By Dennis Cooley MD,FAAP
Legislative Coordinator KAAP
Rather than concentrating on one topic in this issue I thought I would update you on a number of issues pertaining to children and pediatricians in our state. So I apologize in advance for any rambling. First, let me look at the federal level.
Now that CHIP funding has been reauthorized for another 2 years nationally, the AAP is shifting a large portion of our efforts to refunding nutrition programs. Before I launch into a discussion of this I want to remark about the CHIP funding. I read in a recent editorial in the New England Journal of Medicine where the CHIP program was described as the new SGR. I hadn’t thought of it in these terms but I think there is some real truth to the statement. I can envision every two years this refunding problem rising to the surface much as the SGR did on a yearly basis. If you are wondering why the program only received two years of funding, it all boiled down to politics. In the current political climate I think the decision to compromise and accept this short extension was correct but it does mean we will be doing it all over again in two years. And I doubt the political climate will be much better then. Will we ever have a solution to CHIP funding as finally happened with the SGR? Let’s hope we do and that it won’t take as long to occur. Now back to nutrition.
Kansas is in a unique situation of power on the national front concerning nutrition programs. This is because these programs are under the auspices of the Department of Agriculture and reauthorization for funding is due. Chairing the Senate Agriculture Committee is none other than Kansas Senator Pat Roberts. Committee hearings have already occurred and AAP President Sandy Hassick provided excellent testimony before his Committee. Some quick facts about the children of our state and how they are relying on these programs: Food insecurity in our children runs at 27.5%. We have on average 37,134 children monthly enrolled in WIC and over 340,000 children in the school lunch programs. By the way, if you are wondering about how Kansas schools are doing with the new nutrition requirements, 99% are compliant (despite the initial uproar from schools and students). This doesn’t mean there still aren’t problems but schools are complying. Finally 132,000 households in the state are in the SNAP (food stamps) program. The majority of these households have children. The next few months will be important as there are efforts to reduce funding in these programs. The bottom line is that many children in our state rely on these programs for food. It is vital that they be funded.
One final note at the federal level. There continue to be efforts to get the Senate to ratify the “Convention of Rights of the Child” treaty. The AAP hosted the annual meeting for ratification of this treaty. Currently, there are only two countries in the world that have not ratified this treaty- the US and South Sudan. While the fact that we have not ratified this may seem inconsequential in the big picture, I think it actually speaks volumes about the low priority of children that certain groups in our countries hold.
Moving on to the state. Will there ever be a time when I am not writing about a budget crisis? This has been ongoing since 2008 and it seems that it will continue for years to come. So far the state is looking at over a $400 million shortfall for the coming year. The state legislators seem unable to agree on how this should be dealt with. The legislature is going into overtime at a cost of over $40,000 a day to the taxpayers. A Topeka TV station does a daily cost update for this extension and at the time of writing this article it had already cost Kansas taxpayers well over a quarter of a million dollars. Many of the legislators who swore to not raise taxes are now looking at having to renege on those promises. Proposals to raise sales, tobacco and liquor taxes have been made. In addition there is some movement to eliminate the exemption for income taxes on owners of LLCs. How has all of this affected children? First there have been proposals to raid the KEY Fund to help eliminate the shortfall. In case you don’t remember, the KEY Fund is a trust fund set up using money from the tobacco settlement to pay for children’s programs in the state. Each year, money in excess of what was budgeted for programs by the Children’s Cabinet was to go into the trust and allowed to grow. The earnings from this were to go toward future funding of the programs. Unfortunately, the funds have never been allowed to accumulate. What money that hasn’t been used has often been swept into the general fund instead. This is the case again this year with a proposal to use $378,000 of Key Fund money to help cover the shortfall. In essence, legislators are using money that was originally designated for children to bail the state out of a financial crisis of their own making. In addition, there is movement to eliminate the Earned Income Tax Credit. Cutting this would affect 280,000 children in the state according the Kansas Action for Children.
Which now leads me to Medicaid Expansion. First, let me talk about the reduction in payments for the care of Medicaid patients, which started this January, and then how I think expansion affects this. These payment reductions have hit pediatricians hard. The practice that I am in has already seen a large loss of income four months into the year. At the federal level the AAP is fighting hard to get these payments back up to Medicare levels. But remember these payments were increased not because Congress wanted to pay pediatricians a reasonable amount for the care they provided. No, they were increased because the ACA was going to expand Medicaid to cover adults. The rates were increased so providers would provide care for these adult patients. When this section of the ACA was found unconstitutional many states, including Kansas, chose not to expand coverage. The main reason to increase payments was no longer there. Also the makeup of Congress changed. The result was reauthorization for the funding vanished. But doesn’t Congress feel it is important for children on Medicaid to continue to be seen? While at a COFGA meeting last fall we had a Congressional staffer tell us the reality. He said that Congress has no incentive to raise the rates because they know pediatricians and our family practice colleagues won’t turn children away. Remember, he told us, before the rate increases you saw the kids so why would we expect you to not do it now. Also he said don’t make threats about stopping to see Medicaid patients because Congress knows the vast majority of pediatricians won’t follow through with the threat. Wow! Was that an eye-opener. (Remember my earlier comment about the “Convention of Rights of the Child” treaty?) President Obama has included the increase in payments in his 2016 budget, but there is no assurance it will be accepted. Which leads me to Medicaid expansion. Unless this happens nationwide I don’t think we will get the rates back up to Medicare levels. In Kansas, there is movement with strong backing from the Kansas Hospital Association to expand our Medicaid program. I don’t see this occurring this year but I still hold out hope about next year. (In truth, I think that eventually all states will go along with expansion-but how long will it take?) Do I support Medicaid expansion? Most definitely. First, we know that expanding Medicaid to cover low income adults will increase the number of children who are already eligible for Medicaid but not enrolled to get coverage. Second as mentioned above I think that if we are ever to get properly paid for our services adults will have to be included in the program. There are many other reasons to support expansion as extensively detailed by a recent KHA report. I would encourage all of you to read this report and to advocate for this expansion.
One last comment on Medicaid. There is still no good outcomes data on how the changes in KanCare have fared. There is a lot of anecdotal evidence but this has been mixed and varies with each MCO. I know that pediatricians in the state have been frustrated with the program. Kansas Foundation for Medical Care has been contracted to determine the effectiveness of the program. It provided an annual report for 2013 but because of a lack of available data it wasn’t of much help. The 2014 report has been completed but is now under review of the CMS.
Finally, let me close with this item I saw in the AAP News. Tweets that are done at medical conferences from attendees may not be accurate. In a small study about half of the tweets reviewed by the speakers were considered only partially correct. This was a small study and the authors recommended much larger studies but it certainly makes us be aware of potential problems from this use of social media.
As always if I can help or answer questions in any way please feel free to contact me at firstname.lastname@example.org.