

All kids want for Christmas

Is some help to pay

For a hospital stay

At $10,000 a day

All kids want for Christmas

Is chance to say,

“We didn’t go bankrupt for Christmas!”

It seems so odd that we demand

Paperwork for Medicaid determination

Gosh, oh gee, how much cheaper it would be
to have online verification?

All I want for Christmas

Is someone who cares

That kids get care

Everywhere

Thanks to each of you who helped a kid get care

I wish you all a Merry Christmas!

Hope you enjoyed the holiday fun. To read last year’s The Grinch who ALMOST stole Medicaid, click here