[Senate Hearing 113-638]
[From the U.S. Government Publishing Office]
S. Hrg. 113-638
THE CHILDREN'S HEALTH INSURANCE PROGRAM:
PROTECTING AMERICA'S CHILDREN AND FAMILIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH CARE
of the
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 16, 2014
__________
Printed for the use of the Committee on Finance
______
U.S. GOVERNMENT PUBLISHING OFFICE
94-479 PDF WASHINGTON : 2015
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COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
JOHN D. ROCKEFELLER IV, West ORRIN G. HATCH, Utah
Virginia CHUCK GRASSLEY, Iowa
CHARLES E. SCHUMER, New York MIKE CRAPO, Idaho
DEBBIE STABENOW, Michigan PAT ROBERTS, Kansas
MARIA CANTWELL, Washington MICHAEL B. ENZI, Wyoming
BILL NELSON, Florida JOHN CORNYN, Texas
ROBERT MENENDEZ, New Jersey JOHN THUNE, South Dakota
THOMAS R. CARPER, Delaware RICHARD BURR, North Carolina
BENJAMIN L. CARDIN, Maryland JOHNNY ISAKSON, Georgia
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania
MARK R. WARNER, Virginia
Joshua Sheinkman, Staff Director
Chris Campbell, Republican Staff Director
______
Subcommittee on Health Care
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
DEBBIE STABENOW, Michigan PAT ROBERTS, Kansas
MARIA CANTWELL, Washington ORRIN G. HATCH, Utah
BILL NELSON, Florida CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey MICHAEL B. ENZI, Wyoming
THOMAS R. CARPER, Delaware JOHN CORNYN, Texas
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
ROBERT P. CASEY, Jr., Pennsylvania PATRICK J. TOOMEY, Pennsylvania
(ii)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Rockefeller, Hon. John D., IV, a U.S. Senator from West Virginia,
chairman, Subcommittee on Health Care, Committee on Finance.... 1
Enzi, Hon. Michael B., a U.S. Senator from Wyoming............... 4
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 5
Brown, Hon. Sherrod, a U.S. Senator from Ohio.................... 6
Casey, Hon. Robert P., Jr., a U.S. Senator from Pennsylvania..... 7
Schumer, Hon. Charles E., a U.S. Senator from New York........... 7
Menendez, Hon. Robert, a U.S. Senator from New Jersey............ 8
Bennet, Hon. Michael F., a U.S. Senator from Colorado............ 9
Portman, Hon. Rob, a U.S. Senator from Ohio...................... 9
WITNESSES
Lesley, Bruce D., president, First Focus, Washington, DC......... 9
Perrin, James M., M.D., FAAP, president, American Academy of
Pediatrics, Elk Grove Village, IL.............................. 12
Caldwell, Cathy, Director, Bureau of Children's Health Insurance,
Alabama Department of Public Health, Montgomery, AL............ 14
Holtz-Eakin, Douglas, Ph.D., president, American Action Forum,
Washington, DC................................................. 15
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bennet, Hon. Michael F.:
Opening statement............................................ 9
Brown, Hon. Sherrod:
Opening statement............................................ 6
Caldwell, Cathy:
Testimony.................................................... 14
Prepared statement........................................... 35
Responses to questions from subcommittee members............. 37
Casey, Hon. Robert P., Jr.:
Opening statement............................................ 7
Enzi, Hon. Michael B.:
Opening statement............................................ 4
Prepared statement........................................... 39
Holtz-Eakin, Douglas, Ph.D.:
Testimony.................................................... 15
Prepared statement........................................... 40
Lesley, Bruce D.:
Testimony.................................................... 9
Prepared statement........................................... 47
Responses to questions from subcommittee members............. 62
Menendez, Hon. Robert:
Opening statement............................................ 8
``The Way to Beat Poverty,'' by Nicholas Kristof and Sheryl
WuDunn, The New York Times, September 12, 2014............. 67
Perrin, James M., M.D., FAAP:
Testimony.................................................... 12
Prepared statement........................................... 73
Responses to questions from subcommittee members............. 77
Portman, Hon. Rob:
Opening statement............................................ 9
Rockefeller, Hon. John D., IV:
Opening statement............................................ 1
Prepared statement........................................... 79
Schumer, Hon. Charles E.:
Opening statement............................................ 7
Wyden, Hon. Ron:
Opening statement............................................ 5
Communications
Academy of General Dentistry..................................... 81
Children's Hospital Association.................................. 83
National Association of Pediatric Nurse Practitioners............ 84
THE CHILDREN'S HEALTH INSURANCE
PROGRAM: PROTECTING AMERICA'S CHILDREN AND FAMILIES
----------
TUESDAY, SEPTEMBER 16, 2014
U.S. Senate,
Subcommittee on Health Care,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 2:54 p.m.,
in room SD-215, Dirksen Senate Office Building, Hon. John D.
Rockefeller IV (chairman of the subcommittee) presiding.
Present: Senators Wyden, Schumer, Stabenow, Menendez,
Brown, Bennet, Casey, Enzi, and Portman.
Also present: Democratic Staff: Anne Dwyer, Professional
Staff; Elizabeth Jurinka, Chief Health Advisor; and Jocelyn
Moore, Deputy Staff Director. Republican Staff: Becky Shipp,
Health Policy Advisor.
OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV, A U.S.
SENATOR FROM WEST VIRGINIA, CHAIRMAN, SUBCOMMITTEE ON HEALTH
CARE, COMMITTEE ON FINANCE
Senator Rockefeller. Good afternoon. My apologies for being
late. There was a long discussion at caucus, several votes, and
the discussions were important, actually. I will make my
opening statement. I am very grateful to Senator Enzi for being
here. He cannot stay a long time, but he is here, and that
counts.
I have been on this Finance Committee for a long time, and
I have chaired this subcommittee for a very long time. I really
do not remember ever having had a meeting of it before. The
previous chairman had a different philosophy than the present
chairman, who likes his subcommittees to be active. This, I
have to say without sentiment, will be the last Health
Subcommittee hearing that I chair. The first and the last. I
think that has a certain panache. [Laughter.] I could not think
of anything more important than doing it on the Children's
Health Insurance Program.
The year 2014 marks the 17th anniversary of one of the most
successful programs for improving children's health care in the
United States, which is the CHIP program. It is a marvel. Eight
million American children and families look to CHIP for
comprehensive and affordable health care coverage, including
40,000 children from my own State in West Virginia. I am not
sure about Wyoming and Ohio. Wyoming would have lower numbers.
Ohio would have higher numbers.
CHIP's success has played an essential role in cutting the
number of uninsured children in half over the last 14 years,
from about 14 percent to about 7 percent. That was as of 2
years ago. This kind of progress is something we should
celebrate. We must continue to invest in CHIP so that we can
celebrate many more of the program's milestones.
In 1997, Senators Kennedy and Hatch and I spent countless
hours discussing how we could increase health care access for
children in a way that members of both political parties could
support, not only to pass the program, but to sustain it, to
keep it going, which is what we are trying to do now. Creating
this program has been one of the most meaningful things I have
done in my career in public service. I just flat out say that.
If you are helping 8 million children all across the country,
how can that not be important? How can that not be important?
So, without congressional action, I say again, CHIP will
run out of funding next fall, placing at risk the well-being of
hundreds of thousands of children and pregnant women. I hope
that the members of this subcommittee will not let that happen.
It is an interesting program, because the Governors, both
Democratic and Republican, tend to like it because there is a
lot of flexibility in the way they can allocate funds and work
with the way it is carried out. So I do not think there are a
lot of Republican Governors who are against it. I do not think
there are many Democratic Governors who are against it. In this
case, since so much rests with the States, I think that is
important for our decision-making.
But, it will run out of funding next fall. CHIP is a game
changer for millions of children. No other form of coverage
provides the same level of specific and comprehensive pediatric
networks at an affordable cost for working families.
The challenges that many children face are too similar to
the ones I first saw when I was a VISTA volunteer in Emmons,
WV, nearly 150 years ago. [Laughter.] Every sight I saw there,
Chairman Wyden, has stayed with me--every sight I saw there.
Like when we went to Sago. I remember the look in your eyes as
you listened to those families. Experiences like that make for
lifetime commitments.
When I first arrived as a VISTA volunteer in Emmons, there
were children in the town and across the State who had never
seen a doctor because their families simply did not have the
money to cover the cost of a physician visit or dental care.
Dental care was out of the question. The wonderful thing about
CHIP, generally speaking, is its coverage is better than that
in the Affordable Care Act, which I do not like to say, but I
have to in order to be honest. I thought then to myself, as I
still do now, that no parent should have to carry the stresses
of knowing that you cannot afford care for your children if
something goes terribly wrong, and something goes terribly
wrong very often with children in these rural areas and poor
areas, which my State basically is.
I am proud to say that ever since CHIP's inception, the
program has consistently enjoyed strong bipartisan support. One
member of the Finance Committee, Senator Hatch, has remained a
steadfast champion of CHIP from the very beginning. We have
shared a goal of making certain that every child in America
gets a fair shot at a healthy start in life. While we have not
always agreed on every provision in the CHIP program, I have
always appreciated Senator Hatch's strong, fundamental
commitment to it.
For as long as I can recall, Congress has been able to, Mr.
Chairman----
Senator Wyden. You are Mr. Chairman.
Senator Rockefeller. I am glad you are here, very glad.
Congress has been able to put aside its differences and
come together when it was called upon to do what is right for
American children. That time has come again, otherwise we will
run out of money, and we will put the States into total
disruption if they are not able to plan. You are going to help
us understand that.
CHIP is currently at a crossroads. Funding for CHIP must be
reauthorized soon, otherwise the program as we know it will
come to an end, and as many as 2 million children could lose
their coverage. This would threaten their health and their
well-being, not to mention the significant gains that we have
made over the past 17 years to reduce the number of uninsured
children in this country. We simply cannot afford to take this
major step backwards and jeopardize the future of generations
by allowing CHIP to expire. We cannot do it. We just cannot do
it.
If it was a matter of high controversy, that would be one
thing--Republicans and Democrats clawing at each other's
eyeballs, et cetera--but that is not the case. It just is not
the case on this one. We do coalesce around children. This is a
good bill. It has helped. It has done even what the Affordable
Care Act has not been able to do.
A recent study by Wakely Consulting Group demonstrated that
moving children into other forms of private insurance would
cause a tenfold increase in out-of-pocket spending for CHIP
families who cannot afford that. We just cannot have that. It
is not right to shift the added financial burdens onto working
families when a cost-
effective solution for maintaining the coverage they already
have exists.
Although funding for CHIP expires in 2015, the program is
authorized through 2019. Now that is one of those anomalies
that we produce sometimes in Congress. It usually helps, but if
it does not, it is really bad. In other words, it is wonderful
if the program is authorized, but it does not mean much if the
money is not there. So, although the funding for CHIP expires
in 2015, the program is authorized through 2019, which
therefore could lead to significant disruption to State
governments, private health plans, hospitals, and numerous
other stakeholders, in addition to the families whose children
are enrolled in the program. States have been budgeting and
planning under the assumption that Congress would extend
funding for another 4 years. They simply are not prepared to
rapidly develop and implement plans to transition millions of
children into other forms of coverage. In short, State
legislatures and budget officials are relying on us to act now.
Colleagues, let us do our job. Let us show the American
people that we can work together, that we can do something
good. With that, I lay my case on the mercy of the
subcommittee, the full committee, and the Congress.
[The prepared statement of Senator Rockefeller appears in
the appendix.]
Senator Rockefeller. Senator Enzi?
OPENING STATEMENT OF HON. MICHAEL B. ENZI,
A U.S. SENATOR FROM WYOMING
Senator Enzi. Thank you, Mr. Chairman. I want to thank you
for holding this hearing on a very important issue in health
care. We may not always agree on every health care bill that
comes before us, but we certainly can agree that the health of
our young people is vitally important to our health as a
Nation. You have made children's health the cornerstone of your
career in the Senate, and I applaud you for your effort in
raising the profile of this issue. I hope that your last
hearing is your most productive hearing. [Laughter.]
I want to reiterate again, you mentioned that the
Children's Health Insurance Program, CHIP, has been extended
through 2019, but the funding only through September 30, 2015.
So this hearing is intended to focus on the fact that the
program funding will expire and needs extension.
We will draw attention to the administrative burden on
States and the logistics and planning that require action
sooner rather than later. I am pleased that we have such a
distinguished panel to do that. The CHIP program is a valuable
option for children who need health insurance, and I would like
us to focus more on the core mission of the program in a way
that builds on the good that many States are doing and which
serves the population that truly needs help.
Wyoming's Kid Care CHIP is an example of targeting kids who
are really in need and building a program that leverages the
best of the public and private sectors to get children who do
not have any other options the coverage that they need. That
program is doing well, partly because of the flexibility that
is allowed under this.
In 2003, Wyoming formed a public/private partnership with
Blue Cross Blue Shield of Wyoming and Delta Dental of Wyoming
to provide the health, vision, and dental benefits in Wyoming.
All children enrolled in the program will receive a wide range
of benefits including inpatient and outpatient hospital
services, lab and
x-ray services, prescription drugs, mental health and substance
abuse services, durable medical equipment, physical therapy,
dental, and vision services. The families do share in the cost
of their children's health by paying copayments for a portion
of the care that is provided.
I am hopeful that we can have a very positive dialogue
about the path forward for CHIP. I think one of the greatest
things that this program has is the flexibility. I hope that we
continue that. We need to focus our efforts here on identifying
the core mission of the program in a way that builds on the
good work that many States are doing and what serves this
population that truly needs help.
I appreciate the testimony of the people who are here. I
have read through that and am impressed, and I hope that you
will allow us to submit some questions when we cannot be here
so that we can get additional information to get this right. So
again, I thank you for holding this hearing.
Senator Rockefeller. I thank you, sir.
[The prepared statement of Senator Enzi appears in the
appendix.]
Senator Rockefeller. The chairman of the full committee,
Senator Wyden.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
Senator Wyden. Chairman Rockefeller, thank you very much
for doing this. I want to commend you and Senator Enzi for
bringing us together to talk about this important program.
Colleagues, I think it is worth noting that, at a time of
extraordinary dysfunction and polarization here in Washington,
this is a program where there is a consensus that it genuinely
helps people in need, and particularly our vulnerable children.
This is medical care. It is dental care to millions of kids
nationwide who otherwise, without CHIP, would be falling
between the cracks. In particular, it has reduced disparities
in health coverage for economically vulnerable Americans.
I just want to take a couple of minutes to note how we have
arrived at this point, because you do not see a consensus built
for an incredibly important program for vulnerable people by
osmosis. It just does not happen that way. This program has
come together because of the extraordinary leadership of
Chairman Rockefeller. We certainly had Senator Hatch all of
these years, and he was in your corner, Chairman Rockefeller,
but make no mistake about it: this has come about because a
humble person who has been relentless, relentless in his
admirable desire to stand up for those in need, said he was
going to go to bat for this program every step of the way, and
that is why this program is on the books, Chairman Rockefeller.
This is a particularly meaningful day, and we are going to have
other times, colleagues, to talk about the great contributions
of Chairman Rockefeller, what he has done to protect the
retirement security for miners. I sat next to him, have for
years, in the Intelligence Committee. None of you can know that
because that is kind of classified. [Laughter.]
He did extraordinary work on cyber-security back when I had
a full head of hair and rugged good looks and was director of
the Gray Panthers. We passed petitions, actually, for work that
Chairman Rockefeller did for seniors in terms of home health
care.
We take a few minutes today to recognize what he has done
for those who are vulnerable, and that legacy is going to
continue. That legacy is going to continue in the days and
years ahead, that legacy of grace, tenacity, and particularly
making sure that, every time debates are conducted here in the
Finance Committee and in Washington, DC, those without power,
those without clout, those without political action committees,
have a big voice. That is what Chairman Rockefeller's legacy is
all about, standing up for those people.
I am going to have a chance to talk about other aspects of
his career. I am particularly pleased that he is the leader of
the Tall Senator's Caucus. [Laughter.] That is kind of
meaningful to me, and I want to note one other point before I
wrap up, and that is Chairman Rockefeller's selfless decision
to decline the opportunity to chair the full Finance Committee,
which allowed me to accept this position and the responsibility
that goes with it. We all understand that Chairman Rockefeller
would have been a superb chairman of the Finance Committee. I
just want you and colleagues here to know that my gratitude for
that selfless act, Chairman Rockefeller, is profound.
My goal here in the Senate Finance Committee is going to be
to try to live up to the standards that you have set during
your time in public service. Thank you.
Senator Rockefeller. That is pretty nice. [Laughter.]
Actually, I was really happy as the chairman of the
Commerce Committee. I am really happy that you are here.
Senator Brown?
OPENING STATEMENT OF HON. SHERROD BROWN,
A U.S. SENATOR FROM OHIO
Senator Brown. Thank you, Mr. Chairman. I appreciate the
chance to say a couple of words, first about you and second
about this issue which is so very important. I do not speak for
others, but I know that others agree with this, that Senator
Rockefeller has been a friend and a mentor to me. He has taught
me a great deal about translating human need into action in
what this committee has done.
I am a relatively new member of this committee. I have been
on--as has Senator Casey--for less than 2 years. I welcome the
chance to help in a leadership role to build on the legacy of
Medicaid and on CHIP that Senator Rockefeller has established
in more than 2 decades on this committee. The work he has done,
I followed that when I was in the House, saw what he did, and
then got to work up close with him.
My State's CHIP program, fortunately for us I guess, is an
extension of Medicaid. Kids will continue to receive coverage
if funding is not authorized. We also know, though, that that
means significant budget cuts. The type of cut is more cost-
shifting to the States.
One thing I think we have learned is, we cannot keep doing
that with Medicaid. We have also learned that Medicaid payment
equity expires at the end of the year. We have made some
progress in leveling the field between Medicaid and Medicare
payment. That is something we need to continue. I think there
is bipartisan support, too, for that.
Most importantly, Senator Rockefeller, thanks for making a
difference in the lives of a lot of children on the other side
of the Ohio River, on the north side, in addition to the south
side of the Ohio River. Thank you.
Senator Rockefeller. Thank you, Senator Brown. My only
regret is that West Virginia owns the Ohio River. [Laughter.]
Senator Brown. Which is actually true.
Senator Rockefeller. Yes. I built eight bridges across, but
you guys just put up about 20 cents.
Senator Brown. Right.
Senator Rockefeller. We had to carry the whole load.
Senator Brown. I just think if you have a Rockefeller and a
Brown, that Rockefeller puts up 80, Brown puts up 20.
[Laughter.]
Senator Schumer. Let us have no class warfare here,
Sherrod.
Senator Rockefeller. That is right. Logic rules.
Okay. Senator Casey?
OPENING STATEMENT OF HON. ROBERT P. CASEY, JR.,
A U.S. SENATOR FROM PENNSYLVANIA
Senator Casey. Mr. Chairman, thank you very much. I would
want to incorporate by reference much of what Chairman Wyden
said, as well as Senator Brown, in their praise of your public
service and also your work for children.
There is an old expression about being summoned to give
testimony at some point in our lives, and whenever Jay
Rockefeller has been summoned to give testimony, it was almost
in every case about kids, fighting and fighting and fighting on
their behalf and, as Senator Brown mentioned, the Children's
Health Insurance Program as well as Medicaid, two vitally
important programs.
The chairman served as Governor. I want to mention another
Governor, my father. After losing three times for that office,
on his fourth try he won, and Pennsylvania was one of the first
States to enact a Children's Health Insurance Program that
became the national model, which you led with your colleagues.
I think, Mr. Chairman, we will have longer statements for
the record about the benefits of CHIP. Let me just read you
this, then I will conclude. This is from one of the families
giving their own testimony about CHIP. ``The CHIP Program has
been great. We know that there is quality insurance, and we are
finally able to sleep at night knowing that our kids can be
seen by excellent pediatricians. I do not know what we would
have done without CHIP. Now my children can play sports and go
away to camp like other kids, and, if they get hurt, CHIP is
there for them.''
I could not, if I had an hour, say it better than that.
That testimony is evidence of the benefit of the program, but
also I think it is proof positive of your achievements in
public service, especially for our kids.
Thank you very much.
Senator Rockefeller. Thank you, Senator Casey. Senator
Portman was here, and I am glad he was, because he is for this.
And now, Senator Schumer, if you can overcome your shyness,
sir, you are on.
OPENING STATEMENT OF HON. CHARLES E. SCHUMER,
A U.S. SENATOR FROM NEW YORK
Senator Schumer. Unaccustomed as I am to public speaking--
--[Laughter.]
We could use a lot of nice adjectives for our dear friend
Jay, whom we are so sorely going to miss. But let me just read
you one sentence that would be greater testimony to him from my
State of New York than all of the adjectives in the world.
When CHIP was enacted, New York had over 800,000 uninsured
children. Today that number has decreased by 90 percent--what a
legacy--all because of one person, Jay Rockefeller. His
passion, his strength, and his caring have just been amazing.
They have been an inspiration, I think, to many of us here in
the Senate. Whether we had to fight the fights on the health
care bill or in the CHIP program or throughout the
appropriations process, there was no voice that was stronger or
more effective than Jay Rockefeller's on behalf of kids and all
of the voiceless in this country.
Just on a more serious note, as Sherrod was saying, that
somebody who came from a background of plenty could care so
much for the people who had nothing and then accomplish so
much, is still a testament to the greatness of America. So
anyone who doubts the future of this country, look at the
biography and accomplishments of Jay Rockefeller, and you will
feel really good about the United States of America and about
him. Thank you.
Senator Rockefeller. I am getting confused here. I am not
going to break out into tears because I do not do that, but I
really thought this was a hearing about CHIP. [Laughter.]
Senator Schumer. CHIP equals Rockefeller.
Senator Rockefeller. All right. If I am going to hand out
chances for punishment, I should certainly recognize Senator
Menendez.
OPENING STATEMENT OF HON. ROBERT MENENDEZ,
A U.S. SENATOR FROM NEW JERSEY
Senator Menendez. Well, thank you, Mr. Chairman. I am going
to be brief, but I hope that in your modesty you will not
continue to use humor to deflect the praise that is coming your
way.
I think that if I would sum up the lifetime of work that
you have led here in the Senate, it is as a champion of
children--children in the CHIP program, children in poverty,
children in foster care. The people and the children of West
Virginia, and for that matter, the children of the Nation
including my home State of New Jersey, are better off because
of Jay Rockefeller and his mission in life to help, as Senator
Schumer said, the most vulnerable.
Nearly a generation now of children have received the
benefits of your leadership as a result of what you have done
in CHIP. Your landmark study in 1991 opened the floodgates to a
lot of these initiatives. That is a tremendous testament. As
the only Hispanic on this committee, I want to also say that
immigrant children have benefitted as a result of your resolve
to make sure that all children are included in the benefits of
CHIP and other programs.
Jay, we have a great admiration for you. The best way we
can show that admiration is to continue that legacy as we
continue to reauthorize CHIP and these other critical programs
so that future generations of children in West Virginia and
throughout the country will continue to receive the benefits of
what you have ultimately achieved for them and for our country.
I have specific questions when we have the witnesses finish
their testimony, but I did not want to lose this opportunity to
join my colleagues in echoing their sentiments.
Senator Rockefeller. You are a kind man, and I appreciate
you. You all are.
Senator Bennet?
OPENING STATEMENT OF HON. MICHAEL F. BENNET,
A U.S. SENATOR FROM COLORADO
Senator Bennet. Thank you, Mr. Chairman. If I could, I
would like to take just one minute also to say how grateful I
am for your leadership on these issues. I came here having
spent almost 5 years of my life being Superintendent of Denver
public schools, wondering who in Washington cared about the
kids in that school district. I never had any doubt that you
did, and my time here has only reaffirmed that.
The New York Times columnist, David Brooks, wrote in a
different context not that long ago that the future has no
lobby in Washington, DC. I think that is a huge part of the
problem we have in this city, but he was not exactly right,
because the future had a huge lobby in you. I think it is
incumbent on all of us in this committee to carry on that work.
So, thank you for everything that you have done, Mr.
Chairman.
Senator Rockefeller. Thank you, Senator Bennet, very much.
Is it all right if I go to the witnesses? [Laughter.]
Senator Wyden. I think Senator Portman just joined us.
Senator Rockefeller. Senator Portman, thank you for being
here, sir.
Senator Portman. I was here earlier, Mr. Chairman, so I got
to hear your opening remarks.
Senator Rockefeller. I know. I saw you.
Senator Portman. That is what I really came for. Forget the
witnesses--no. Thank you all for being here. [Laughter.]
OPENING STATEMENT OF HON. ROB PORTMAN,
A U.S. SENATOR FROM OHIO
Senator Portman. A toast to you from our United States
Senate bottled water. I enjoyed being a colleague and a friend,
and I appreciate your willingness to spend so much of your
career focused on this issue of children's health and other
important matters, important to West Virginia and to our
country.
As you know, you are a neighbor, and so I look forward to
staying in touch and look forward to the testimony today, and
the opportunity to have this be your final hearing on a topic
that is a passion of yours and one that is incredibly important
for all of our States. Thank you, Mr. Chairman.
Senator Rockefeller. Thank you, Senator Portman. You are
kind. You are very kind.
Now we are going to turn to the witnesses. We have a very
good panel.
First, we have Mr. Bruce Lesley. Mr. Lesley is the
president of First Focus, which is a bipartisan advocacy
organization dedicated to making children and families a
priority in Federal policy. Well actually, we will just go
right to you.
STATEMENT OF BRUCE D. LESLEY, PRESIDENT,
FIRST FOCUS, WASHINGTON, DC
Mr. Lesley. Thank you, Chairman Rockefeller, Chairman
Wyden, and Senators Enzi, Brown, Casey, Menendez, Schumer,
Portman, and Bennet, for having this hearing today about the
Children's Health Insurance Program and the positive impact it
has had on the lives of millions of children across the
country. I would like to start by recognizing Chairman
Rockefeller for his lifelong achievements in championing an
array of issues that have been critically important to the
children of West Virginia and this entire country, including
his legacy with respect to CHIP.
Mr. Chairman, as you know, CHIP has been an undeniable
bipartisan success story. As those of us who worked on the
issue back in 1997 can attest, the lack of health insurance
coverage among children was a national tragedy. In fact, one in
seven of our Nation's children had no health insurance
coverage.
As the National Commission on Children--which was chaired
by Senator Rockefeller--found in 1991, perhaps no set of issues
moved members of the National Commission on Children more than
the wrenching consequences of poor health and limited access to
medical care. If this Nation is to succeed in protecting
children's health, there must be a major commitment from
families, communities, health care providers, employers, and
government to meet children's basic health needs and to ensure
that all pregnant women and children have access to health
care.
Mr. Chairman, that commitment to protecting the health of
our Nation's children was answered by Congress in your work in
a bipartisan manner with the passage of CHIP in 1997. Through
the leadership of the Senate and this committee, CHIP was
created toward the goal of dramatically cutting the number of
uninsured children in America.
On that measure, if you look at Figure 1 on page 3 of my
testimony, as those numbers indicate, CHIP has been an
incredible success story, as the uninsured rate for our
Nation's children has been cut in half--from 14 percent in 1997
to just 7 percent in 2012--while the uninsured rates for adults
during that period increased.
In addition to the fact that CHIP is a national success
story, it is also bipartisan. One of the hallmarks of CHIP has
been the willingness of leaders on both sides of the aisle--you
noted this in your work with Senators Hatch, Kennedy, Grassley,
and others on this committee--to work together to increase the
enrollment of children.
CHIP is also a public/private partnership. CHIP gives
States discretion in working with their providers and insurance
plans to set premiums, cost-sharing benefits, income
eligibility levels, and provider networks for children and
pregnant women, rather than having a one-size-fits-all Federal
standard.
CHIP is also child-focused. By definition, CHIP is child-
focused, and that has been a critical factor in its success for
children. CHIP provider networks have been built and improved
over the 17 years of its history in every single State, and
they meet specific pediatric quality standards that address the
unique development and health care needs of children.
CHIP has also been successful in reducing health
disparities. In addition to the coverage improvements, a study
published by the National Institutes of Health found that CHIP
coverage has been critically important and successful in
reducing disparities in access to care measures and quality of
care.
CHIP is also overwhelmingly popular with the American
people. In poll after poll, CHIP has remained popular with the
public. The American Viewpoint Poll this past May found that
voters support extending CHIP by a wide margin of 74 to 14
percent, and by more than a 3\1/2\ to 1 margin even among Tea
Party supporters. No matter the political, ethnic, gender, age,
or geographic breakdown, CHIP is overwhelmingly popular.
Unfortunately, CHIP's 8 million children are at risk.
Although CHIP celebrates its 17th birthday this year and has
achieved a remarkable record of success, funding for the
program expires on September 30, 2015, and there is some
urgency to addressing this issue as soon as possible, because
States are beginning their budget preparations now and are
facing uncertainty about how to handle CHIP beginning in
October 2015.
The consequences of CHIP expiring would spell disaster for
more than 8 million children. The reasons are, first, due to
what is referred to as the kid glitch in the Affordable Care
Act or ACA. It is estimated that up to 2 million children could
lose coverage entirely if CHIP were to expire. Second, as a
recent First Focus study highlights, rural children will be at
the greatest risk if CHIP expires, because children in rural
communities would disproportionately lose their health
coverage. Last, even for the children who would be able to
transition to the Affordable Care Act exchange plans or
marketplace, a report by Wakely Consulting Group found that
children in every single State would be left with fewer
benefits and far-higher cost sharing if they lost CHIP
coverage.
Therefore, we urge Congress to, first and foremost, adopt a
4-year extension of CHIP funding through 2019. This would
rightfully align the funding with the program's reauthorization
date. We urge the Congress to pass such an extension during the
lame duck session, as there is some urgency to this.
In addition, we would urge the extension of outreach and
enrollment grants, the pediatric quality standards, and Express
Lane Eligibility, which expires in March 2015, so that we
continue to make progress toward the goal of covering all
children.
In closing, I would like to, once again, thank Chairman
Rockefeller and the members of this committee for holding this
important hearing about children's health. This committee has
always provided the leadership on CHIP, and we look forward to
working with you toward its extension.
I would also like to personally recognize and thank
Chairman Rockefeller--during my time on this committee, my 12
years on the Hill, 10 years in the Senate--for his outstanding
career as a champion for our Nation's most vulnerable citizens,
its children. We appreciate all that you have done over the
years for kids. Thank you very much.
Senator Rockefeller. Thank you, sir, very, very much.
[The prepared statement of Mr. Lesley appears in the
appendix.]
Senator Rockefeller. Dr. James Perrin is a primary care
pediatrician and president of the American Academy of
Pediatrics. In addition to being a lifelong advocate for
improving children's health, he is a former professor of
pediatrics at Harvard and director of the division of
pediatrics at Massachusetts General Hospital.
We welcome you, sir.
STATEMENT OF JAMES M. PERRIN, M.D., FAAP, PRESIDENT, AMERICAN
ACADEMY OF PEDIATRICS, ELK GROVE VILLAGE, IL
Dr. Perrin. Thank you, Senator Rockefeller. I am Jim
Perrin, and I join you today on behalf of the 62,000 primary
care pediatricians, pediatric subspecialists, and pediatric
surgeons at the Academy of Pediatrics. I am in Massachusetts
and currently president of the Academy.
Let me start by thanking you and your colleagues here for
the opportunity to testify before the subcommittee regarding
the CHIP program. Strongly bipartisan in its beginning and
strongly bipartisan today, CHIP has developed into a critical
program that finances health coverage for over 8 million
children across the country and has improved three important
aspects of children's health. One is access to coverage, second
is utilization of those services, and third is the population
health of millions of children who have benefitted from this
program.
Coverage is important for a number of reasons, and I think
we know that. Uninsured children are three times more likely
than children with insurance to lack access to needed
medications and five times more likely to have an unmet need
for medical care. And a just-released report from the CDC shows
that uninsured children receive substantially lower rates of
preventative services.
We all know that children are different from adults, and
the needs of children--in the sense of their health care needs,
in the context of their developmental needs over time, the
changing manifestations of disease at different times in the
child's life, and the different response to treatments--all
require children-specific kinds of benefits. That is exactly
what the Children's Health Insurance Program has provided to
us.
Most children are healthy, so the epidemiology of pediatric
disease really does differ from that of the adult population.
Care for all children is marked by adequate immunization and
other preventative services. Pediatricians really think
prevention is a critical aspect of what we do. Nevertheless, we
also have large and increasing numbers of children with chronic
health conditions that affect their health and development and
require specific care to generate, maintain, and restore age-
appropriate functioning to maximize their potential--another
area of prevention that is incredibly important.
Children also are different because they represent the most
economically, ethnically, and racially diverse population in
the United States, with very high rates of childhood poverty.
The resulting health care disparities that relate to poverty
really increase the risk of adverse outcomes. So these
differences between children and adults require distinct and
specific services for infants, children, and adolescents that
do emphasize the preventative notion.
Now, we have not achieved coverage of these services for
every child in the United States, but we should all be proud
and thankful for the vast strides we have made since SCHIP was
established, as Bruce just reminded us. Today CHIP is critical
in helping to ensure that no child falls through the cracks and
that the vast majority of U.S. children have access to high-
quality affordable health insurance. In fact, even with
persistent poverty among children, since SCHIP's enactment in
1997, the number of uninsured children has been cut in half
while, on the other hand, the number of uninsured adults rose
significantly.
So the reauthorization in 2009 included several
improvements, such as better age-appropriate health benefits;
coverage of dental, mental health, and substance abuse services
to the same extent as medical and surgical treatments; and a
strong Federal investment for the first time ever in children's
health care quality improvement.
The Academy urges Congress to fully fund CHIP through at
least 2019, and to do so during this Congress, for a host of
reasons. Pediatricians are intimately familiar. We work closely
with our friends in Alabama, for example, with the interaction
between the Federal and State Governments related to Medicaid
and CHIP.
States, in particular, need the time to plan and to have an
understanding of what the Federal Government will do in order
to make wise budgetary decisions. Children and families need
the stability that a medical home offers, consistent rules
regarding what their insurance covers and the managed care
company with which they will interact, and the peace of mind,
which we heard about earlier, that quality, affordable health
care offers. Pediatricians need to know that they will be able
to operate their practices with a reliable payer as well, so
that they can keep the medical home open to as many publically
insured families as possible.
CHIP has made important contributions to the advancement of
health care delivery to near-poor children in recent years and
has the potential to accomplish more in the years to come. The
Academy specifically offers the following recommendations to
strengthen the CHIP program for children: first, to fully fund
the program through 2019; to expand awareness of CHIP among
eligible families (and indeed, the movement towards exchange
plans has helped enroll people in CHIP, which we are very
excited about); to facilitate enrollment in CHIP for eligible
children; to maximize comprehensive coverage and affordability
for children whose care is financed by CHIP; to enhance and
continue the very important quality measurement funding and
quality improvement funding in the CHIPRA Act; and to ensure
adequate payment for physicians who care for CHIP patients.
Children and pediatricians owe tremendous thanks to you,
Chairman Rockefeller, to Senator Hatch, Senator Wyden, Senator
Roberts, and the other Senators who are here and have been here
today, for your bipartisan leadership and working to keep CHIP
strong for children. America's pediatricians urge Congress to
support your efforts and others in Congress to continue CHIP's
success for at least 4 more years.
Thank you very much.
Senator Rockefeller. Thank you, sir, very much.
[The prepared statement of Dr. Perrin appears in the
appendix.]
Senator Rockefeller. Ms. Cathy Caldwell is the Director of
the Bureau of Children's Health Insurance in the State of
Alabama at its Department of Public Health.
You head up the CHIP program, All Kids. I think that is
what it is called. It provides coverage to about 85,000
children. I am interested in what you have to say, and I will
have follow-up questions as to the disruption in State
government and planning, generally.
We welcome you here very much.
STATEMENT OF CATHY CALDWELL, DIRECTOR, BUREAU OF CHILDREN'S
HEALTH INSURANCE, ALABAMA DEPARTMENT OF PUBLIC HEALTH,
MONTGOMERY, AL
Ms. Caldwell. Chairman Rockefeller, Chairman Wyden, Ranking
Member Roberts, Ranking Member Hatch, Senator Enzi, and
distinguished members of the committee, I thank you for
allowing me to speak.
In Alabama, more than 82,000 children are currently
enrolled in CHIP. More than 56,000 are enrolled in All Kids,
which is a separate, stand-alone program, and 26,000 enrollees
receive services through the Medicaid program. I am here to ask
you to extend CHIP funding beyond fiscal year 2015. Extension
is critically needed to continue providing quality care for our
children.
CHIP is a successful program. For example, 90 percent of
our enrollees have at least one visit with a primary-care
physician annually, and our immunization rate for 2-year-olds
exceeds 70 percent. We encourage families to seek preventive
care over emergency care, and we have seen success. For
instance, only 10 percent of our enrollees with asthma have an
asthma-related trip to the emergency room, and more than 80
percent of our enrollees with diabetes have an annual A1c test.
We provide an enhanced, child-based dental benefit, and more
than 60 percent of our enrollees receive a dental visit within
90 days of enrollment.
We also take care of very sick children. Last year alone,
we provided coverage to 33 children who have leukemia. In May,
we covered a sound processor for a cochlear implant for a 14-
year-old boy with hearing loss, allowing him to hear clearly.
In June, we enrolled a 7-year-old uninsured child hospitalized
with pneumonia, and we enrolled a 13-year-old uninsured girl
with cystic fibrosis who had not been able to buy her
medication.
These stories are not unique. We hear them every day. We
are passionate about taking care of these children who, without
CHIP, likely would be uninsured and unable to get the care they
need. Across the Nation, there are 8 million children enrolled
and depending on an extension of CHIP funding.
While some CHIP children may have access to coverage
through an employer group, the cost of dependent coverage may
be cost-
prohibitive for the family. In addition, employer-sponsored or
marketplace coverage may have higher deductibles, premiums, and
co-pays than CHIP, leaving even insured children without access
to the services and medications they need.
CHIP is a very efficient program. In Alabama, our
administrative cost is less than 6 percent of the total cost of
our program. We process 99 percent of applications within 10
days, and 90 percent of our claims are processed within 14
days, ensuring our providers are paid timely.
It is important that a decision to extend CHIP funding be
made soon. States are developing budgets for fiscal year 2016
now. States cannot make adequate plans with the uncertainty of
continued funding for CHIP. Families are relying on you to make
this decision soon. The uncertainty of CHIP continuation is
stressful for them. The uncertainty also is stressful for
employees of these programs. We may lose our very best
employees because of this uncertainty. They may seek employment
elsewhere.
Before CHIP, the un-insurance rate for children in Alabama
was 15 percent. In 2013, the un-insurance rate for Alabama was
8.2 percent. CHIP is successful. It was started to give kids
access to health insurance. There is still a need for CHIP.
Through CHIP, you have provided routine and life-saving care to
our kids.
I ask you to extend funding for the Children's Health
Insurance Program, and to do it soon.
Thank you again, chairmen, ranking members, and
distinguished members of the committee, for allowing me to
speak.
Senator Rockefeller. Thank you very, very much, Ms.
Caldwell.
[The prepared statement of Ms. Caldwell appears in the
appendix.]
Senator Rockefeller. Finally, we have Dr. Douglas Holtz-
Eakin, who is the president of the American Action Forum and is
former Director of the Congressional Budget Office, which is
fairly awesome. He is an acclaimed expert on fiscal policy
matters who has held positions at multiple conservative think
tanks and congressional fiscal commissions.
We welcome you.
STATEMENT OF DOUGLAS HOLTZ-EAKIN, Ph.D., PRESIDENT, AMERICAN
ACTION FORUM, WASHINGTON, DC
Dr. Holtz-Eakin. Thank you, Mr. Chairman, Senator Portman,
and Senator Casey. It is a privilege to be here today to talk
about this topic. I have a longer statement I have submitted
for the record.
In these opening remarks, I have three simple points, the
first of which is that inaction looks very problematic, to say
the least. The second is that the ACA has changed the landscape
and that, going forward, the CHIP program should likely be
modified to reflect that changed landscape. And three, the CHIP
Program has a lot of features which have proven to be very,
very successful and durable and should be kept in the program
as those modifications take place. Let me elaborate a little
bit on that.
There are three key aspects of the budgetary situation that
really stand out. The first has been noted: funding ends after
2015. The second is that the ACA has a requirement of a
Maintenance of Effort for States in their CHIP programs through
2019. The third is that the CBO baseline funding for the
program is only $5.7 billion for the years after 2015.
The first two of those features mean that if nothing is
done, States are going to be in significant budgetary trouble.
They have an obligation to continue the programs, and,
depending on how they have done it--as a stand-alone, Medicaid
expansion, or a partnership--they are going to face deficits of
one type or another. The third feature means that if the
Congress chooses to go forward with a program that is anything
like the size of the current one, it is going to need more
budgetary resources. So something is going to have to give, and
action will be required.
The second key point is that the ACA has really changed the
landscape. First and foremost, the exchange subsidies are now
available for those at 138 percent of the Federal poverty line,
up to 400 percent, overlapping with the traditional CHIP
eligibility. Indeed, when the ACA was first passed, I thought
we would not need a CHIP program anymore. I think many people
thought that, but it turns out that is just not true.
As has been mentioned, there is this family glitch in the
ACA where employers can satisfy their obligation under the
mandate by offering the employee coverage, but not family
coverage, and, as a result, he or she will have a family and
children who are not eligible for subsidies in the exchanges.
Our estimate at the American Action Forum is that there are
about 1.6 million children in CHIP right now who will find
themselves in that situation. There are another 645,000 who are
uninsured at the moment who will find themselves in that
situation. That is a population that CHIP traditionally has
covered and should cover going forward.
It is also true that, depending on how States have done it,
some of those who use CHIP money to expand Medicaid are going
to have insufficient funding if nothing is done. That is
another almost 500,000 children at risk. That brings a targeted
population of about 2.7 million that have a real need for a
CHIP program, despite the passage of the ACA.
The third thing I would mention is, simply, in trying to
remodel the program for the future, hold on to some things that
have been successful. The bipartisanship has been mentioned in
the past, and I want to echo that. When I was CBO Director,
working on CHIP was a relative pleasure. Very few Senators
yelled at me. [Laughter.]
It would be wonderful to see that tradition continued. It
also is a program that, in part, got that success because it
was narrowly targeted. It is not an open-ended entitlement.
Congress thought hard about who belonged in there and provided
the funds for that.
Right now, if we did the 2.7 million that I mentioned, that
would be under $6 billion a year, based on a rough estimate of
ours. Or you could continue the program in its current
incarnation, and that would be, maybe, $20 billion in 2016. So
there is a real range of funding amounts that would come out of
trying to figure out the population that the Congress wants to
cover.
And the last thing is the great success at letting the
States manage this in a flexible fashion. I think that has been
a hallmark of the CHIP program and something that both the
committee and the Congress should think about as they build a
CHIP program for the future.
In closing, just let me add my voice to those
congratulating you on an outstanding record of public service
and say it is a privilege to be here today and to answer your
questions. Thank you.
Senator Rockefeller. Thank you, sir, very, very much.
[The prepared statement of Dr. Holtz-Eakin appears in the
appendix.]
Senator Rockefeller. I am interested in the children who
still have to be reached out to, in the Alabamas and West
Virginias and Pennsylvanias and Ohios, et cetera. There are
still so many.
Let us just take Alabama. I am going to ask you a two-part
question, Ms. Caldwell. The business of outreach is often not
the question of the State, or a group of doctors, or citizen
action groups reaching out. It is getting past the parents and
getting the parents to buy into the program.
Having health insurance is a fabulous thing. So is having
an education. But you and I both know that in West Virginia and
in Alabama, with bus service often scanty for most rural areas,
parents will withhold the child going to school, saying, if you
go to school, it is not going to get you anywhere anyway, so
stay home and let us work on the garden.
In other words, that is a problem. That is a problem. It is
not something that the parents faced--they had education, they
did not have education--but, with respect to their children,
they just think differently, and they think in terms of
convenience. From their real-world perspective, getting an
education does not seem to prove that it is going to turn into
a lot of dollars.
So, one, how do you go about outreach in Alabama, or how
should we do it generally? And second, this whole question of
disruption is really hard for me. I will just put it this way:
it is a really popular program. But it was, I think, Senator
Casey, Senator Portman, the last amendment at 2 o'clock in the
morning on the--what was it?--8-day markup we had on the
Affordable Care Act. It was the last amendment, and the
presiding person at that session turned to me--I was sitting at
his side--and asked me not to bring up CHIP. I did not ask him
what his reasons were. I just said that I was not going to
follow those instructions. I was going to bring it up, and it
did pass.
We talk about bipartisanship, how people agree on things,
but then things can come up, either placement or disposition of
time, or the mood of the leadership, or whatever it is.
Politics can come into it. So you cannot always count on
something which has been bipartisan to continue to be
bipartisan. I hope we can. All I know is, I am fighting really
hard, knowing that there are people who do not want to see this
happen.
So could you address the question of outreach and also the
question of disruption and why having multiple ways of going at
the CHIP program is comforting to your Governor and to
Governors throughout the United States?
Ms. Caldwell. I would love to, and I too would like to add
my thanks for your service, particularly to the children of our
country and your great CHIP Director, Sharon Carte. She is one
of my very special colleagues and friends, and she is retiring
in the near future as well, but she has just worked so hard for
the children of West Virginia.
So, outreach--I think Alabama has some best practices
around previous outreach. We had always conducted a lot of
outreach targeted to all uninsured children in our State. The
higher percentage of those were Medicaid-eligible, as is seen
in every other State.
The bulk of the uninsured children in our country are actually
Medicaid-eligible, then a smaller proportion are CHIP-eligible.
Approximately 2\1/2\ years ago, we stopped outreach in
Alabama because of State budget problems. There just was not
sufficient State funding for us to continue the outreach we
were doing. Particularly, we could not really afford for our
program to grow at the rate it had been growing, so we stopped
outreach. Nobody was particularly happy with that. It was just
the reality of funding.
What we found through all of the years we were doing
outreach is that it is important to keep the message out there
continuously, because families find themselves in different
situations. If your children have always been privately
insured, you may tend to not pay that much attention to
Medicaid or CHIP. Then all of a sudden, there may be a job
loss, and the family needs these programs.
So we found that we needed to be out there telling families
what Medicaid was, what CHIP was, really targeting all of the
uninsured children. We have always partnered with all of our
provider groups. The Alabama chapter of the American Academy of
Pediatrics is just one of our number one partners.
So, even though the State has not conducted organized
outreach in the last few years, our community partners have
absolutely stepped up. So, in getting the word out, getting the
information out to all of our partners, we certainly have
always partnered very closely with school nurses and other
school staff. So just being everywhere and targeting all of the
uninsured children I think is great, and I certainly have hated
that we have stopped outreach in Alabama. Hopefully it will
come back before too long.
As far as the disruption, if funding is not continued for
CHIP, it is going to be a nightmare. It is going to be a
nightmare on many levels. Certainly on the State level, we are
already dealing with issues related to the uncertainty of CHIP
funding. We are preparing our 2016 budget right now. What I
have asked my staff to do is to prepare a budget assuming we
are funded and assuming the current match rate, because, as you
know, the law calls for an increase of 23 percentage points for
the Federal match rate for CHIP beginning in 2016. That would
be 100-percent Federal funding for Alabama.
That versus no continuation of funding which--I see a zero.
That is two opposite ends of the spectrum, zero funding versus
100-
percent Federal funding. So we are picking something in the
middle of the road.
That is just my guidance to my staff. Now, as far as how
the legislature will view funding the program under this
uncertainty, I think we will just have to wait and see. We have
families already getting stressed. We have staff already
getting stressed.
When we enroll a child in CHIP, we award them 12 months of
continuous coverage. So right now, within just a month, when we
award a child 12 months of coverage, we are not certain that we
can actually guarantee that 12 months of coverage because, by
that point in time, if funding has not been extended, possibly
the program may not even be in existence. Even that question
comes with a huge amount of uncertainty in that, if we knew the
program was ending September 2015, we would really need to
start ramping down, quit enrolling new kids, possibly start
disenrolling current enrollees well before that.
We cannot really do that because, if funding was extended
at the last minute, then we would be in violation of
Maintenance of Effort. The truth is, there seems to be an awful
lot of uncertainty around a State's obligation to the
Maintenance of Effort requirement even if funding is not
continued.
So those are just a few examples of why I think it would be
a nightmare, and the families and the enrolled children are
going to be the most affected by far, because just the peace
and comfort that enrollment in CHIP has given so many
families--this issue just brings about a lot of anxiety. For
many of the children who are dis-enrolled from CHIP, they may
find coverage through an employer plan or a marketplace plan,
but it is my belief that many will not, and they will go back
to being uninsured and not have access to the health services
that they need.
Senator Rockefeller. I thank you very, very much, and I
apologize to Senator Casey and to Senator Portman that I have
overrun my time.
So let us go to Senator Casey, followed by Senator Portman.
Senator Casey. Mr. Chairman, thank you very much. You have
that prerogative anytime, but I guess you have it especially
today, to go over your time.
We are grateful for the witnesses' testimony. There is a
lot to focus on, but I wanted to focus on the consequences of
inaction, the consequences of not moving forward in the
direction that we all hope. Mr. Lesley, could you walk through
that, just kind of what could happen if we do not act?
Mr. Lesley. A couple of things, I think, are important. I
think my colleague talked about some of the things that her
State faces. I would also say that--and I would emphasize Ms.
Caldwell's point on what happens to the families and the
uncertainty around that and whether the State can commit to a
12-month continuous enrollment.
There is also the issue of the States and their contracts
with providers and plans. So how does a State sign a contract
with a managed care provider, and how does a managed care
provider sign contracts with their provider networks, when
there is so much uncertainty about the future of the program,
and so much uncertainty about the funding levels, and so much
uncertainty about the Maintenance of Effort provision and what
all those things mean?
So for us, I think that, even with all the positives about
CHIP and all the issues that we found that would happen to kids
if they lose insurance, we all know--I have worked up here for
12 years--things happen in Congress, and, if we wait until next
year, you would have to look at the vehicles. Would we try to
attach it to the SGR? Would there be some sort of budget
reconciliation package? There is so much uncertainty around any
of that.
In 2007, we know we had this experience: President Bush
vetoed the Children's Health Insurance Program at one point,
and, as we went through the process, the program actually
expired. States were beginning to send out dis-enrollment
notices to families. So dis-enrollment notices went out to
families in something like more than a dozen States at some
point as funding was starting to lapse. Fortunately, Congress
stepped in at that point and did an extension. But it was a
disaster, because States were looking to fire employees,
families were freaking out because they were being told they
were about to lose their coverage, and providers did not have
any certainty.
One of the things that we know is so important about CHIP
in this whole issue of 12-month continuous coverage is that the
incentives are to make sure that the kids remain healthy. It
really disrupts that, to use Senator Rockefeller's term.
Senator Casey. I wanted to highlight the chart that you
have on page 3 of your testimony and just note it for the
record, and not by way of a question, just by way of
highlighting it. Based upon your Figure 1 on page 3, if you
start in 1997, 14 percent of the children in the country were
uninsured. As of 2012, that was cut to 7 percent, so cut in
half in that time frame. Obviously, 7 percent is still too high
in my judgment. We have work to do, but it is a substantial
achievement.
Moving to Dr. Perrin, I guess the point that you made is an
oft-repeated maxim, which is that children are not small
adults. You cannot just take a health care program and impose
that upon the life of a child and expect to get the results we
hope for.
I think what your testimony gave us in addition to
validating the program from the perspective of the American
Academy of Pediatrics--we certainly appreciate that--is a to do
list at the end of your testimony: fully funding CHIP through
at least 2019, number 1; number 2, expanding awareness; number
3, facilitating enrollment; number 4, maximizing comprehensive
coverage and affordability; number 5, enhancing the quality
measurement; and number 6, ensuring adequate payments for
physicians. So, among other things, that is critically
important. I wanted to ask you if there is anything else, any
other point you wanted to make from the vantage point of the
Academy?
Dr. Perrin. Senator Casey, thank you. As a native
Pennsylvanian, you know a lot about what is going on in CHIP in
Pennsylvania. It is an incredibly robust program, really
important to the children and families in your great State, so
I think it is really critical that we maintain it.
I talked about prevention. I really want to stress that.
Obviously we are interested in prevention of coronary artery
disease in 50-year-old people as well, but the prevention
aspect of what we do with children is so critical to what is
going on. We know so much more about the science of development
than we did even 10 years ago. We know how much more important
it is that we provide early intervention services in the health
realm, to really keep kids growing well and successfully.
We know how important it is to our future economy, frankly,
that we have a healthy workforce ready to go to work and keep
our economy robust. So that preventive aspect is really
critical, and it is one of the key aspects of the CHIP program,
also of the Medicaid program, by the way, really a critical
part of what is going on there.
I will make one other quick comment, which is, we did pass
Medicare a couple years ago, in 1965. At that time, a third of
elderly Americans lived below the poverty line. Today it is 8
percent, and it is partly because families were kept from
health-related bankruptcy.
The CHIP program does some similar things. It does not cut
our poverty rate as much as I might like for children, but it
surely keeps families able to do things to raise their kids
effectively, to be able to let them play sports safely. All
those sorts of things are really critical here and, again,
because it is a child-specific benefit that really works.
Thank you for that.
Senator Casey. Thanks, Doctor. Thanks for the plug for our
State too.
Senator Rockefeller. Senator Portman?
Senator Portman. Thank you, Mr. Chairman, and thanks to our
witnesses. You have given us some good information to be able
to prepare for the reauthorization before the end of next year.
I am just a little confused on the cost run. Probably, that
is on purpose, but when you look at it, really it is
interesting. We have a situation now where we are funding
through September 30th of next year, which will be the fiscal
year, and yet you have an authorization through 2019. Under the
Affordable Care Act, you have a Maintenance of Effort
requirement, as I understand it, through 2019, which is really
an unfunded mandate, because the funding level is at best
uncertain and there is no requirement for funding beyond
September 30th of next year.
I also think, on the ACA requirement, it does not have the
flexibility you would need, as Ms. Caldwell just talked about
in response to the chairman's question.
So, Doug, help us here. As a former Budget Director, what
is the situation here in terms of what is in the baseline? What
are the assumptions that CBO makes? Is it true that because it
is built into the baseline that, say a 2-year extension, for
instance, would actually not end up having a cost attached to
it because it is assumed that it will be extended? What is the
budget situation?
Dr. Holtz-Eakin. The CBO budget numbers reflect what I
would label a gimmick in the final passage when it was last
funded. In that year, they provided funding for 2015 that
consisted of three pieces: a lump sum of about $11 billion, one
time, and then two 6-month appropriations at a rate of $2.85
billion for the first and the second half of the year.
CBO, under its rules, when it is asked to extend a program
that has not been refunded or reauthorized, continues at the
last funding level that the Congress has authorized, so that is
$2.85 billion for 6 months, or $5.7 billion per year. That is
what is in their baseline.
That clearly will not cover the cost of the existing
program if you were to run it out for another 2 years. So the
Congress would have to come up with more resources in the
process of doing any such extension. And that is a problem for
the Congress that was created by the way this was done the last
time they passed it.
Senator Portman. You got into this a little bit earlier in
your testimony, but do you have an estimate of what that cost
increase would be, what the shortfall would be, through a 2-
year extension?
Dr. Holtz-Eakin. You are running somewhere between the $5.7
billion you have and the $20 billion you need at the Federal
level to fund the program under current law. So you have to
come up with another $14 billion a year.
Senator Portman. In terms of the ACA requirement, have you
spent any time looking at that?
Dr. Holtz-Eakin. Not in great detail. We know it exists.
The CBO, again, in its baseline, does not reflect the higher
match rate that the States are counting on, because there is no
money to pay that higher match rate, so it simply assumes it
does not happen.
Senator Portman. So it goes to a 50-percent match for most
States?
Dr. Holtz-Eakin. It just stays at the current match rate,
so they do not get the 23 percentage point bump, and it is
silent on how the States are supposed to manage that at the
other end. The cost of the program still is what it is, but
there is no money there.
I am not a legal expert. Just what you do in terms of
Maintenance of Effort when it is not funded, I think remains
uncertain at best.
Senator Portman. Yes. I see a lot of heads nodding.
[Laughter.]
Uncertainty is a concern in Ohio, I know. Every State has a
little different approach to this, but one thing we talked
about earlier was the fact that States get the opportunity to
design these programs so they work best for their children.
That flexibility, it seems to me, is the positive thing,
actually something that, under Medicaid, we could use some more
of. In States like Ohio, where we do have some good innovative
ideas, we are looking for the ability to design and administer
the program that way.
One question I would have--and I guess, Ms. Caldwell, you
would be a good person to answer this--is, could you talk a
little about the structure of CHIP as a State block grant and
how your State has used that flexibility that you have to
provide coverage that is best suited to the children of
Alabama?
Ms. Caldwell. Absolutely, and I think Alabama is a great
model. We have a separate stand-alone CHIP program administered
in the Alabama Department of Public Health. So we are even in a
separate State agency from Medicaid, but we have always worked
very, very closely with the Medicaid agency. We have a joint
application. We have always had a joint application. Certainly
with the Affordable Care Act implementation, we built a joint
eligibility system.
When decisions were made about Alabama's CHIP design, there
were some very vocal advocates who said, we would like to see a
separate stand-alone program, not an expansion of Medicaid, and
that is how it was designed. We actually deliver our CHIP
benefits through Blue Cross and Blue Shield of Alabama. So our
enrollees have access to the exact same network as almost every
privately insured individual in our State. I am not saying that
would be the best model for every State, but I am saying that
it has been a great model in Alabama.
Senator Portman. By the way--I guess this is maybe obvious
to all of our witnesses, but, in a State like Ohio, where CHIP
is part of our Medicaid program, we take a hit too. So it is
not as though, just because you have a stand-alone program, at
the end of next year you are going to be in some special
situation. All States will have to face this.
I guess if maybe one of our other witnesses could just talk
briefly--Mr. Chairman, my time has expired. I am sorry.
Senator Rockefeller. Go ahead.
Senator Portman. Could someone just talk briefly about what
impact it would have on States like Ohio where we have it as
part of our Medicaid program?
Mr. Lesley. Senator Portman, thank you. I will speak to
that issue and also your previous question too, if that is all
right.
So first of all, if CHIP expires, then you would go back to
the regular matching rate, and, because of the MOE, you would
still be covering the kids. So children would lose coverage,
and the State would be out significant financial resources. I
believe in Ohio, it would be tens of millions of dollars
annually over the course of that period of time. I know with
California it would be something like $500 million dollars, for
example. So that is a huge impact that it would have on the
States.
With respect to the costs, one of the interesting things we
know is, when Senator Rockefeller offered his amendment in the
Finance Committee to save the CHIP program, one of the things
that happened with the CBO scoring was that yes, there was a
cost because you were keeping CHIP operating, but there was a
savings because the children were not transferring into the
Affordable Care Act, for example. The costs were estimated by
CBO in the Affordable Care Act to actually be 25 percent
greater than the costs in CHIP.
As a result of that, there actually was a scored savings
for Senator Rockefeller's amendment, which then allowed for
some other improvements to the Affordable Care Act. One of the
things we know is that MACPAC asked the CBO to look at this
issue, and we understand, secondhand--I have not seen a score
on this--that, if you keep CHIP in place without the bump, it
actually saves money. With the bump, it actually costs a little
bit, but it is within $1 to $5 billion over the 4-year period.
Senator Portman. Thank you. That is very helpful.
Dr. Perrin?
Dr. Perrin. If I could just make a quick comment, Senator
Portman. You, I know, have been very supportive of the really
strong network of children's hospitals in Ohio. It is one of
the real great activities in Ohio. It is one of your stellar
parts of the State----
Senator Portman. I wish my wife were here to hear you say
that. She is very involved in one of them.
Dr. Perrin. I attended medical school in Cleveland, so I
was a part of that for a bit of that time. Seriously, it is an
incredible benefit to the State and to the children of the
State of Ohio.
Those hospitals are highly dependent on Medicaid and CHIP
funding. The ability to build the kind of extraordinary
programs you have in Cincinnati, Columbus, Youngstown, Dayton,
Cleveland, Toledo, et cetera----
Senator Portman. Akron.
Dr. Perrin. Akron, sorry. Thank you, sir. [Laughter.]
It is really quite amazing. These places would change
dramatically without CHIP. There would be cuts in staff. There
would be cuts in critical programs to take care of kids with
asthma in the State of Ohio, et cetera. There a lot of things
that are going on that would change very dramatically in your
State if this happened.
Senator Portman. Yes. That is a great point, and we are
blessed to have some of the great ones, three of the top ten in
the country as rated by at least some rating agencies,
including yours, probably.
Thank you, Mr. Chairman.
Senator Rockefeller. Thank you, Senator Portman, very much.
I remember when we got our children tested for sensitivity
to ragweed and all kinds of things. We took them out to the
University of Cincinnati. It was a wise decision. You did not
mention Cincinnati, so I thought I would. [Laughter.]
Senator Portman. Cincinnati Children's Hospital Medical
Center, number three in the country based on the latest rating.
Senator Rockefeller. Of course. Of course. [Laughter.]
Just as a follow-up to the question of funding which was
addressed, CBO actually has come out with an estimate on what
all of this would cost. It is not $20 billion; it is in the
area of zero up to $10 billion over that period of 4 years. I
only say that, not to argue with you, but simply to say that,
in this program, where everything is ``maybe, but, if,'' it is
important not to scare people. That was not your purpose, but I
just wanted to put that on the record.
To you, Dr. Perrin, the whole question of prevention and
health care for children strikes me as so vastly greater than
it would have been 10 years ago. I spent a lot of time--every
one of my 30 years I have been on the Veterans Committee--
working on the Gulf War Syndrome and post-traumatic stress
disorder. Actually, there are some remarkable experiments going
on with that which are FDA-approved, clinical trials, which
show that, by doing certain things, with 2 years of
psychotherapy, you can reduce PTSD in veterans--of course, that
takes you all the way back to Civil War veterans--by 83
percent. It does not mean it will happen. It is not an approved
protocol at this point, but it is on its way.
It is not just adults or veterans who get stressed out and
have trauma. Children have extraordinary trauma. You can see
that going on now in football. You can see that with kids being
molested, kids being beaten up. People have kids who really do
not want to have kids, so the family is in turmoil--a mother-
in-law does not agree with something, or a father-in-law. Kids
can be put down, slammed down really hard at a very early age,
and remember it for a long time.
To me, all of that enters into the world of prevention. I
remember--and this is a little heretical to say--back in 1989,
Senator Jack Danforth, who was a marvelous, marvelous Senator,
and I put out the first kind of discussion about end-of-life
care, which was immediately slammed down, but we kept bringing
it up year after year. It began to be discussed.
I think that sort of discussion is also important for
children. What is prevention? It is not just looking for
tonsillitis or whatever, giving an immunization shot. There is
a lot of psychological aspect to it. I think that this country
has opened up enormously to the whole field of mental health,
and it is much more tolerant, families are becoming more
tolerant, they are becoming more open, about talking about
their own situations on that, but much less their children's
needs on that.
I would love you to take the field of children and expand
it from when you were practicing, let us say 20 years ago, to
today's context of horrible television and all kinds of traumas
going on in all directions. In what ways are children, do you
think, more vulnerable and, therefore, more needy of the kind
of prevention that the CHIP program provides?
Dr. Perrin. Thank you, Mr. Chairman. This is a tremendously
important area for how we think as pediatricians. So we are
really committed to the notion that a number of folks are
working on about making communities places where children can
be healthy, where we have a culture of health as part of what
our communities are about, rather than a culture of abuse or a
culture of violence or a culture of danger where children are
not allowed to go outside because they may get shot, et cetera.
We really are working to change that kind of notion. That
is the kind of prevention that we really are working on. It is
really critical. We know so much more about the science of
brain development than we did 15 years ago, and we know that
those experiences you just mentioned, about being slammed down
and so forth, leave permanent scars, permanent changes in brain
architecture and neuroendocrine function of the brain, that
really stay there forever and really do limit the child's
ability to do the kinds of things that she ought to be able to
do as she grows up. So that is where we think of prevention,
and we as clinicians are increasingly working on the area of
prevention in our collaboration with our other partners in
communities to make communities a place of health.
So one of the things that is really exciting about CHIP and
Medicaid today is a return to the notion that mental health
really belongs in community health. It should not be carved out
as it was for probably 25 years, making it such that I could
not see a patient in my office with a diagnosis of attention
deficit hyperactivity disorder because that was a psychiatric
diagnosis. I certainly saw kids with that diagnosis in my
office all the time, but I was not allowed to do so under the
carve-out arrangements.
Preventative services--identifying children early,
identifying family issues early--were very difficult to do
because we carved them out of regular health. We considered
mental health not regular health. Well, we are bringing it back
in.
Senator Rockefeller. You could see it, but you could not do
anything about it.
Dr. Perrin. You could not do anything about it; right. We
are bringing that back in. Medicaid and CHIP programs across
the Nation, in so many of our States, are moving to
reintegration of mental health into primary care.
I will tell you, by the way, clinically, it is incredibly
exciting to me. It is so much fun. It is so interesting to work
with families to sort of help them understand their strengths,
not their weaknesses, to help them build on that, help them
think about how to nurture children effectively. That is where
we are going, and again, Medicaid and CHIP are moving back in
that direction and allowing us to do it. These are really
exciting times.
Senator Rockefeller. I am already over my time, and I want
to go to Senator Stabenow and, of course, the chairman.
One of the things that always disturbs me--I work a lot
with seniors, as the chairman has done for his whole life. One
of the things you see is doctors in medical school going into
geriatrics, and they are very intense, very determined on that.
When they get into the field, it does not pay as well as
some of the other specialties. That was, sort of, one of the
things that brought about that ``resource base relative to
value scale'' adjustment back in--what was it?--1989 or
something like that, where you try to get more parity between
primary care physicians and the better-paying specialties.
We found that geriatricians were wandering away from
geriatrics and going into other fields for which they were, for
the most part, trained. On the contrary is this new emphasis
and the excitement which you exhibit, and all of you exhibit,
in terms of taking care of children. And they are not little
adults, but they are getting a lot of what adults are getting,
but have no defenses against it. They just absorb it and so it,
sort of, sits in there roiling.
Are you finding that people are more attracted to being
pediatricians? Are the rolls growing on that?
Dr. Perrin. So we have been fortunate in pediatrics in
continuing to maintain a pipeline of young people excited about
this field and coming into it. I think we are, actually, still
doing all right. We are not sure why, because it never pays
well compared to all of our other areas in medicine.
Behind me is a young person from the great State of West
Virginia who is a young person training in medicine and
pediatrics together. These are people who are committed to
doing this, and that is what we still recruit. We have not seen
a drop-off in people coming into pediatrics. I am really
excited to be able to say that.
Now, you know, we still have lots of problems in financing,
paying for the kind of care we are trying to provide. Our
pediatric subspecialties are not a great pipeline right now. We
have a lot of places where we are not getting the people who
are kidney specialists, or heart specialists, or blood and guts
specialists coming into pediatrics. We need to be working on
paying them better, but the Medicaid payment increase is only
for primary care. We do not want to treat a child with cystic
fibrosis as being worth only two-thirds what a child without
cystic fibrosis is.
So we do have some issues to deal with here, but the
exciting thing is, it is an incredibly rewarding life. I can
say that personally, how wonderful it has been to be a
pediatrician in my career. We are still getting wonderfully
bright, interesting, committed, passionate people coming into
our field. It is different from geriatrics.
Senator Rockefeller. That is great.
Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman.
I am so glad I got here before the meeting was over. I
apologize, I was----
Senator Rockefeller. It was not going to be over until you
got here.
Senator Stabenow. Well, thank you. I was on the floor, as
you know, from 3 o'clock to 4 o'clock with other business. I
loved when I came into the room that you were talking about
mental health, one of the many, many reasons that we are not
letting you leave, by the way. You may think you are leaving,
but we are not letting you. Senator Wyden, our chairman, has a
room, and we are locking you in it. So we are not going to let
you leave. [Laughter.]
I really, rather than to ask a question, came specifically,
not only to say you need to reauthorize CHIP so that anywhere
from 2 million to 4.5 million children who are currently
enrolled will not lose their insurance, but also to thank you
as the father of CHIP. You are the health care father to
millions of children who would not have health care or mental
health services, would not have preventative services, without
the incredible work that you have done.
I just want to thank you for that. You have not only
touched children and families in your beloved West Virginia,
but in my beloved Michigan, and Oregon, and everywhere in
between. There are generations of adults who will live
healthier, happier lives, and parents who have gone to bed at
night not having to worry about whether or not the kids got
sick, because of your efforts. That is primarily what I wanted
to say.
I am also passionate about treating the entire person, the
child or adult, and very pleased that, with Chairman Wyden's
support, we actually have put in place the beginning of the
change here with a first-step pilot project to equalize funding
in the community for mental health and public health. I have
said over and over again, we need to treat illnesses above the
neck the same as below the neck and in a comprehensive way.
So I look forward to working with all of you on that, and
to doing everything possible to make sure that CHIP is
reauthorized. I think, most importantly today, it is an
opportunity to say ``thank you'' on behalf of tens of millions
of people in the country who are living better lives because of
Senator Jay Rockefeller. So, thank you.
Senator Rockefeller. I will allow that to stay in the
record. [Laughter.]
I want to call on the chairman and then Senator Menendez.
Senator Wyden. Thank you, Chairman Rockefeller.
Senator Stabenow's comments were, of course, spot-on. I am
now trying to figure out how we are going to enforce some of
these rules. Senator Stabenow said that Chairman Rockefeller
was going to be locked in that room nearby, and I am going to
have to discuss that with Sharon. [Laughter.]
I think at this point, Chairman Rockefeller, you have
gotten the drift about how strongly our colleagues feel about
you.
What I want to do--and today has been a hectic afternoon--
is get back to, kind of, one question which I think is pretty
key to preserving Chairman Rockefeller's legacy. It deals with
what I am sure we are going to get in this debate as it gets
fast and furious. I think we are going to get the question with
respect to, so we have the ACA, we have the Affordable Care
Act, and it expands coverage. So, if we have the Affordable
Care Act and it expands coverage, so how come we need this
other deal called CHIP?
You and Senator Menendez and everybody else here, you can
agree that Chairman Rockefeller is the best thing since night
baseball, which has been pretty clearly annunciated here. But
people might still say, so, how come we need the CHIP program?
So I want to go through something that I think really
outlines it, because it really raises the issue of what I think
people in the field have come to call the kid glitch in terms
of what might happen, and it actually is sort of a branch of
what I am concerned about with respect to health policy
generally, which we talked about during the course of the
Affordable Care Act, and that is the family glitch. When the
free choice voucher that I added to the Affordable Care Act was
eliminated, that meant we were going to have a bunch of
families falling between the cracks. There is going to be a
family glitch.
Let us talk about kids, specifically. Now, my understanding
is, for the purposes of determining if a person is eligible for
a Federal subsidy to buy health insurance, the IRS bases the
calculation off the cost of an individual, rather than a family
plan. So we are going to have some real barriers for families
who cannot afford to pay the monthly premium for a real family
plan. It is going to be more expensive.
So parents may be covered through an employer, though they
are unable to afford the cost of insuring their child as well.
We will still be in the situation where Medicaid is often not
an option, as these families often make too much to qualify,
thereby leaving the kids in that no-man's land with respect to
being uninsured, generally.
So to me, that would be a real kid glitch which would come
about, certainly if CHIP were eliminated, but even if it was
reduced substantially. You would have a lot of kids getting
hammered by this kind of kid glitch. So I thought of asking
this question of two people I have admired for quite some
time--Bruce Lesley and Doug Holtz-Eakin. We have others who are
very knowledgeable in this field as well.
Mr. Lesley and Dr. Holtz-Eakin, why don't you give me your
view about what your take is with respect to the kid glitch. Am
I missing something? What are the implications, because it sure
looks to me that, certainly if CHIP were even cut back in a
significant way, we would have a lot of kids in this no-man's
land I have been calling the kid glitch.
Mr. Lesley, Dr. Holtz-Eakin, either of you. I know Senator
Menendez has a busy schedule, but I wanted to ask that one
question.
Mr. Lesley?
Mr. Lesley. Yes, sir. Thank you very much, Chairman Wyden.
The kid glitch is absolutely a tremendous problem with
respect to the interaction between CHIP and the Affordable Care
Act. If CHIP were to expire, we estimate that somewhere in the
neighborhood of 2 million kids could lose coverage because of
exactly what you described. The family member would be deemed
to have affordable coverage, or the employee, but the dependent
coverage would not be affordable.
So, even if the family was offered coverage that was maybe
like 8 percent of their family income, they would be deemed to
have affordable coverage. The family coverage could be as high
as 30 percent of family income, which is absolutely
unaffordable. Often, we know for a fact that employee coverage
is less subsidized for family coverage, and family coverage is
2.7 times the cost of employee-only sponsored coverage.
It is a huge issue. In addition to that, I would note that
the Wakely Group report shows that, even for the kids who can
migrate and who can get subsidies, we also know, even for them,
the cost of coverage, as Chairman Rockefeller talked about
earlier, is as much as nine times more expensive in the
Affordable Care Act plans than it is in CHIP.
The cost would go up substantially in either setting. The
interesting thing to note is that CHIP has been deemed to be a
cheaper package than that in the exchange plan. So it does not
make a lot of sense that we would move kids from one to the
other and leave kids stranded, either uninsured or with more
costly out-of-pocket costs and fewer benefits for more money.
It would cost the Federal Government more money.
That whole rationale, it leads us to very strongly support
the extension of CHIP.
Senator Wyden. Dr. Holtz-Eakin, is there anything you want
to add?
Dr. Holtz-Eakin. As I emphasized in my remarks at the
outset, this is a real problem. There is no way around that.
Our numbers are a bit higher. We think if you combine the kid
glitch and those who get CHIP money devoted to Medicaid
expansions, we have 2.7 million children in this category of
risk.
The thing I would emphasize for the committee and the
Congress is, it is really not a matter of bigger or smaller.
CHIP should change. It is in a different environment. There are
other vehicles for coverage for other people, and it now
resides in an insurance landscape. This is very different than
the one in which it was created. It would be beneficial for
Congress to address the funding cliff that it faces, but also
to think about a CHIP program for the future that fits into
this landscape.
Senator Wyden. Thank you. Thank you, Mr. Chairman.
Senator Rockefeller. Thank you very much.
Senator Menendez?
Senator Menendez. Thank you, Mr. Chairman. I want to talk
about two dimensions of CHIP that I think sometimes do not get
the attention they deserve. Having heard the last answer about
the kid glitch, in my mind it is even more imperative.
Mr. Lesley, in your testimony, you mentioned something that
I do not think gets enough attention when discussing CHIP, and
that is the impact it has on reducing racial and ethnic
disparities. And then there is the success of the promotora
models of engagement. As a matter of fact, this past Sunday,
Nicholas Kristof and Sheryl WuDunn published an article in the
New York Times highlighting the benefits of early intervention
with pregnant women and newborn babies.
Mr. Chairman, I would ask unanimous consent that that
article be included in the record.
Senator Rockefeller. So ordered.
[The article appears in the appendix on p. 67.]
Senator Menendez. It highlights a substantial benefit to
children and families from early intervention and home
visitation. For example, these early intervention programs
resulted in a 79-
percent reduction in child abuse and neglect, a greater than
50-
percent reduction in arrests later in a child's life, and more
than 2 fewer years on public assistance programs. So, if you
combined those evidence-based programs, they offer nearly a $6
return for every dollar that we invest.
The article also highlights the work of the Nurse-Family
Partnership, a group that I have worked with extensively on the
Maternal, Infant, and Early Childhood Program, which provides
women and children incredibly important and successful
services.
So that is a big preface, but what I want to get from you
is, can you speak to the impact on children starting at
childhood and moving through adolescence when they have access
to services like home-visitation alongside other health care
services as well?
Mr. Lesley. Yes. Thank you, Senator Menendez. First and
foremost, I would also like to acknowledge an amendment that
you offered that was so important in all of this, which is the
Child Only Option, which really recognized that children and
families often get their coverage separate and apart from their
parents. Their parent may be a veteran and have VA care, but
the child gets coverage under Kinship Care. Their grandparents
may be on Medicare, but they need to get CHIP coverage. That
amendment has been huge, and we are really working to try to
make it work.
CHIP and Medicaid have had an enormous impact on health
disparities. I would note a National Institute of Medicine
report in my testimony that talked about some of the impact on
disparities. There are also reports from the CDC and ASPE that
talk about that.
The coverage differences have been remarkable. We have
really shrunk the disparities in coverage. I would note exactly
what you said--also noted in Dr. Perrin's testimony and a
question I answered--which is this importance of prevention.
And NFP has proven that for every dollar you spend, you save
enormous amounts of money in long-term savings. It is a medical
model where nurses go into the home, and we really believe that
it has really facilitated the combination of Medicaid and CHIP
in partnership with organizations like NFP.
Also, you mentioned the community health workers or
promotoras program. When I worked for Senator Bingaman, there
was a grant that went to a promotora program in Las Cruces, NM,
and they had a target of trying to reduce the uninsured rate. I
think the uninsured rate in Las Cruces was something around 35
percent, about a third. Literally, these two women got this
grant and went from county fair to county fair doing the
outreach that Senator Rockefeller was talking about doing--
outreach to the community. They had a target of ``x,'' and they
actually exceeded it.
The other day we were laughing, because you have 102-
percent coverage in Las Cruces now. It was enormously
successful, and, not only was it successful in getting coverage
to people, but it was also successful in helping families
navigate the system. That is another bill you have done in the
past, the Patient Navigator, which really helps people navigate
the health care system. It was huge for the people in Las
Cruces, the combination of those things working together.
Senator Menendez. I appreciate it. Part of our challenge
when we score here is that I wish we scored in ways in which we
recognize the upside, like the ratio I just described, so that
we could factor that in.
If I may, Mr. Chairman, could I ask one other question?
Senator Rockefeller. Please.
Senator Menendez. Dr. Perrin, first of all, I want to thank
you and the Academy for the work that you did with me and
Senator Enzi on the Autism Care Act earlier this year. I think
it is incredibly important.
As you know from that, the State of New Jersey has the
highest incidence of children diagnosed with an autism spectrum
disorder--one in 49 receiving a diagnosis by the age of 8,
compared to one in 68 nationally. Providing resources for
children with autism and their families is one of my top
priorities, and we are elated that the President signed the
Autism Care Act into law, which continues some critical Federal
autism programs that were set to expire and a provision that I
included in the Affordable Care Act requiring autism services
to be included as essential health benefits in all new
marketplace insurance plans.
I want to see if you can help me discuss the role that CHIP
plays in providing critical behavioral health and autism
services to children, and how that help and intervention
impacts a child in the autism spectrum disorder in terms of how
we maximize whatever their God-given ability might be, and how
it affects them as they grow up?
Dr. Perrin. Thank you, Senator Menendez, and thank you so
much for your incredible advocacy for the Autism Care Act. We
are really grateful for that. We think that is an incredibly
important act for America's children, and it is doing really
some extraordinarily important things.
I have been talking about prevention and early intervention
all afternoon. I think it is really the critical part of it. We
know in an area like autism that it is really critical that we
provide services early on, because the brain is still more
plastic in a child who is 6 months or a year old to 2 years old
than in a child who is really over the hill at age 5--not
really, of course, but still, it is really critical to identify
kids early and to get them the kind of early intervention
services.
You mentioned before, home-visitation as well. It is an
area that we have been incredibly supportive of as well, and it
is one where we are working very much to integrate and really
connect much more actively what is happening in home-visitation
and what is happening in community-based pediatrics, because we
are working with the same families. We are trying to make sure
that the communication is really going well in that context and
that we are using that opportunity, again, to build community
linkages, link families with resources, and try to help
families find the kinds of resources to let them do better.
CHIP is really very important, because the benefits in CHIP
are preventive and child-oriented benefits. Yes indeed, we
wanted the Affordable Care Act to have similar benefits in the
exchange plans, but, as we know well, as the exchange plans
have been implemented in large numbers of the States, the
benefits for children, especially in behavioral areas and
abilitative services, are not really very good.
The CHIP benefits are substantially better in those realms.
That is one of the reasons that we are really strongly
advocating for the persistence of CHIP here. We will work to
make the exchange plans better, no question about it. But right
now the benefits for children in exchange plans in general--
very much State options as you know--are not great. That is why
we are really very committed to CHIP as an important preventive
benefit for children.
Senator Menendez. I appreciate that. Thank you, Mr.
Chairman.
Senator Rockefeller. Thank you, Senator Menendez.
I have a guilt complex because I have not asked you any
questions, Mr. Lesley, but I am going to forgive myself in the
interest of everybody else in this room. [Laughter.]
All of us have asked you questions but me. So I apologize.
Let me just say, in bringing this to a conclusion, I am
struck by that number. Senator Menendez, you said one in 49 in
New Jersey, one in 68 nationally?
Senator Menendez. Yes.
Senator Rockefeller. That is stunning. It has not been
reauthorized, CHIP. It is still out there, floating. We are--
for reasons that only God could possibly understand--going into
recess again in 3 days. The reason for that is actually
something which is fairly important in public life, not
attractive to many, but important, and that is elections.
That puts terrible pressure on the lame duck session. We
are talking about dealing with everything from continuing
resolutions, all of the appropriations, what are we going to do
about ISIS, and all the rest of it, in a lame duck session
forum. That, in turn, will be shaped by whoever wins the
Senate. If we keep the Senate, if we do not keep the Senate,
that will have its affect.
That, in turn, will have its affect on how CHIP is treated
or put in priority. Lots of things are favored and wanted on a
bipartisan basis, but they do not make it because the stars and
the watches do not align properly for a discussion to be had,
for votes to be held, or somebody can hold that up and cannot
be talked out of not holding it up.
The Senate has many, many mysterious ways of protecting the
rights of the minority and others, but it can fall short in
terms of passing legislation. So I want to emphasize that CHIP
is not yet included. It is not included. It is out there still.
I think it has terrific bipartisan support, but people are so
good at picking something in it they do not like, and they do
it dramatically, and then it blows up and goes viral.
I worked very hard with Olympia Snowe to start something
called the E-Rate to provide connectivity in schools and
libraries. I am really happy that we did that, and sometimes I
am really unhappy that we did it, because that is now the
source of hacking, that is the source of bullying of children,
that is the source of all kinds of invasions of privacy, and
even shutting down whole hospital systems or power plants. It
can have a devastating effect, and often the kids who can do
this are less than 15 years old. It is the property and the
power that we have given to people for one purpose but that has
been used for other purposes.
This is not that kind of a discussion. This is simply a
matter of making sure that we get the CHIP program passed, that
we get it extended, and that we get it done in what will have
to be the lame duck session.
The lame duck session does not sound like anything, but it
is. It is a regular session. It is just that some people are
there who will not be there, myself included, in the future. I
do not want to fool around with CHIP. There just are not that
many efforts which are as broadly supported.
I have experienced so many things. Mike Enzi comes from a
big coal mining State, but it is a different kind of coal
mining State. It is, sort of, digging it out from the earth
from the top. West Virginia has underground mining, which is
not so much prevalent in Wyoming, and we had a terrible series
of explosions there. Senator Enzi came and met with the
families, with myself and a few other Senators. You could just
see it working on him and within him.
One of his colleagues on the Republican side, Senator
Isakson, was one of those who came, and he still carries in his
wallet the picture of one of the coal miners who died, which
had been given to him by one of the coal miner's children.
So who knows what it is that passes bills and does not pass
bills. An endless amount of time helps. We never have that,
because the world is in such crisis. Things are happening so
disastrously and so unhealthfully. We have to do it as best we
can.
CHIP is something we can do. CHIP is something we have to
do. I just encourage all of us to think about children, about
the problems they face, and about our responsibility to help
them navigate their way through those waters.
I thank all of you for your courtesy in coming, and I wish
all of us well on the legislation.
The hearing is adjourned.
[Whereupon, at 4:48 p.m., the hearing was concluded.]
A P P E N D I X
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