As federal officials hint at overwhelming changes in how state health programs will be funded in the future, policymakers are strategizing how to reconfigure their programs to take advantage of the promised brave new world of flexibility and realigned funding. The National Academy for State Health Policy (NASHP), the de Beaumont Foundation, and the Association of State and Territorial Health Officials recently convened a small group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from changes to the federal funding landscape.
The meeting produced a new paper, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, that charts a way forward for states interested in coordinating work and resources across programs.
“This paper is an important and much needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Ana Novais, executive director of health at the Rhode Island Department of Health. To learn more about Rhode Island’s innovative financing to advance health and health equity, read this blog.
The 2017 annual NASHP state health policy conference also addressed braiding and blending funds for improved population health. The session, presented in partnership with the de Beaumont Foundation, featured officials from Rhode Island, Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address population health and non-clinical health needs through programs such as supportive housing and nurse home visiting for low-income first-time mothers. Read more.
Presented in partnership with the de Beaumont Foundation
How long would you drive your car with its gasoline gauge on empty when it’s full of people you care about as you speed along a highway? That was the analogy used by Children’s Health Insurance Program (CHIP) and Medicaid officials during National Academy for State Health Policy’s (NASHP) annual conference held late last month.
Congress has repeatedly promised state officials that there is broad support for CHIP, and that new funds will be available soon and they should just hold on until then. However, it has been over a month since federal CHIP funding expired and it is still unclear if and when Congress will successfully pass a bill to provide more federal funding.
On Nov. 3, 2017, the House of Representatives passed H.R. 3922, a bill combining funding extensions for both CHIP and community health centers. The bill passed the House by a vote of 242-174, with most Democrats voting against it because of their opposition how to the bill is paid for. The pay-fors or off-sets in the House bill include taking money away from the Affordable Care Act’s (ACA) public health and prevention fund and increasing premiums for higher-income Medicare enrollees. Given the current partisan divide over the funding off-sets, the bill’s future remains uncertain.
In the absence of certainty over its future and funding, state officials must weigh multiple factors in making difficult decisions in the weeks ahead. As stewards of health coverage for low- to moderate-income children and pregnant women who depend on CHIP, state officials are first and foremost considering what is currently best for families and are trying to maintain this coverage for as long as possible.
Officials are actively scrutinizing their state’s CHIP finances to determine how long their current funding will last and are trying to figure out if there is any way within their already stressed budgets to extend CHIP once federal carryover and redistribution funds have been exhausted. For example, Arizona is one of the first states expected to exhaust their available federal funds and officials there are considering using money from the state’s “rainy day fund” to continue CHIP coverage. This is not an option for most, as a growing number of states are struggling to address budget shortfalls or address unexpected costs resulting from multiple natural disasters that occurred this year.
Reality is setting in as an increasing number states (MN, AZ, WA, CA, OR, UT, and DC) exhaust their available 2017 carryover allotment and receive their limited redistribution funds from the Centers for Medicare & Medicaid Services (CMS). Without federal funds, most states will need to shut down their CHIP programs and in doing so must consider state notification requirements, costs that the state will incur to close this program, and more. So, why haven’t states sent notices to families warning that the program will shut down? During NASHP’s conference, officials voiced concerns that termination notices could create unnecessary panic for families that could result in far-reaching ramifications that may take months or years to nullify.
Officials know from some states’ experience from freezing enrollment and establishing wait lists for CHIP approximately15 years ago when the block grant’s funding was not adequate that those changes can instill distrust of the program for families. Officials fear parents may disenroll their children sooner than necessary or not renew their coverage. There is also a concern that knowing a child’s coverage is limited will influence medical care decisions, particularly for longer-term treatments. And if Congress does extend federal funding for CHIP after termination notices are sent, states will need to send another notice letting families know they can re-enroll. Officials fear that not all families will re-enroll their children in CHIP if they perceive it to offer unstable coverage. And finally, there is a cost to states to develop, generate, and send notices.
Unfortunately, there are states that expect to exhaust their CHIP funds in December and January that will have no other option than to disenroll children and pregnant women from coverage. As a result, state officials’ questions about their own next steps have increased and intensified. Such questions include:
- What is more important? 1) Giving families more notice and time to plan and research other possible coverage options, which risks potential unnecessary panic or, 2) Minimize panic and only alert families when absolutely necessary?
- What kind of assistance needs to be available to families who are losing CHIP coverage so they can weigh and navigate the potential other coverage options that may be available to them? And, how to pay for that assistance considering states did not assume this would be necessary in designing their budgets and given that the Trump Administration has cut outreach funds for the Marketplaces?
- hould states handle the timing of possibly closing down CHIP programs for pregnant women given their time sensitive, ongoing needs for medical attention?
- What needs to be done to ensure children are transferred successfully from CHIP to the Marketplace so families can enroll them in Qualified Health Plans (QHPs) if they are eligible to receive subsidies? Is it possible to have a data feedback loop from the federally-facilitated marketplace to know if CHIP children are in fact enrolling in QHPs or need further assistance?
State officials are frustrated that they find themselves preparing to shut down a program that has had such success. During a NASHP conference session, state officials offered a snapshot of their unique children’s coverage programs and highlighted the impact of CHIP in their states. Comparing data points from 1997 (the year CHIP was enacted) to today, states shared statistics showing the decline in uninsured children’s rates as well as increases in their access to care, particularly for primary care. States have also made strides to integrate CHIP with other programs so families can experience a continuum of coverage that could soon be significantly disrupted.
Just because states have yet to alert families that CHIP is in jeopardy doesn’t mean officials are not feeling the pressure of their gas tanks approaching empty. States are anxious for Congress to come together as its members have done throughout the history of CHIP to find a bipartisan agreement that provides funding certainty to ensure families and pregnant women do not experience unnecessary panic or loss of coverage.
Medicaid beneficiaries often need support outside the scope of clinical health care in order to lead healthy lives, and states are uniquely poised to provide this support by addressing the social determinants of health. While states steward a variety of funding sources that address the needs of low-income populations, too often a Medicaid beneficiary must navigate a labyrinth of referrals in order to access available resources. This brief aims to bring attention to non-Medicaid funding sources that states could potentially blend or braid to address health-related social needs, and to outline a continuum of options for states seeking to coordinate funding to better serve the needs of low-income populations.