SCHIP Response

Last week John E. McDonough responded to my entry on SCHIP by making a couple of statements that are typical of those I’m hearing about SCHIP, so I will respond.

John’s comment: First, though you decry New York State's proposed expansion of SCHIP eligibility to 400%fpl, you and the President ignore the fact that the bipartisan Congressional bill would make it harder for states to expand SCHIP above 300%fpl than it is now.

Answer: Yes, the bill would allow New York to offer SCHIP to families of four making $83,000 or 400% of the FPL, or federal poverty level. We do not think children living in families with that much income qualify as poor. We also believe states should focus on children under 200% of the poverty level before offering coverage to families over 250%. New York for example still has 12% of the children under 200% who don’t have insurance. Yet they now want to expand to cover children at 400%.

As you point out, the vetoed bill does contain a requirement for states to enroll children under 300% equal to the average of the top ten states. We agree there should be a standard of performance before states can expand eligibility. We see the bill's standard as weak. We think it should also measure performance on children below 200% FPL not 300%. I would also point out New York and New Jersey, who have expanded above 300%, are exempted from the requirement.

John’s comment: Second, though you say you care about poor children, you ignore that the vast majority of new funds in the bipartisan Congressional legislation would only help about four million children who are currently eligible for SCHIP and who are not enrolled because state's lack the funding to enroll these children.

Answer: John, of the four million children the sponsors say the bill would help, only 500,000 are currently eligible for SCHIP. Over a million are eligible for Medicaid. In other words, these children are eligible for government insurance and could enroll today. Of the remaining 2.5 million, nearly half already have private insurance (according to the Congressional Budget Office).

Most of the money in this bill isn’t going to pay for newly insured children. The majority of the funding will provide states with better match rates and cover children who are already eligible or have private insurance.

Comments

Secretary Leavitt,

I have a son with an expensive chronic condition: Hemophilia B, severe. He was born with this condition, just like your children are born with the color of their eyes or hair. Thirty percent of hemophilia cases show up spontaneously, so it could happen to any child. Hemophilia costs between 150,000 and 400,000 a year to treat -- and that's best case scenario with a child who responds well to the medicine. Worst case scenario, treatment costs much more. The issue for children with severe hemophilia is spontaneous internal bleeding. Treatment saves these children's lives, saves them from brain damage, debilitating pain and joint damage or joint fusion.

Insurance premiums for kids with hemophilia start at normal levels, let's say 400 a month for a family of three -- 4,800 a year. But then there's the twenty percent co-insurance that's due, up to a maximum out of pocket, which is commonly 7000-10,000 dollars. Families with hemophilia are guaranteed to hit their out of pocket limit every year, and have to plan for that as part of the cost of insurance. So now we're up to a cost of about 15,000 a year -- but that's before the insurance company raises their premiums in response to the high bills. This has happened to almost every family with hemophilia I know, and when it happens it's not just that family that pays more, but all their co-workers. Premiums often go up to as much as 1100 a month. The cost of insurance then shoots up to around 23, 000 a year -- and that's if they keep the out-of-pocket at only 10,000.

Then let's consider lifetime caps, which most insurance policies available to us normal folks have. Normally the cap is around 1 million. For a kid running bills of 400,000 a year, that lasts about two years. I know a family who has a three figure income and had really great insurance where they didn't have to pay anything and had no lifetime cap. Within three years of having their son, he had LOST his insurance because the insurance company instituted a lifetime cap in response to the cost of his condition. All the coworkers were priced out of the monthly premiums of over 1000, and even this family's three figure income was strained by having to pay close to 30,000 a year on insurance. Their son now has lost his insurance at age 3 1/2, and the company his father works for has trouble hiring new workers because the insurance company will only offer them expensive junk policies. This family has been told that the only long-term solution is to divorce so that the wife and kids can qualify for Medicaid. All the other solutions are only short term. And, of course, they don't qualify for SCHIP programs.

In our family, we do qualify for SCHIP, but only because higher incomes are allowed. Our son relies on SCHIP for the medicine that stops his bleeding. We are in the human services field (I'm a counselor, my husband's a children's educator), and aren't offered high salaries or good insurance to begin with. Purchasing insurance for our son would cost us between 15,000 - 30,000 a year, depending on which carrier we chose -- and that's before they found out about his high treatment costs. Even at the low (!) cost of 15,000, that cost plus the costs of daycare would completely wipe out my salary.

The aim of private insurance is to weed out high-cost patients like my son. And when they've weeded us out, where are we to turn if SCHIP isn't available to us???

Your administration's ignorance about the real world is shocking to me. Your children or grandchildren, or your coworker's children, could be born with hemophilia, because 30% of cases are spontaneous. What will you do when affordable health insurance becomes unavailable to your family simply because of their genetic code??

Hemophilia is not the only expensive chronic condition out there. Many, many people are faced with these same issues. I don't think that socialized health care is the answer to all our problems, but I do know that the current private insurance system is broken for many, many families, which is something your administration is not admitting. We can't solve the problem until we admit it exists. I don't have the luxury of ignoring the problem, and perhaps someday you won't either. Please start acknowledging it now, and stop the political rhetoric and scare tactics. SCHIP is not socialized health care; it is an appopriate response to a private system that simply does not work for many, many families.

April Bennett

Posted by: April Bennett | October 18, 2007 at 06:34 PM

Ms. Bennett is correct. You elite, sequestered government officials have NO IDEA what a regular person goes through in this society to make ends meet. For example, NO ONE can raise a family with four kids on 60K (or even 80K) having to pay 1000K a month on health insurance. You really have no idea how hard that is. I defy you to do, Mr. Leavitt.

You really need to get out of the DC bubble and see how real people live their lives in this country. Your "market utopia" is completely unrealistic. A health care savings account??? Gotta be kidding. If you can't even afford to pay for food, mortgage, utilities,etc.--how do you expect a person of modest means to squirrel away money in a health care savings account? I defy you to do it. Most people are living paycheck to paycheck in this country, if you haven't noticed.

The Western European democracies are much more "Christian" and pragmatic when it comes to how they deal with health care. They pool their resources so as to cover everyone at a largely reduced cost. They believe that health care is a human right, not just another commodity to be bought and sold in the "marketplace" for profit. Kudos to them, and shame on our broken and (and yes, unethical) system.

Posted by: David Bishop | October 21, 2007 at 06:50 PM

Poor April. You don't understand. Affordable health insurance will never become unavailable to his family! That's why he and all the others in this current administration don't give a [edit] about you or me!

Posted by: Bob Spencer | October 21, 2007 at 08:00 PM

Mr. Secretary
I live in Arkansas, not New York, so I am unfamiliar with the details for New York. But here in Arkansas children can be enrolled in ArKids First for up to 90 days subsequent to the need for the insurance. Their medical bills will be paid after they enroll. That means that uninsurance in Arkansas is meaningless. The healthy children who do not need medical care may appear to be uninsured. But if they do incur a need they can be enrolled up to 90 days after medical bills are incurred.

When your boss comments that children needing medical care should go to the emergency room he displays appalling ignorance. Emergency room care is the most expensive way to treat children. Children should be treated in clinics.

Posted by: Robert Walker | October 21, 2007 at 08:52 PM

Please spare me the hypocrisy. We all know for a fact if the Republican were in charge of Congress and Senate and they offered the same CHIP bill, President Bush would HAVE signed it, period. Bush let the Republicans run whatever and however they felt like it the first 6 years of his presidency. We Americans can see that!!!!

Posted by: casscubs | October 22, 2007 at 12:38 AM

Secretary Leavitt,

I'm sorry you haven't responded to April's story. And there are many others like hers.

You should listen to this NPR report

http://www.npr.org/templates/story/story.php?storyId=15377334

It profiles a family whose income is only $100 over the current cutoff in NY for SCHIP.

While President Bush abandoned any pretense of being a "compassionate conservative" years ago, his veto shows he and the Republicans who upheld it are cruel conservatives.

How can you deny even one child health care?

Conservatives like Senators Grassley and Hatch (your own senator) basically said the president lied while vainly trying to defend his veto:

http://www.npr.org/templates/story/story.php?storyId=14980830

The president told the group that it is right to help poor children, but he said some people were using this bill as a step toward federalized health care. He said the SCHIP bill went too far.

"Here's the thing, just so you know, this program expands coverage, federal coverage, up to families earning $83,000 a year," he said. "That doesn't sound poor to me. The intent of the program was to focus on poor children, not adults or families earning up to $83,000 a year."

Supporters Refute Claim

But supporters of the bill immediately seized on that claim and said it was not true. Republican Sen. Orrin Hatch of Utah, a loyal supporter of the Bush White House, responded angrily to the president during a Capitol Hill news conference.

"Are families of four making $83,000 going to get benefit(s) under this? Not unless the administration agrees to it. This bill does not call for that high level of expenditure," Hatch said.

Hatch explained that the only way such families would get SCHIP coverage would be if their states petitioned the administration for a waiver — just like under the current program. When New York, made such a petition, the Bush administration turned it down.

The new law would be the same, Hatch said, and even if the White House were willing to grant waivers, such families would make up just a tiny percentage of those eligible.

"To call this a step toward one-size-fits-all, government-mandated health care is just political in my view," he said. "This is a block grant. States have tremendous power over this bill — not total power, but power."

Hatch said he found the veto difficult to understand, and senior Republican Sen. Charles Grassley said the same thing.

"Every effort was made to bring the administration into the process, but it decided to veto the bill, I think, before it was even written. From their position, it was either my way or the highway. Well, that's not how the legislative process works," the Iowa senator said.

The SCHIP compromise bill was not a step towards federalize health care. It would have given more children the health care they need.

On the scale of the federal budget, the money involved was a pittance, but it would have made the lives of many children better (and kept some from dying).

Posted by: Steve Rhodes | October 22, 2007 at 06:53 AM

Secretary Leavitt,

As your concern grows for the expenses incurred for health care for our most valuable asset and precious possession, it leaves me wondering... why is America the only major entity that doesn’t have a form of federal healthcare for everyone. We have the more people that work here than any other country with an economy similar to ours and yet thousands of children go without health care because the poverty level vs. the COL is ridiculously scaled. Employment that provides proper healthcare costs are few and far between and our taxes rival that of other countries that provide federal healthcare for all it's citizens. You have programs that usurp funds that are under your control. Some of these programs steal from budget and place children into a system that makes them dependent on federally funded health care (which by the way, the doctors within that system are seldom paid enough and therefore, our children suffer from inadequate care). I think a push towards standardizing care and cost would be a much more effective way to make sure ALL our children have good health care and All parents would no longer have to worry about our childrens' health care.
Now this brings me to the subject, what would happen to the organization under your direction? Well funding would surely be cut for all states. There would be less neglect issues, less abuse issues, and less need for breaking up the American family. Everything is interconnected. So, if you are truly in the business of caring for children, why not help them? Why are you wasting time arguing over who makes more money etc... and why don't you just do the right thing and get ALL children the health care they need. Would it take away from your Insurance funding that helps pay your salary?
As an aside, our children have health care that we pay for. It's a very expensive part of our family budget. I can't imagine what our children could have if you could appropriate funds in a more effective way.

Posted by: someone's mom | October 22, 2007 at 11:03 AM

Secretary Leavitt,
I worked for several years in public health back when Hillary Clinton was going to reform health care. What bothered me was the fact the front line worker was ignored and the task force for reformation was made of policy guru's with no front line or old front line experience.
Currently reforming health care is a hot topic again. I'm wondering at what point the real problem of public health clinic and doctors clinic "no show" rates will be addressed by the reinbursement system.
When I worked in public health patients who were fully insured by Medicaid only showed up for their preventive health appointments 30% of the time. My clinic had to triple book to keep me busy.
Our health care statistics will not improve by fully insuring all Americans unless the same Americans engage and use preventive health practices, show up for their appointments, and do what the doctors and nurses prescribe at the visits.
My recommdation is if Americans do not keep necessary medical appointments they should face a penalty.

Posted by: Louise | October 22, 2007 at 12:53 PM

I just want to say how cool it is that someone reading this comment will probably be someone who has directly spoken with the president, my personal hero.

The reality is that there will always be sob stories about any program, no matter how perfect it appears to be. If you're making your policies with your emotions based on those sob stories, than you're not doing your job as a policy-maker.

Posted by: James | October 22, 2007 at 06:47 PM

Secretary Leavitt:
First of all I would like to congratulate you for having a blog where an ordinary citizen can talk to you and give her/his opinions on various healthcare issues.
I am a law graduate who has been working in the healthcare field for over fifteen years.During this period I have very closely noticed and observed reasons of healthcare hardships by thousands of people.
In my opinion most of the time we try to resolve a problem without finding the root cause of it. I don't think that healthcare problem is out of hands and I am also quite positive that our country has enough resources to grant healthcare to every one who deserves it and who needs it .Only problem is to be able to bring those resources together and follow through with them strongly .
I would like to hear from you and if interested I would like to meet with you bring certain important issues to your attention.
Thanks again and I hope more senior officials have blogs like this.

Posted by: kiran lamba-bhtia | October 25, 2007 at 10:43 AM

I am not opposed to an expansion of SCHIP but if that is done, I think it should be assessed in conjunction with what we want to spend for Medicare and Medicaid as a whole. I agree with many of the commenters that poor children should be provided a way to rise (and health care is on that list) but we are also facing the Medicare crisis with the aging of the baby boom. And recall that we recently added prescription drug coverage for seniors. Like it or not, government spending on medical care as the programs are currently in place is unsustainable. I think it is fine that we want to spend more on health care for children but then we probably need to have a discussion about the government services each of us is willing to sacrifice to allow that to happen.

Posted by: Rob | October 27, 2007 at 11:02 AM

Dear Representative Bilirakis,

Please vote to override President Bush's veto of children's
FYI:

Docket Management Comment Form Docket: CMS-2287-P - Medicaid
Program; Elimination of Reimbursement under Medicaid for School
Administration Expenditures and Costs Related to Transportation
of School-Age Children between Home and School Temporary Comment
Number: 214007

I have been a nurse for almost 30 yrs and a Nationally Certified
School Nurse since 2001. I ride a school bus daily with a 5year
old student who has at times needed oxygen and emergency seizure
medication while on the bus. This child needs a nurse on his
bus. I have worked for the school districts of Pasco and
Pinellas and am now working for an independently contracted
agency. I have watched for the last 13 years as funds have been
cut to school districts for the care of its most vulnerable and
fragile recipients, disabled children.It is insulting that you
give the rationale for cutting funds to be to prevent potential
waste and abuse of funds. There is a plethora of nursing
documentation on file with the school district and its
independently contracted nursing agencies, which clearly
demonstrates the need for medicaid funding in order to safely
transport these medically fragile students both to and from
school. Respectfully, Mary Wheeler-McFarland RN JD NCSN

The Centers for Medicare and Medicaid Services (CMS) has a
proposed rule (CMS-2287-P) regarding Medicaid reimbursement for
school based administration and transportation. Improper billing
by school districts (nationally) for administrative costs and
transportation services under the Medicaid program is a
longstanding concern of the Department of Health and Human
Services (HHS). Both HHS Office of the Inspector General (OIG)
and the Government Accountability Office (GAO) have identified
these categories of expenses as being susceptible to fraud,
waste, and abuse. Based on their determinations, under the
proposed rule, Federal Medicaid payments would no longer be
available for administrative activities performed by school
employees or contractors, or anyone under the control of a
public or private educational institution, and transportation
from home to school and back for school-aged children.

What does this mean? If this proposal is approved, effective
October 1, 2008, the SDAC program and the reimbursement for
transportation will cease to exist. Since 1998 (when we began
participation in the program), Pinellas County has received
(paid through 2006) $19,666,295.56.

CMS claims that this action (elimination of School District
Administrative Claiming and reimbursement for transportation)
would save $635 million the first year and $3.6 billion over the
next five years. This represents about three percent of the
total (federal) Medicaid annual budget.
The comment period is open until November 6, 2007.
If you are interested in providing comment regarding the impact
of this proposal on the students and services of Pinellas County
Schools Contact HHS Secretary Leavitt:
The Honorable Michael Leavitt Secretary, Health and Human
Services [edit]

Posted by: Mary McFarland RN JD NCSN | October 28, 2007 at 03:56 PM

I understand the need to verify income to stage off abuse of the system by parties who can afford the needs of their children.

I think the bigger picture is helping companies waste less. The pharmaceutical distribution system is among the least efficient in the world.

Providers continue to practice w/paper methods despite advances in EMR/EHR systems.

We could make tremendous advances if we could get strategic medical academies encourage efficiency in their practices. We could see an overnight improvement in the availability of healthcare and the price of healthcare if more physicians adopted systems that streamlined their own processes.

Furthermore, if pharmacies practiced more efficiently in the long term care market, the bulk of pharmaceuticals in this space would also drop substantially.

I think the focus should be on the care providers.

With regard to lunch. My single mother raised me on "poor kid" lunch tickets while she worked 3 jobs and my father didn't pay a lick of alimony or child support. I proudly pay my alimony and child support so that my 3 kids don't have to worry about it. And my ex-wife complains about it being a day or two late occasionally. She has no idea how good she has it.

The embarassment of taking the poor-kid ticket through the line was more than enough to help me make sure my kids don't have to do that.

I think it's time Americans own up, get some education and take some pride in their work. Start a business, do whatever it takes to stay off welfare. The world's a much better place when they do. This economy is full of opportunity.

Regards to all.

David H. Smith, MBA of Richmond, Va

Posted by: David Smith | November 02, 2007 at 10:23 AM