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<p class="BlueSubHead"><strong>Seems that Louisiana could do some of these things....a concept<br></strong></p><p class="BlueSubHead"><strong><br></strong></p><p class="BlueSubHead"><strong>With the fed offering 1.6 bil, for Health, we should redo the healthcare system in Louisiana. DHH Levine has made a convincing case that we need to change the way we are doing things. My understanding from DHH is their needs assessment may be helpful. Single payer; parish or regional system of care Yes we can.<br></strong></p><p class="BlueSubHead"><strong>Russell Henderson</strong></p><p class="BlueSubHead"><strong>Organizing for Louisiana<br></strong></p><p class="BlueSubHead"><strong><br></strong></p><p class="BlueSubHead"><strong><br></strong></p><p align="center"><b><font size="2" face="Arial">IMPROVING MEDICAID AS PART OF BUILDING ON THE CURRENT SYSTEM TO ACHIEVE UNIVERSAL COVERAGE<br>
</font></b><font size="1" face="Arial">by <a href="http://www.cbpp.org/staff/january-angeles.htm">January Angeles</a></font></p>
<p><font size="2" face="Arial">The U.S. health care system suffers from
a number of problems. Almost 46 million individuals were uninsured in
2007, an increase of 6 million people since 2001. Employer-based
coverage, the primary source of health insurance across the nation,
continues to erode. Costs continue to rise and bear primary
responsibility for the nation’s bleak long-term fiscal outlook. While
the United States spends more on health care than any other country, it
falls short of other industrialized nations on key dimensions of care
such as quality, access, and efficiency.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn1" name="_ftnref1" title=""><!--[if !supportFootnotes]-->[1]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">Against this backdrop, there is broad
agreement that comprehensive health care reform is essential and that
ensuring access to affordable health insurance for all Americans, while
containing costs and improving quality, is a top priority. But there
is less agreement about the appropriate path to universal coverage.
Some have suggested replacing the current mix of employer-sponsored
insurance and public programs with a universal public health insurance
system (a “single-payer” system). Others would rely heavily on the
non-group private insurance market.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn2" name="_ftnref2" title=""><!--[if !supportFootnotes]-->[2]<!--[endif]--></a> </font></p>
<p><font size="2" face="Arial">Alternatively, several leading proposals
favor building on the strengths of the current system — preserving what
works and improving the current framework of employer-sponsored
insurance and public programs in an attempt to achieve a seamless,
integrated health care system. Senator Max Baucus, Chairman of the
Senate Finance Committee, has proposed extending Medicaid to cover
everyone below a certain income level, noting that those with low
incomes are least likely to be able to afford and purchase coverage on
their own. President Obama’s health care reform proposal during the
presidential campaign would expand eligibility for Medicaid and the
Children’s Health Insurance Program (CHIP). Similarly, researchers
from the Commonwealth Fund argue that Medicaid should be one of the
“building blocks” in developing a system that provides seamless
coverage to all Americans.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn3" name="_ftnref3" title=""><!--[if !supportFootnotes]-->[3]<!--[endif]--></a> </font></p>
<p><font size="2" face="Arial">Currently, Medicaid covers many
low-income individuals but leaves many others out. It does not cover
childless adults unless they are pregnant, over the age of 65, or have
serious disabilities.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn4" name="_ftnref4" title=""><!--[if !supportFootnotes]-->[4]<!--[endif]--></a>
While it covers all children up to age six with family incomes below
133 percent of the poverty line, and all poor children aged six to 19,
the income eligibility standards for parents are much lower, leaving
many families with only partial coverage.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn5" name="_ftnref5" title=""><!--[if !supportFootnotes]-->[5]<!--[endif]--></a> </font></p>
<p><font size="2" face="Arial">In a reformed system that builds on
employer-sponsored and public programs to achieve universal coverage,
Medicaid should be expanded so that any American below a certain income
level can qualify for benefits regardless of age or disability status.
Since Medicaid provides more comprehensive and affordable coverage than
other insurance options, it is an attractive vehicle for extending
coverage to low-income Americans who cannot afford to pay premiums,
cost-sharing, or deductibles. For Medicaid to serve as a base for
expanding coverage, however, it needs to be strengthened and integrated
into a broader system of coverage. </font></p>
<p> </p>
<p><font size="2" face="Arial"><b>Expanding Medicaid an Effective Way to Cover Low-Income, Uninsured Americans</b></font></p>
<p><font size="2" face="Arial">Medicaid’s proven success at providing
comprehensive, affordable coverage to tens of millions of low-income
children, parents, seniors, and people with disabilities makes it an
excellent option for expanding coverage to a broader group of
low-income, uninsured Americans. A substantial portion of uninsured
people have characteristics that are similar to current Medicaid
beneficiaries: two-thirds of them are poor or near-poor, 10 percent
are in fair or poor health, and almost half suffer from a chronic
condition.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn6" name="_ftnref6" title=""><!--[if !supportFootnotes]-->[6]<!--[endif]--></a> Medicaid’s benefit package and cost-sharing structure are well-matched to this population’s needs.</font></p>
<p> </p>
<p align="center"><b><font size="2" face="Arial">Medicaid’s Benefits Are Suited to the Needs of Low-Income Populations</font></b></p>
<p><font size="2" face="Arial">Medicaid provides an array of services
and supports that private health insurance generally does not. Because
many Medicaid beneficiaries have disabilities or chronic health
conditions, these services are critical to maintaining and improving
their health. For example, Medicaid’s Early Periodic Screening,
Diagnostic and Treatment (EPSDT) benefit guarantees low-income children
coverage for any service needed to treat any diagnosed health condition
they have, even if it is not otherwise covered by a state’s Medicaid
program. These include, among other things, physical and speech
therapies, hearing services, and vision exams and eyeglasses. The
EPSDT benefit is more comprehensive than the comparable children’s
benefit under most private insurance plans.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn7" name="_ftnref7" title=""><!--[if !supportFootnotes]-->[7]<!--[endif]--></a>
This is especially important, since poor families whose children are
covered through Medicaid generally would not be able to afford to
purchase health care services that their children needed but their
insurance did not cover.</font></p>
<p><font size="2" face="Arial">Medicaid also provides a number of
health services not offered by private insurance that are tailored to
meet the particular needs of low-income people who have serious
disabilities, chronic illnesses, or other complex health conditions.
For beneficiaries with serious disabilities, for example, Medicaid
covers services and supports to facilitate independent living and to
help them function at the highest level possible. In contrast, private
insurance tends either to cover services such as physical therapy only
to the extent that they meet a narrow definition of medical necessity —
when a condition can actually be ameliorated and normal functioning
restored — or not to cover such services at all.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn8" name="_ftnref8" title=""><!--[if !supportFootnotes]-->[8]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">The Kaiser Commission on Medicaid and
the Uninsured has noted, “Medicaid plays a critical role in providing
health care services to people with disabilities — both filling in the
gaps in Medicare and in private health insurance and . . . offer[ing]
the broad array of services needed by people with severe disabling
conditions.”<a href="http://www.cbpp.org/2-24-09health.htm#_ftn9" name="_ftnref9" title=""><!--[if !supportFootnotes]-->[9]<!--[endif]--></a></font></p>
<p> </p>
<p align="center"><b><font size="2" face="Arial">Medicaid Improves Beneficiaries’ Health </font></b></p>
<p><font size="2" face="Arial">Almost all children in Medicaid and CHIP
have a usual source of care, i.e., a regular place where they receive
preventive care or treatment when they are sick. Having a usual source
of care generally increases the quality of care a person receives.
Children served by Medicaid and CHIP are much more likely than
uninsured children to obtain important preventive services, for
example, and they have checkups at rates similar to privately insured
children.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn10" name="_ftnref10" title=""><!--[if !supportFootnotes]-->[10]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">Better health care, in turn, contributes
to better health. Studies have shown that low-income children’s health
status improved after one year of enrollment in Medicaid or CHIP. In
California, children in poor health showed improvements both in their
health and in their ability to function socially after two years of
coverage through CHIP.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn11" name="_ftnref11" title=""><!--[if !supportFootnotes]-->[11]<!--[endif]--></a> Children with chronic illnesses showed similar kinds of improvements after enrolling in CHIP.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn12" name="_ftnref12" title=""><!--[if !supportFootnotes]-->[12]<!--[endif]--></a></font></p>
<p> </p>
<p align="center"><b><font size="2" face="Arial">Medicaid Is Affordable for Beneficiaries</font></b></p>
<p><font size="2" face="Arial">Medicaid’s premiums and cost-sharing are
well below those that private insurance plans charge. Medicaid
generally does not charge premiums and requires only small co-payments
of approximately $3 per service.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn13" name="_ftnref13" title=""><!--[if !supportFootnotes]-->[13]<!--[endif]--></a>
In contrast, many private plans charge co-payments of $15 to $25 per
office visit to primary care physicians, and $20 to $30 for specialty
care physicians within the plan network.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn14" name="_ftnref14" title=""><!--[if !supportFootnotes]-->[14]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">For low-income populations, this
protection against high out-of-pocket costs is essential. Research
shows that even modest premiums can make it difficult for low-income
people to enroll in Medicaid and keep their coverage. Higher
co-payments also tend to cause low-income individuals to use less
primary and preventive care.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn15" name="_ftnref15" title=""><!--[if !supportFootnotes]-->[15]<!--[endif]--></a>
Low-income people may not seek care they need if they are charged the
high co-payments that are typical in most private plans. This could
lead to complications that eventually require more expensive forms of
care, such as emergency room treatment or hospitalization. </font></p>
<p> </p>
<p><b><font size="2" face="Arial">A Stronger Medicaid Could Play an Essential Role in a Reformed Health System</font></b></p>
<p><font size="2" face="Arial">For Medicaid to serve effectively as the
foundation for expanding coverage to low-income Americans, however, it
needs to be strengthened as part of a comprehensive reform that builds
on the current system of private insurance and public programs. Four
particularly important steps are outlined below.</font></p>
<p align="left"> </p>
<p align="left"><b><font size="2" face="Arial">1. Modernizing Eligibility Rules and Processes </font></b></p>
<p><font size="2" face="Arial">An estimated one-quarter of all
uninsured individuals, and about three-quarters of uninsured children,
are eligible for public programs like Medicaid and CHIP but remain
unenrolled.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn16" name="_ftnref16" title=""><!--[if !supportFootnotes]-->[16]<!--[endif]--></a>
Many low-income parents are unaware that they qualify for these
programs due to complicated eligibility rules. (Some working-poor
parents mistakenly assume that these programs are not for working
families and that their earnings are too high to qualify for benefits,
for example.) In addition, administrative barriers such as burdensome
documentation and face-to-face interview requirements have sometimes
prevented eligible families from completing the eligibility process.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn17" name="_ftnref17" title=""><!--[if !supportFootnotes]-->[17]<!--[endif]--></a> </font></p>
<p><font size="2" face="Arial">Moreover, Medicaid and CHIP
beneficiaries often have difficulty retaining coverage. Many of the
beneficiaries who are “disenrolled” during the renewal period lose
coverage because of procedural problems, such as failing to renew their
eligibility within a certain timeframe or not having complete
documentation. Only a small portion of disenrollments are actually the
result of changes in eligibility. As a result, many families end up
losing coverage at renewal, subsequently reapplying for benefits, and
getting re-enrolled a few months later.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn18" name="_ftnref18" title=""><!--[if !supportFootnotes]-->[18]<!--[endif]--></a>
This “churning” unnecessarily increases administrative costs, leads to
disruptions in coverage, and adds to the ranks of the uninsured. </font></p>
<p><font size="2" face="Arial">Making Medicaid available to everyone
below a certain income threshold would go a long way toward simplifying
and increasing the effectiveness of outreach and enrollment efforts.
It would eliminate much of the uncertainty about who is eligible and
would allow all members of a family to be covered under the same
program, a particularly important reform. Research has shown that
expanding Medicaid and CHIP to cover low-income parents raises
participation rates among eligible children significantly and improves
continuity of coverage. Family coverage also increases the likelihood
that enrolled children actually receive health care services they need.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn19" name="_ftnref19" title=""><!--[if !supportFootnotes]-->[19]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">More uniform eligibility standards
should be accompanied by measures to simplify enrollment and renewal
processes. Since CHIP was established in 1997, states have made
significant strides in enrolling eligible children in both CHIP and
Medicaid; most states have eliminated the asset test and done away with
face-to-face interviews, for example. Many states, however, have not
applied these same simplification measures to parents who apply for
Medicaid. Aligning the rules and procedures for children and parents
would represent a significant first step in reducing barriers to
enrollment.</font></p>
<p><font size="2" face="Arial">More progress also is needed in other
areas. For example, fewer than half of the states provide 12 months of
“continuous eligibility” for children, which allows them to retain
coverage for a full year regardless of changes in family income or
circumstances during that period.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn20" name="_ftnref20" title=""><!--[if !supportFootnotes]-->[20]<!--[endif]--></a>
Continuous eligibility prevents disruptions in care and the negative
health consequences these disruptions can cause. In addition, by
modernizing state Medicaid eligibility systems (such as by using data
from other public programs to verify family income and other
information), states could make it easier for families to obtain
coverage.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn21" name="_ftnref21" title=""><!--[if !supportFootnotes]-->[21]<!--[endif]--></a> Measures like these would improve efficiency and decrease administrative costs. </font></p>
<p><font size="2" face="Arial">Finally, since Medicaid would only be
one component of a broader system of universal coverage, it is
important to coordinate the eligibility rules for Medicaid and other
subsidy programs so that people can easily move from one program to
another if their circumstances change. One strategy for doing so
involves using the same rules across all of the programs for counting
income and verifying eligibility. </font></p>
<p align="left"> </p>
<p align="left"><b><font size="2" face="Arial">2. Increasing Provider Payments</font></b></p>
<p><font size="2" face="Arial">Medicaid beneficiaries are more likely
than other individuals to need services because of difficult health and
social problems, but the program generally pays health care providers
at much lower rates than private insurance or Medicare.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn22" name="_ftnref22" title=""><!--[if !supportFootnotes]-->[22]<!--[endif]--></a> In addition, Medicaid provider payments are often the first to be cut when states reduce spending due to an economic downturn.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn23" name="_ftnref23" title=""><!--[if !supportFootnotes]-->[23]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">In a reformed system where Medicaid
serves as a foundation for universal coverage, it is essential that
payment rates be brought up to levels sufficient to encourage more
providers to participate in the program.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn24" name="_ftnref24" title=""><!--[if !supportFootnotes]-->[24]<!--[endif]--></a>
This is critical to ensuring access to necessary services, since in a
system of universal coverage, Medicaid will cover more people than it
does now. The Children’s Health Insurance Program Reauthorization Act
of 2009 established the Medicaid and CHIP Payment Access Commission
(MACPAC) to review policies affecting children’s access to services and
other issues affecting Medicaid and CHIP. MACPAC can be set up to
operate like the Medicare Payment Advisory Commission, an independent
entity that advises Congress on payment and related Medicare issues,
and to make recommendations on provider payment rates in Medicaid. </font></p>
<p align="left"> </p>
<p align="left"><b><font size="2" face="Arial">3. Strengthening Medicaid Financing </font></b></p>
<p><font size="2" face="Arial">Medicaid needs a reliable and adequate
source of funds if it is to serve as a base for a reformed health care
system. The financing mechanism must allow Medicaid to adapt to
changing needs and economic circumstances without putting beneficiaries
or services at risk. </font></p>
<p><font size="2" face="Arial">In a reformed health care system,
Medicaid would play a larger role in covering the uninsured. New
federal resources would be needed to ensure that states have the
capacity to cover those who enter the program as a result of
eligibility expansions and improved enrollment and renewal procedures.
States would also need financial assistance to raise payment rates for
providers. </font></p>
<p><font size="2" face="Arial">There are a number of ways to provide
additional federal support. One option is to increase the Medicaid
federal matching rate for all states to help offset costs stemming from
increased enrollment. Another is to shift more of Medicaid’s financial
responsibilities for “dual eligibles” — individuals who are eligible
for both Medicaid and Medicare — to the federal government.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn25" name="_ftnref25" title=""><!--[if !supportFootnotes]-->[25]<!--[endif]--></a></font></p>
<p><font size="2" face="Arial">In addition, to ensure that Medicaid is
stable and secure during bad economic times as well as good ones,
federal support should increase automatically during recessions. In a
recession, Medicaid enrollment increases as people lose their jobs and
job-based health coverage; at the same time, rising unemployment
shrinks state tax revenues, limiting the state’s ability to finance the
program just when it is most needed.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn26" name="_ftnref26" title=""><!--[if !supportFootnotes]-->[26]<!--[endif]--></a>
These pressures place Medicaid at risk for significant cuts,
particularly because states are required to balance their budgets each
year, even in recessions. </font></p>
<p><font size="2" face="Arial">The recent economic stimulus package
temporarily increases the percentage of state Medicaid costs that the
federal government pays, in order to help states maintain their
Medicaid programs during the current downturn. Such adjustments should
be made automatic in recessions, through the creation of a trigger that
increases federal matching rates during economic downturns, based on
changes in a combination of economic indicators at both the national
and state levels. </font></p>
<p align="left"> </p>
<p align="left"><b><font size="2" face="Arial">4. Integrating Medicaid into Broader Efforts to Improve the Quality and Efficiency of Care </font></b></p>
<p><font size="2" face="Arial">Health reform needs not only to expand
coverage; it also must address the quality and costs of health care.
It is evident that the current health care delivery system contains
inefficiencies and excesses and does not always lead to appropriate
care. Moreover, without fundamental changes in the way care is
provided, health care costs will rise to unsustainable levels.</font></p>
<p><font size="2" face="Arial">Medicaid has strong incentives to “bend
the trend” in health care spending by improving the quality and
efficiency of care. Fewer than one-quarter of all Medicaid
beneficiaries account for 70 percent of program spending; these
beneficiaries, many of whom have chronic conditions and disabilities
and require social supports to help them deal with their health or
other issues, are also the patients who would benefit most from care
and disease management programs and other efforts to improve service
delivery. <a href="http://www.cbpp.org/2-24-09health.htm#_ftn27" name="_ftnref27" title=""><!--[if !supportFootnotes]-->[27]<!--[endif]--></a>
Focusing on improving care for this segment of the Medicaid population
may allow states and the federal government ultimately to contain
costs. </font></p>
<p><font size="2" face="Arial">Medicaid should be an integral part of
broader efforts to improve the quality and efficiency of health care,
such as initiatives that promote access to appropriate care, advance
the use of information technology, and emphasize prevention and disease
management. Many states are already engaged in these activities;
Medicaid can be a leader in these efforts. For example, North
Carolina’s Medicaid program is a pioneer in implementing the “medical
home” concept: Medicaid patients in the state have a usual source of
care, and primary care physicians manage patient care on an ongoing
basis. As a result, the state has demonstrated savings by preventing
hospitalizations and reducing unnecessary care.<a href="http://www.cbpp.org/2-24-09health.htm#_ftn28" name="_ftnref28" title=""><!--[if !supportFootnotes]-->[28]<!--[endif]--></a> </font></p>
<p> </p>
<p><b><font size="2" face="Arial">Conclusion</font></b></p>
<p><font size="2" face="Arial">Medicaid plays a critical role in
providing needed and affordable health care to tens of millions of
low-income Americans, particularly those with disabilities and special
health care needs. It is difficult to imagine how a reformed system
would function without it. </font></p>
<p><font size="2" face="Arial">If Medicaid is to serve as a foundation
for a reformed health care system that builds on the existing base of
employer-sponsored insurance and public programs, it will need to be
strengthened so it can work effectively in concert with other parts of
the reformed system to ensure seamless coverage. By streamlining
Medicaid enrollment, enhancing beneficiaries’ access to providers,
putting the program on a sounder financial footing, and improving the
quality and efficiency of health care services, policymakers can help
Medicaid fulfill this essential task.</font></p>
<hr width="50%" align="left" color="#0768a9">
<p><b><font size="2" face="Arial">End Notes:</font></b></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref1" name="_ftn1" title=""><!--[if !supportFootnotes]-->[1]<!--[endif]--></a>
Karen Davis, “Closing the Quality Chasm: Opportunities and Strategies
for Moving Toward a High Performing Health System,” testimony before
the Senate Committee on Health, Education, Labor and Pensions, January
29, 2009.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref2" name="_ftn2" title=""><!--[if !supportFootnotes]-->[2]<!--[endif]--></a>
For example, some have proposed eliminating the tax exclusion for
employee health care benefits and replacing it with tax credits for
individuals to secure private health coverage on their own in the
individual health insurance market. See Nina Owcharenko, “Health Care
Tax Credits: Designing an Alternative to Employer-Based Coverage,”
Backgrounder #1895, The Heritage Foundation, November 8, 2005.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref3" name="_ftn3" title=""><!--[if !supportFootnotes]-->[3]<!--[endif]--></a>
Senator Max Baucus has proposed broadening Medicaid so it covers
everyone living below the poverty line. Researchers from The
Commonwealth Fund propose using a threshold of 150 percent of poverty.
See Max Baucus, “Call to Action: Health Reform 2009,” November 2008,
available at
http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf. See
also and Cathy Schoen, Karen Davis and Sara Collins, “Building Blocks
for Reform: Achieving Universal Coverage with Private and Public Group
Health Insurance,” Health Affairs, Vol 27, No 3, May/June 2008. </font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref4" name="_ftn4" title=""><!--[if !supportFootnotes]-->[4]<!--[endif]--></a> Some states have expanded Medicaid to cover low-income childless adults through Section 1115 waivers.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref5" name="_ftn5" title=""><!--[if !supportFootnotes]-->[5]<!--[endif]--></a>
Donna Cohen Ross and Caryn Marks, “Challenges of Providing Health
Coverage for Parents and Children in a Recession: A 50 State Update on
Eligibility Rules, Enrollment and Renewal Procedures, and Cost-Sharing
Practices in Medicaid and SCHIP in 2009,” Kaiser Commission on Medicaid
and the Uninsured, January 2009.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref6" name="_ftn6" title=""><!--[if !supportFootnotes]-->[6]<!--[endif]--></a> Henry J. Kaiser Family Foundation, “The Uninsured: A Primer, Key Facts About Americans Without Health Insurance,” October 2008.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref7" name="_ftn7" title=""><!--[if !supportFootnotes]-->[7]<!--[endif]--></a> “Comparing EPSDT and Commercial Insurance Benefits,” The Commonwealth Fund, September 2005.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref8" name="_ftn8" title=""><!--[if !supportFootnotes]-->[8]<!--[endif]--></a>
See, for example, “Comparing EPSDT and Commercial Insurance Benefits,”
The Commonwealth Fund and George Washington University, September 2005.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref9" name="_ftn9" title=""><!--[if !supportFootnotes]-->[9]<!--[endif]--></a>
Diane Rowland, “Medicaid’s Role for People with Disabilities,”
testimony before the House Energy and Commerce Committee, Kaiser
Commission on Medicaid and the Uninsured, January 16, 2008.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref10" name="_ftn10" title=""><!--[if !supportFootnotes]-->[10]<!--[endif]--></a>
Leighton Ku, Mark Lin and Matthew Broaddus, “Improving Children’s
Health: A Chartbook about the Roles of Medicaid and SCHIP,” Center on
Budget and Policy Priorities, January 2007.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref11" name="_ftn11" title=""><!--[if !supportFootnotes]-->[11]<!--[endif]--></a>
“The Healthy Families Program: Health Status Assessment (PedsQL) Final
Report,” California Managed Risk Medical Insurance Board, 2004. </font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref12" name="_ftn12" title=""><!--[if !supportFootnotes]-->[12]<!--[endif]--></a>
Amy Davidoff et al, “Effects of the State Children’s Health Insurance
Program Expansions on Children With Chronic Health Conditions,”
Pediatrics, 2005.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref13" name="_ftn13" title=""><!--[if !supportFootnotes]-->[13]<!--[endif]--></a>
The Deficit Reduction Act of 2005 gave states greater flexibility to
charge certain Medicaid populations higher premiums and cost-sharing,
as long as aggregate premiums and cost-sharing do not exceed 5 percent
of a family’s income.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref14" name="_ftn14" title=""><!--[if !supportFootnotes]-->[14]<!--[endif]--></a>
“Employer Health Benefits: 2008 Annual Survey,” Kaiser Family
Foundation and Health Research Educational Trust, September 2008. </font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref15" name="_ftn15" title=""><!--[if !supportFootnotes]-->[15]<!--[endif]--></a>
The research on cost-sharing and premiums is summarized by Julie Hudman
and Molly O’Malley, “Health Insurance Premiums and Cost-Sharing:
Findings from the Research on Low-Income Populations,” Kaiser
Commission on Medicaid and The Uninsured, March 2003.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref16" name="_ftn16" title=""><!--[if !supportFootnotes]-->[16]<!--[endif]--></a>
Kaiser Commission on Medicaid and the Uninsured, “Characteristics of
the Uninsured: Who is Eligible for Public Coverage and Who Needs Help
Affording Coverage?” February 2007.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref17" name="_ftn17" title=""><!--[if !supportFootnotes]-->[17]<!--[endif]--></a> Michael Perry and Julia Paradise, “Enrolling Children in <span lang="EN-CA">Medicaid
and SCHIP: Insights from Focus Groups with Low-Income Parents,” Kaiser
Commission on Medicaid and the Uninsured, May 2007.</span></font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref18" name="_ftn18" title=""><!--[if !supportFootnotes]-->[18]<!--[endif]--></a>
Victoria Wachino and Alice Weiss, “Maximizing Kids Enrollment in
Medicaid and SCHIP: What Works in Reaching, Enrolling, and Retaining
Eligible Children,” the Robert Wood Johnson Foundation and National
Academy for State Health Policy, February 2009.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref19" name="_ftn19" title=""><!--[if !supportFootnotes]-->[19]<!--[endif]--></a>
Leighton Ku and Matthew Broaddus, “Coverage of Parents Helps Children
Too,” Center on Budget and Policy Priorities, October 2006.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref20" name="_ftn20" title=""><!--[if !supportFootnotes]-->[20]<!--[endif]--></a> Donna Cohen Ross and Caryn Marks, op cit.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref21" name="_ftn21" title=""><!--[if !supportFootnotes]-->[21]<!--[endif]--></a>
The new Express Lane Eligibility option under CHIP, enacted as part of
CHIP legislation that became law on February 4, will allow states to
rely on information previously collected by public agencies that
determine eligibility for other public programs, such as the school
lunch program, in order to facilitate enrollment in Medicaid and CHIP.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref22" name="_ftn22" title=""><!--[if !supportFootnotes]-->[22]<!--[endif]--></a>
Will Fox and John Pickering, “Hospital and Physician Cost Shift:
Payment Level Comparison of Medicare, Medicaid, and Commercial Payers,”
Milliman, December 2008.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref23" name="_ftn23" title=""><!--[if !supportFootnotes]-->[23]<!--[endif]--></a>
Vern Smith et al., “States Respond to Fiscal Pressure: State Medicaid
Spending Growth and Cost Containment in Fiscal Years 2003 and 2004:
Results from a Fifty-State Survey,” Kaiser Commission on Medicaid and
the Uninsured, September 2003.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref24" name="_ftn24" title=""><!--[if !supportFootnotes]-->[24]<!--[endif]--></a>
Studies have shown greater Medicaid participation among physicians in
states where fee levels are higher. See Stephen Zuckerman et al.,
“Changes in Medicaid Physician Fees, 1998-2003,” Health Affairs (Web
Exclusive), June 23, 2004.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref25" name="_ftn25" title=""><!--[if !supportFootnotes]-->[25]<!--[endif]--></a>
See, for example, John Holahan and Alan Weil, “Toward Real Medicaid
Reform,” Health Affairs (Web Exclusive), February 23, 2007. </font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref26" name="_ftn26" title=""><!--[if !supportFootnotes]-->[26]<!--[endif]--></a>
A one percentage point increase in the national unemployment rate
results in 1 million new Medicaid enrollees and a 3 to 4 percent
decline in state revenues. See “Impact of Unemployment Growth on
Medicaid and SCHIP and the Number Uninsured,” Henry J. Kaiser Family
Foundation, April 2008.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref27" name="_ftn27" title=""><!--[if !supportFootnotes]-->[27]<!--[endif]--></a>
“Medicaid Enrollees and Expenditures by Enrollment Group, 2005,” Kaiser
Commission on Medicaid and the Uninsured and the Urban Institute, May
19, 2008.</font><!--[if !supportFootnotes]--><!--[endif]--></p>
<p><font size="1" face="Arial"><a href="http://www.cbpp.org/2-24-09health.htm#_ftnref28" name="_ftn28" title=""><!--[if !supportFootnotes]-->[28]<!--[endif]--></a>
Thomas Ricketts et al., “Evaluation of Community Care of North Carolina
Asthma and Diabetes Management Initiatives: January 2000 – December
2002,” The Cecil G. Sheps Center for Health Services Research, April
15, 2004.</font></p>
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