One of the biggest mistakes that advocates make is their failure to embrace and publicize success. After making the case for change and building the political will to pass legislation, advocates sometimes forget to circle back to celebrate wins and reinforce success.
For the children's community, passage of the Children's Health Insurance Program (CHIP) in 1997 was achieved after a long, arduous process that included a number of compromises that created some shortcomings with the legislation, such as its capped financial structure and poor funding formula. And, even after passage of the reauthorization of the program in 2009 (12 years later), those initial shortcomings were still not easily forgotten even by proponents of the program. And yet, the enormous success that CHIP has achieved through its implementation is sometimes unknown among key national policymakers and the public.
The reality is that CHIP is a tremendous success story. In close partnership with Medicaid, CHIP has successfully led to at least a 47 percent reduction in the uninsured rate for children in this country over the last 15 years. Moreover, despite drops in private sector family coverage and the recent recession, the number of uninsured children has dropped to the point where less than 1 in 12 children (below 8 percent) are uninsured nationwide. This is in sharp contrast to adults, where the uninsured rate for adults ages 19-64 is now over 20 percent.
In fact, CHIP has worked so well that Senate Finance Committee Chairman Max Baucus told the Great Falls Tribune on January 3, 2010, that CHIP was the most significant development in the previous decade. In addition, Senator Jay Rockefeller told the Charleston Gazette in February, "Health care is a right, not a privilege, and is essential for giving kids a strong start and fair shot in life. That's why championing CHIP is one of my proudest fights in nearly 50 years of public service."
Moreover, Senator Orrin Hatch told Politico about how he and Senator Edward M. Kennedy believed CHIP would "go down in history as one of the great bills." Very high praise, indeed.
And yet, during consideration of the Affordable Care Act (ACA), the Democratic-led House of Representatives voted to repeal CHIP. The argument was that the program's shortcomings, including the fact the program is not an entitlement and has a fixed amount of overall funding, could be addressed by abolishing CHIP - a program with a support level over 80 percent - and transferring children's coverage to ACA's insurance exchanges.
Unfortunately, for children's health, there were serious and unfortunate unintended consequences to that proposal, as exchange coverage and thereby health reform, would have left children worse off. In fact, although the value of CHIP appears to be modest on paper, every state in the country had used CHIP to either build upon the Medicaid program directly or to create a separate program that effectively provided comprehensive coverage with quality, pediatric-focused health networks. As a result, an actuarial value comparison of CHIP to the forthcoming insurance exchanges shows that CHIP will be vastly superior. For example, the study shows that the out-of-pocket costs for a child living in a family earning 225 percent of the federal poverty level would have increased by 1,100 percent, if the Congress had proceeded in repealing CHIP.
CHIP is also superior to the coverage that will be provided in the insurance exchanges in other ways. For example, CHIP provides more extensive and pediatric-focused benefits than what will be offered through the insurance exchanges. CHIP is also focused on the unique health care needs of children, which includes pediatric-specific networks and quality measures that would have been lost in any conversion of children from CHIP to the exchange plans. And, according to the Congressional Budget Office (CBO), coverage within CHIP is less expensive than the inferior coverage that will be offered in the exchange.
In addition, as the Administration has moved to implement the ACA, the Treasury Department has issued a rule that, if CHIP has been repealed, would have caused potentially millions of children to have lost health coverage entirely. According to the Treasury rule, people can only access coverage under the exchange if they do not have another source of coverage or that offer is deemed unaffordable, which is defined as having an offer of employee coverage that is more costly than 9.5 percent of income. The problem is that the Treasury Department has ruled that coverage under the "affordability test" only applied to employee coverage and not for family coverage. Therefore, family coverage could far exceed the affordability test requirement, and yet, children would still not be eligible for coverage through the exchange. As a result, if CHIP had been repealed, a large percentage of those children would not have been allowed to move into the insurance exchanges due to recent Treasury rule - otherwise known as the "kid glitch" or "family penalty" and millions of children could have lost health insurance coverage.
Fortunately, a coalition of over 600 national, state, and local organizations worked with Senators Jay Rockefeller, Max Baucus, Bob Casey, Olympia Snowe, Jeff Bingaman, and others in the Senate worked to successfully save CHIP from outright repeal in health reform. This massive mobilization was necessary because, nationally, child advocates had failed to educate the public, policymakers, and even other advocates properly as to the incredible success of CHIP.
After the passage of health reform, CHIP was once again threatened by another piece of legislation, led by Republicans this time, to eliminate the "maintenance of effort" requirement in health reform that prevented states from making cuts to either Medicaid or CHIP. This bill, the "State Flexibility Act," had the potential of encouraging states to repeal CHIP in their states with the idea that children could get coverage through the insurance exchanges instead. CBO estimated the legislation would result in half the states entirely eliminating their CHIP programs by 2016 and the remainder of states scaling back their coverage for children. By 2016, CBO estimated that 1.7 million children would have been dropped from CHIP coverage - leaving some children uninsured completely and moving others into the new state exchanges.
The irony here was that this Republican proposal would have caused 1.7 million children to either lose coverage altogether or move children out of CHIP, an extremely popular program among Republican voters, and into something less popular, ObamaCare. In either scenario, all 1.7 million children would have been left worse off if that proposal would have been enacted. Fortunately, although the bill was passed out of the Health Subcommittee in the House of Representatives, it stalled there and never reached either the floor in the House of Representatives or the Senate.
Yet, threats remain. House Budget Committee Chairman Paul Ryan has issued a budget proposal that would slash over $750 billion out of Medicaid and eliminate CHIP as we know it but rolling it into a newly constructed block grant with Medicaid. If passed, this would destroy the progress we have made since 1997 on children's health and roll back coverage for millions of our nation's children.
To protect the health of children in the future, we need to emulate some of the excellent work advocacy that has been done in states over the years to educate policymakers about the importance and success of both Medicaid and CHIP. As Gene Lewit of the Packard Foundation wrote:
Healthy public programs that invest in affordable children's coverage deliver a positive return on investment. States that work to make Medicaid and CHIP function cost-effectively see more federal dollars flowing into their programs and communities, health providers and schools. This investment in turn helps ensure that health problems are prevented or treated early, which not only improves health outcomes for children but also reduces costs in the long term. Modest investments in Medicaid and CHIP programs yield positive returns over a long time horizon.
Furthermore, opinion research consistently shows that covering all children is one of the public's highest priorities. However, the ongoing debate about the effectiveness of public programs suggests that more work needs to be done to educate the public about the successes of Medicaid and CHIP, not to mention the promising gains already being made by the ACA.
As a result, we must be relentless in our effort to education policymakers, the media, and the public as to the success of CHIP. This is critical, as the program facing yet another threat - a financial cliff in FY 2016 when funding is scheduled to drop from $21.1 billion to $5.7 billion (a pending 73 percent cut!). To protect the health of children, now is the time to be vigilant to protect it from this financial crisis and all other possible threats.
In this country, we stand on the verge of reaching the lofty goal of covering all kids. Although most Members of Congress are probably unaware of this fact, the uninsured rate for children today has dropped below 6 percent in a majority of the states in this country, including: Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, South Dakota, Tennessee, Vermont, Virginia, West Virginia, and Wisconsin.
Clearly, for our nation's children, the Medicaid and CHIP partnership has proven to be an enormous success. We are just steps away from the finish line and now is not the time to turn back on our children's health.