Reforming the Children's Health Insurance Program: a proposal

As a modest expansion of public health insurance coverage that followed President Clinton’s failed comprehensive 1994 reform proposal, the Children’s Health Insurance Program (CHIP, formerly known as SCHIP) has led to substantial reductions in the percentage of uninsured, low-income children since its enactment in 1997. Due to aggressive CHIP outreach efforts, the percentage of eligible children who received Medicaid coverage also increased during this time period, a phenomenon known as the “spillover effect.” Compared to uninsured children, children covered by Medicaid and CHIP are more likely to have a usual source of care and fewer unmet health needs; there is also evidence that children with public insurance coverage receive higher quality care for chronic conditions such as asthma. The CHIP Reauthorization Act of 2009 continued federal funding of this successful program through 2013 and added dental benefits.

Despite CHIP’s accomplishments, the program still struggles to meet two critical challenges: ensuring that millions of eligible low-income children actually have coverage, and sustaining funding to support coverage for all eligible children during economic downturns. Nearly 3 in 4 children who were eligible for Medicaid or CHIP in 2005 were not enrolled in either program, a problem that has been attributed to both inadequate outreach and poor retention. Parents’ confusion about CHIP income eligibility thresholds in the state of Oregon produced what one researcher called a “gray zone” of uncertain insurance coverage that was associated with more unmet care needs. In addition, adequate state financing of CHIP is less assured during times of greatest need, as state tax revenues decline when more parents are unemployed and more children become eligible for public insurance. The end of the American Recovery and Reinvestment Act-enhanced Medicaid federal matching percentage (FMAP) rates in June 2011 is likely to place increased pressure on state budgets; indeed, many states have made deep cuts to Medicaid payments, potentially reducing access to providers for children who remain in the program.

My proposal to reform CHIP to meet the above challenges consists of three related components. First, in order to stabilize CHIP funding when state tax revenues fall, I propose legislation to tie the FMAP directly to state employment rates, so that the FMAP automatically increases when unemployment rises, and decreases when unemployment falls. This proposal resembles the ARRA’s temporary addition of 6.2 points to the FMAP during the 2009 economic recession, but by acknowledging that economic conditions vary from state to state, will target extra federal funding where it is needed most.

Second, to reduce confusion about CHIP eligibility status (and increase enrollment of eligible children), I propose standardizing eligibility criteria across states at 300% of the federal poverty level. The two states that currently provide CHIP coverage above 300% of FPL would have the option to maintain this higher coverage level or to scale it back in anticipation of state health insurance exchanges providing an alternate source of health insurance for these children and their families. Finally, given evidence that much of the gap between CHIP eligibility and coverage is the result of frequent and onerous reenrollment procedures, I propose to streamline this process by requiring that states re-enroll children no more often than an annual basis. I would also require that re-enrollment occur by sending preprinted forms that parents can simply sign and return if their financial circumstances have not changed.

Although this proposal represents a significant improvement over the status quo, it faces political and practical obstacles. Adjusting the FMAP automatically to compensate for economic downturns would change CHIP from a “capped” block grant program to an entitlement program with an essentially unrestrained budget. Requiring states to standardize eligibility criteria and re-enrollment processes would shift the balance of the program from state to federal control. Conservative legislators are likely to resist increased federal spending and centralized control on ideological grounds, much as the Bush Administration blocked CHIP reauthorization in 2007. In addition, even though the best available evidence suggests that few children become ineligible for public insurance due to increases in family income from year to year, critics may raise concerns that a streamlined re-enrollment process will lead to inappropriate continuation of coverage for some children.

Overcoming these obstacles will not be easy. On the other hand, a continuation of current CHIP policy is likely to leave several million eligible children uninsured, reduce program eligibility when state revenues are low, and increasingly limit access to care for children who obtain CHIP coverage, due to reductions in provider payments. Therefore, I recommend that this reform proposal be considered so that CHIP may fulfill its promise of ensuring health care coverage and access for some of America’s most vulnerable citizens.

References:
1. Oberlander JB, Lyons B. Beyond incrementalism? SCHIP and the politics of health reform. Health Affairs 2009;28:w399-w410.
2. Dubay L, Guyer J, Mann C, Odeh M. Medicaid at the ten-year anniversary of SCHIP: looking back and moving forward. Health Affairs 2007;26:370-81.
3. Kaiser Commission on Medicaid and the Uninsured. Policy brief: the impact of Medicaid and SCHIP on low-income children’s health. Pub. No. 7645-02. February 2009.
4. Sommers BD. Why millions of children eligible for Medicaid and SCHIP are uninsured: poor retention versus poor take-up. Health Affairs 2007;26:w560-w567.
5. DeVoe JE, Ray M, Krois L, Carlson MJ. Uncertain health insurance coverage and unmet children’s health care needs. Fam Med 2010;42:121-32.
6. Herring B. The Medicaid program (lecture slides). Introduction to the U.S. Healthcare System. 2011 Summer Institute, Johns Hopkins University Bloomberg School of Public Health.
7. Kaiser Commission on Medicaid and the Uninsured. Fact sheet: enhanced Medicaid match rates expire in June 2011. Pub. No. 8205. June 2011.
8. Galewitz P. A dozen states slice Medicaid payments to doctors, hospitals. Kaiser Health News July 6, 2011.

Decoding doctor-speak: translations of common medical terms

"Mr. Smith, let's review the results of your blood tests. Your CBC, BMP, and LFTs were basically negative. You have prediabetes and a slightly elevated LDL, and since your BMI is 28, you should watch your diet and exercise more to prevent metabolic syndrome. Oh, and it's OK to keep taking an occasional NSAID with food for your idiopathic knee pain."

Huh? Although I hope I've never said anything resembling the above to a real patient, doctors routinely use so many medical terms and abbreviations that it can sometimes sound as if we're speaking gibberish. What's worse, many patients may feel pressure to simply pretend they understand what the doctor is saying. Unfortunately, that approach often leads to misunderstandings and poor health choices. A recent report in the Annals of Internal Medicine found that patients with low health literacy (the ability to read and interpret medical information) were more likely to be hospitalized, use medications inappropriately, and receive fewer recommended vaccines and screening tests. While the report only covered written materials, it stands to reason that patients also make worse health-related decisions when they don't understand medical jargon spoken in the doctor's office.

So let's demystify the terms I just used with my imaginary patient—terms family and friends told me they wished doctors would explain.

CBC: Complete Blood Count. This test contains four separate measurements. The two most important are the white blood cell (WBC) count, which is usually higher in the presence of a bacterial infection and lower in some viral infections, including HIV (the virus that causes AIDS); and the hemoglobin level, which, if low, suggests blood loss, cancer, or kidney problems.

BMP: Basic Metabolic Panel. This test includes levels of sodium, potassium, calcium, glucose (sugar), and measurements of kidney function. It is most often used to check for dehydration in illnesses that cause vomiting and diarrhea, and to monitor patients with heart failure or kidney disease.

LFTs: Liver Function Tests. Higher-than-normal levels may indicate ongoing liver damage from an infection or medicine. Doctors usually check LFTs when starting or tweaking the dose of medicines that lower cholesterol.

Negative: Doctors use this word to mean "normal." Conversely, we call abnormal test results "positive," which actually means bad news. (For example, "the chest X-ray was positive for pneumonia.")

Prediabetes: In most people, a fasting (not eating for at least 8 hours) blood sugar level should be less than 100. A person whose fasting blood sugar level is persistently above 126 has diabetes; between 100 and 126 means a person has "prediabetes," which hikes his or her future diabetes risk. Unlike diabetes, prediabetes is usually treated with diet and exercise rather than medicine.

LDL: low-density lipoprotein, better known as "bad cholesterol." The less you have in your blood, the lower your risk for heart attack or stroke. A normal level is 130 or less; people with heart disease or diabetes should have levels well below 100.

BMI: body mass index, the most widely used measure of weight relative to height. A normal BMI for an adult is between 20 and 25. Adults with BMIs between 25 and 30 are overweight, while those with BMIs over 30 are obese. Doctors may recommend that "morbidly obese" adults (a BMI over 35 or 40) consider weight-loss surgery, as lifestyle changes alone are unlikely to bring them down to a normal weight.

Metabolic syndrome: defined by the National Heart, Lung, and Blood Institute as a cluster of related risk factors that increase a person's risk for diabetes, heart disease, and stroke. These include high blood pressure, a large waistline, prediabetes, and abnormal cholesterol measurements.

NSAID: non-steroidal anti-inflammatory drug. These medicines (think over-the-counter ibuprofen, such as Advil or Motrin) treat occasional aches and pains as well as chronic arthritis. Unfortunately, long-term NSAID use can cause stomach ulcers and heart and kidney problems.

Idiopathic: Defined in the dictionary as "arising from an obscure or unknown cause," this is the term we doctors use when we can't explain what's causing a patient's symptom or condition, despite thorough examination and the usual tests.

For help decoding medical terms you may encounter, see the online glossaries at Dummies.com and Familydoctor.org. Although these resources can be useful, if you don't understand what your doctor is telling you, please ask him or her to translate in plain English. Doctors often don't realize when they're using medical jargon or just not getting their point across. Most importantly, remember that the only "dumb" question at a doctor's visit is the one you have, but don't ask.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Politics in service of public health

Below is the text of a proposed resolution that will be submitted by the District of Columbia Academy of Family Physicians to next month's Congress of Delegates of the American Academy of Family Physicians in Orlando, Florida.

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WHEREAS family physicians rely on current, unbiased sources of evidence-based guidelines to select appropriate screening tests and counseling services for their patients;

WHEREAS the primary source of evidence-based prevention guidelines for family physicians is the federally-sponsored U.S. Preventive Services Task Force (USPSTF), whose recommendation statements commonly serve as the basis for AAFP clinical policies on preventive services;

WHEREAS the delay between the USPSTF vote on a new or updated recommendation statement and publication of the final statement is usually one year or more, and in some cases as long as three years;

WHEREAS the majority of existing USPSTF recommendations have not been updated within the past 5 years, and are considered out-of-date by the National Guideline Clearinghouse;

WHEREAS outdated USPSTF recommendation statements include those on breast cancer preventive medications, screening for ovarian cancer, screening for alcohol misuse, screening for family violence, counseling to prevent tobacco use in children and adolescents, and many other topics critical to the practice of family medicine;

WHEREAS political considerations recently resulted in the cancellation of the USPSTF’s November 2010 meeting and further delays in updating recommendations on screening for prostate and cervical cancer;

WHEREAS the USPSTF has only issued three updated recommendation statements since March of 2010;

NOW, THEREFORE, BE IT

RESOLVED, that the American Academy of Family Physicians request that the USPSTF and its sponsor, the U.S. Department of Health and Human Services, completely explain the reasons for recent delays in the recommendation development process and share its plans for reducing the proportion of outdated recommendations, AND BE IT FURTHER

RESOLVED, that the American Academy of Family Physicians consider developing an independent process for updating selected preventive care guidelines that are not being updated in a timely fashion (e.g., within a 5-year time frame) by the USPSTF.