Volume 29, Issue 516 May 27, 2008 CONTENTS State News • Iowa Takes an Incremental Approach to Universal Coverage • More Churches Start Paying For Health-Care Services, Leaving States To Confront The Question: Are These Groups Insurers? • "Silver Alerts" Sound the Alarm When Certain Seniors Go Missing Highlights A Google provides online health records…Monitoring brain injuries in veterans…Treating autistic adults Graphically Speaking The number of Americans using health savings accounts has nearly doubled in the past two years with growth highest in the small group market. STATE NEWS IOWA TAKES AN INCREMENTAL APPROACH TO UNIVERSAL COVERAGE Anna Wolke When Governor Chet Culver signed a comprehensive piece of health reform legislation (HF 2539) this month, Iowa joined the growing contingent of states reaching for statewide health-care coverage. The law calls for covering all children in part by expanding SCHIP, studying methods for making health care accessible to all adults and developing recommendations for advancing health information technology. A distinctive feature of Iowa's reform is its incremental and decidedly bipartisan nature. Representative Ro Foege, who helped champion the bill in the House, commented, "It truly was a bipartisan effort, or we couldn’t have passed it. In the House [and the Senate], there were only a handful of votes against it on final passage, which says a lot for a major bill." "We spent 18 months on the consensus part of the health bill so all parties could come to the table and no ideas were viewed as being new or being sprung on the Committee on Human Resources," said Representative Linda Miller. "All groups had time to work out disagreements and find constructive approaches." The legislation lays out plans to gradually cover every uninsured child in the state, reaching universal coverage for children by 2011. The law will achieve this partly by expanding its SCHIP, hawk-i, to include children from families earning up to 300 percent of the federal poverty level. Prior to this law, eligibility levels for hawk-i were set at 200 percent of poverty. Lawmakers foresaw that they could have difficulty in expanding SCHIP to children with incomes above 250 percent of poverty, in part because of recent federal actions. The federal SCHIP law has not been reauthorized and on Aug. 17, 2007, the Centers for Medicare & Medicaid Services (CMS) sent out guidance that appears to prohibit SCHIP coverage of children with incomes above 250 percent of poverty. CMS issued a follow-up letter on May 7, 2008, meant to clarify the August 17 directive and demonstrate a willingness to work with states on the issue (see SHN #515). Congress recently included a provision in the supplemental war funding bill that would place a moratorium on the August 17 directive until April 1, 2009. The bill has passed the Senate, and the House is expected to vote on the measure this week. To deal with these obstacles, Iowa's new law stipulates that, if the federal government reauthorizes SCHIP so that it provides enough funding to cover children up to 300 percent of poverty, and if the federal government provides "authorization" to cover these kids (i.e., negates the Aug. 17 guidance), the state will begin expansion using the federal SCHIP match to expand hawk-i. "However, [in HF 2539] the legislature appropriated $25 million to expand hawk-i to 300 percent of poverty and we have instructed the SCHIP board to prepare for the expansion. We hope that the issue over the August 17 guidance is resolved by Congress but we are also prepared to proceed with state-only funds," said Senator Jack Hatch. Children between 200 and 300 percent of poverty will receive coverage under hawk-i, but will likely be subject to higher cost-sharing than lower-income beneficiaries. The law requires the hawk-i board establish premium amounts based on a sliding-scale for eligible. For uninsured children under 19 not eligible for the public assistance expansion, the Iowa law mandates that an advisory council develop a plan by December 2008 to ensure their access to affordable, private coverage. Including the Adults The reform law also paves the way to an even larger goal: providing all Iowans with access to coverage by 2013. Although the legislation does not detail how this goal will be met, it does charge two task forces with recommending affordable coverage options for uninsured adults by December 2008. A cost-sharing cap of 6 1/2 percent (as a percentage of family income) for such coverage is one guideline written into the law. Representative Foege envisions that Iowa's plan for universal coverage among adults may not be unlike the coverage provided through Iowa's SCHIP, which contracts with private insurance plans. "It's not set exactly how we are going to [cover all adults], but one possibility is making available a product for low-income people to buy to which the employer and employee could contribute, with maybe a small subsidy from the state," she said. "This is similar to what we do with the hawk-i program. It is a private insurance product, off the shelf, and parents contribute to it. We see the adult world becoming an expansion of what we do with the kids." In addition to increasing health coverage, the law extends private insurance coverage for children on their parents' plan until they reach 25 years of age, marry or move out of the state. Prior to the law, children were allowed to remain on their parents' plan if they were under the age of 18 or a full-time student. Private insurers also are barred from excluding or limiting coverage based on preexisting conditions when a consumer switches from a group plan to an individual plan. Mandate Debate One of the most contentious issues that lawmakers faced was whether or not to include a coverage mandate. According to Representative Foege, "The biggest sticking point [in the Legislature's debates] was whether or not to mandate health insurance for kids and, eventually, adults. A mandate, however, was not politically doable." The state opted instead for a voluntary effort, including provisions for aggressive outreach to promote children's coverage. The law requires that, beginning with tax returns for the 2008 tax year, taxpayers will be given the opportunity to note on their returns whether or not their children are insured. If a taxpayer indicates their child is uninsured and the family's income suggests the child might be eligible for a medical assistance program, the state will notify the family of the child's eligibility for selected programs. Iowa lawmakers borrowed this idea from the state of Maryland. In May 2008, Maryland enacted a law (H.B. 1391) that requires taxpayers to note the insurance status of their children; the state will follow up with materials on the state's SCHIP, if the family appears to be eligible. The Iowa law's enactment comes on the heels of a January 2008 report from a state legislative commission that recommended ways to reach universal coverage. H.F. 2539 serves as an important first step toward achieving the commission's goals. STATE NEWS MORE CHURCHES START PAYING FOR HEALTH-CARE SERVICES, LEAVING STATES TO CONFRONT THE QUESTION: ARE THESE GROUPS INSURERS? Matthew Gever Faith-based groups have long been active in health-care delivery, most visibly through religion-based hospitals and running community clinics. In recent years, religious groups have expanded their forays into the health-care arena, and some are now looking for ways to set up formal, quasi- insurance organizations, funded by parish members, to help other parishioners pay their medical bills. "I absolutely think it’s the wave of the future," said Representative Joe Armstrong of Tennessee. This is especially the case as more congregations combine into large mega-churches that serve thousands of parishioners. "As they grow larger they will be looking to provide some level of care to fill a gap for people who aren’t insured," said Rep. Armstrong. The rise of such organizations raises multiple important questions for states: should these groups be regulated like insurance companies, e.g., should they be required to cover all medically necessary procedures and establish sufficient reserves to ensure that all members who have had procedures have their bills paid? Or, because they are funded by voluntary donations from church members and because they do not formally enroll members, should they be excluded from state regulation as insurance companies? This question has made its way to the floor in the Sunshine State. Florida lawmakers recently passed Governor Charlie Crist's "Cover Florida Health Access Act," (SB 2534) a comprehensive health reform plan described in a previous SHN article. Inserted into the bill was an amendment that would exempt faith-based health-care programs from oversight by the state's Office of Insurance Regulation if the group qualifies under federal guidelines as a non-profit religious organization. "We set up a new category in our statutes that says if you're a religious organization that pools your interest and pools your money together then the state will leave you alone," said Representative Aaron Bean. The amendment allows faith-based groups to establish rules for behavior among its participants, stipulating that the group must make clear in writing that it is not an insurance company. The groups' members vote on what qualifies for membership and payment while a board of directors oversees administration. Groups such as Medi-Share, a Christian-based health program pools money and shares medical costs among its members, who must also be active in a church. Members who want to participate send monthly dues to the company, which then creates an account for each family.