Meeting 4 Notes
February 15, 2007
Welcome to Child Health Advisory Committee Discussion Group!
Members Present: Dennis Cooley, Shannon Cotsoradis, Paul Getto, Betsy Hineman (phone), Vicki Hoffman, Gerard Lozada, Rand O'Donnell (phone), Tom Ostrander (phone), Nick Rogers, Penney Schwab, Mary Ann Shorman, Mim Wilkey
Staff Present: Linda Kenney, Connie Satzler, Paula Marmet
Guests Present: Graham Bailey, Jennifer Church, Barbara Gibson, Bobbie Graff-Hendrixon, Lori Haskett, Nichole Lambrecht, Mary Murphy, Pam Shaw, Margaret Smith, Valetta Striblin
** Legislative Updates **
*Injury*
Lori Haskett: Handed out list of injury prevention bills. Highlighted:
- Driving Force: Group put together by Kansas Department on Health and Environment, Kansas Department of Transportation, and Kansas Highway Patrol. H 2136 - primary safety belt law. Article in Topeka Capitol Journal today on this.
H 2400 & S 294 - graduated drivers' license bill. (Good bill this year.)
Interest in getting teens to buckle up,
Helmet law introduced, did not receive hearing.
Lori can email this to those on the phone.
*Expanded Newborn Screening - Linda Kenney*
Two bills
S 177 - Senator Barnett
H 2224 - Bob Bethel
They are the exact same bill. One will go through. Rocky times working out finances. In particular, hospitals concerned about absorbing cost for uninsured and underinsured newborns. Resolved - Senate side $565K to cover uninsured.
When are hearings?
Time not set yet.
*Obesity - Jennifer Church*
A lot of bills this year. Two bills on vending machines: S 170, H 2275. One on beverages, one on timing. Both had hearings this week. Neither went well. Not expected to go further. All of Child Health Advisory Committee and Governor’s Council On Fitness recommendations highlighted this year.
H 2423 - Obesity Prevention Task Force. Develop state plan to address so all moving in same direction. Has not received hearing yet.
S 171 - establishing fresh fruit and vegetable program in schools. because of cost involved, does not look good. Modeled after California and USDA? Fresh fruit and vegetable program. Pretty costly. In US Farm Bill, is discussion about 100 schools per state to have this program.
S 281 - Brand new H 2090 - basically the same bill measuring height and weight at schools on surveillance level. Collecting surveillance data only, not sent home to parents. In addition to fitness testing, Senate bill goes to establishing minimum minutes of physical education for students. Also grants program.
Beverage guidelines - weakened because guidelines weaker than national guidelines. (100% versus 50% juice). Voluntary... 2275 - having no vending during the day except water was likely too strict. Schools resisted.
Dennis Cooley: I testified for. 2 for and 5 or 6 against. Some from beverage companies testified, saying already cleaning up act. Lots of opposition from schools, mostly financial.
Where are we with 281 and 2090?
Had hearings last Tuesday, still in committee.
Right now KSDE and KDHE are working to make changes.
Today, hearing on 281 that Paula Marmet is testifying for.
Dennis Cooley: Don't recall opposition to 2090.
Some questions from schools regarding work involved. Didn't really seem to be against.
Other questions?
None.
* Immunization Registry - Nichole Lambrect*
WebIZ
Total providers - 122 (private and local health departments). 545 total users.
Gave other statistics on records and immunizations.
Testing with Kansas Medicaid program.
Will have 3 years of records.
Everyone that is one will have access to records.
*2009: Pharmacy ability to give vaccinations at the pharmacy to those of any age. (KDHE is neutral)
*2097: Pharmacy ability to give vaccination to those over age 5, also allows pharmacy interns to give, they think. (KDHE is neutral)
*2227: HPV vaccination. Dr. Rodenberg testified on this.
Had a hearing. Still in committee.
Is the intent to get more points of access?
Assume that's the intent.
Shannon Cotsoradis: Is there clarity on Governor’s budget for immunization registry, what came out of ways and means of communication?
Nichole Lambrecht will find out.
*Child Care - Mary Murphy*
Mary has copies of bills.
H 2213: Child care act - makes technical clean ups on this. Addresses renewal period on child care licensing.
Had been scheduled for hearing in Health and Human services
S 201: Criminal history & Background checks. Gives authority to do national background checks. Crucial for them to comply with Adam Walsh act of 2006. Was scheduled for hearing yesterday, still in committee.
S 202: Amend definition of child care facility. Allows pre-adoptive home. Home that has assigned placement agreement...remove them from licensure process because already court oversight, sufficient monitoring. Reduces duplication.
*Head Lice Update*
Submitted to Department of Administration. Sitting there. Took out no-nit policy
Schools, school pediatricians are happy about this!
Kids have missed a lot of school because of this.
*Your obesity recommendations will be presented to Healthy Kansans 2010 Steering Committee tomorrow.
** Health Care Coverage Panel Presentation **
* Barbara Gibson - Safety Net Clinic Perspective *
Barb reviewed handout.
State funded clinics - state responded to need seen in communities. Clinics had already started. Most are community- or faith-based. Wonderful public/private partnership.
2nd page - reviewed number of uninsured by county handout. (Counties with most uninsured.)
Gaps in counties - Butler County may be part of Wichita area, Montgomery county is working on a clinic, Cowley county is currently looking at access. Harvey and Reno counties have submitted applications to become Federally-qualified health centers.
These are truly created, unique to Kansas.
Every one is different. (Only federally-qualified clinics are close.)
Next page - highlighted counties with high percentage even though number is low. These areas have high impact, even though low number.
Last page - statistics from 2004. Of those visits, about 38,000 are children. Local community projects decide what eligibility is. Different eligibility requirements by clinic.
Three types of safety-net clinic approaches to seeing children:
1. Mission to see uninsured and those who lacked Medicaid Coverage. They believe that most kids have access to care (through Medicaid, HealthWave, etc.).
2. Others think there may be a need for Medicaid access, children in their community but they don't think they have the resources to take it on.
3. FQHCs - will see some of children that have Medicaid, HW, etc.
Have not placed any requirements on state grants. The clinics contribute $7 for every state dollar.
Are concerned about children who aren't getting children enrolled because someone in the family has immigration issues. There are also restrictions in service areas. Some will see only county residents.
Nick Rogers: Where do communities find dollars?
Barb Gibson: A big piece is volunteer professional time (e.g., retired or active physicians, dentists, PAs, etc. donating time on a rotating basis). Accept this in-kind contribution as a match. Others have worked with hospitals to have them donate diagnostics.
Sunflower Foundation, Health Ministries Fund, etc.
They have delivered cost-effectively. Think they have the heart of the legislators.
How many kids you are seeing in safety-net clinics that are S-CHIP or Medicaid eligible but haven't enrolled?
Barb Gibson: Not sure. Don't think I could make a guess.
Are safety net clinics helping to enroll?
Barb Gibson: Absolutely. In some cases have staff in clinics to help with enrollment.
Nick Rogers: How many are non-citizens?
Doesn't mean that they are undocumented, but someone in the family has an eligibility issue.
Not sure what the percentage is. The infants are born here, so there should be a seamless way to get them enrolled.
Barb Gibson: Our office also administers farmworker program. Discussed SOBRA births. Don't know mechanisms are strong enough at local level to make sure infants are enrolled.
Gerard Lozada: Does each clinic decide whether or not to serve out of county?
Barb Gibson: Yes. In some cases, depends on what volunteers what to do.
* Pam Shaw, Provider Perspective *
Work at KU, volunteer at Turner House Clinic.
Practice is primarily uninsured, HW (60%)
Problem: kids go in and out of coverage.
Dropping in and out makes it difficult.
Health-related issues we see on a day-to-day basis:
-*see handout*-
1. Uninsured children have less access to health care, less likely to get medical care. Children with gaps are the worse. Hard to make regular visits. First five years, those important.
2. uninsured receive care late. Higher risk for hospitalization. 60% of asthma patients hospitalized at KU are uninsured children. This is going up. Related to access to equipment or health care.
3. Results in higher costs overall for hosp. Have to find resources for medication, etc., sometimes have to keep in hosp longer to make sure they get meds they need.
4. Undiagnosed and untreated conditions that are amenable to control.
5. Children with untreated illness cannot keep up in school.
6. Untreated vision problems.
7. Effects of being uninsured at birth.
8. Use of emergency room.
9. Article on immunizations. All of these things work together.
Often feel like providing 2 different kinds of care - those who can afford it and those who can't. Would like to provide the same level of care for all.
* Bobbie Graff-Hendrixon, Public Provider Perspective *
-* See Healthy Kansas First Five handout.
New proposal governor has out on health coverage, birth to age 5. How are we doing this as an agency?
Family has to be screened first for Medicaid. Then look for S-CHIP eligibility. Two managed care companies serving beneficiaries. Trying to find all of those children not being served currently. ...walked through handout.
If raise premiums up to 300% poverty, those families could buy into policy, but it would be at a cost that families could afford.
Governor has proposed, and our agency believes it is good public policy to cover children 0-5 yrs. Most children 0-5 years old have to have insurance to be seen.
Senator Barnett has competing bill for what government has proposed. Waiting to see what happens.
Rand O'Donnell: Premium of 300% poverty. Do you have an estimate of what that would be?
Bobbie Graff-Hendrixon: If looking at a child between 1-5..don't want to be quoted that this is hard and fast number! - approximately $150 premium. Premiums based on age, sex, and region.
$150 is middle of road.
Understood prenatal component.
Yes, hope to increase Medicaid to 185% poverty for women under Medicaid. S-CHIP age limit, Medicaid there is not.
Linda Kenney asked questions about poverty ratios, premiums.
Bobbie wasn't sure; thinks there have been Additional discussions
*Graham Bailey: Private Insurance Perspective*
Can't think of anyone that would be against children 0-5 having access to health care.
There are other access means, as Barb mentioned.
Can agree to a certain extent that insurance to a certain degree equates to access.
Blue Cross/Blue Shield (BC/BS)- we are seeing fewer people covered on policy, which suggests people are being forced to drop some of their dependents from their policy.
$922 from every family insurance policy is being paid to cover uninsured (study showed).
Also remember the underinsured (e.g., $5K deductible basically doesn't have insurance)
States are getting tired of waiting for federal government, looking at own system.
BC/BS is not against some system (we are against single payer...unless we are that single payer!)
Mentioned initiatives in other states. People are talking and trying to find solutions.
Who are the uninsured. BC/BS nationally found out...
1/5 are people who make more than $75K and choose not to have.
1/3 are eligible for existing programs but don't get on.
1/2 are people who cannot afford.
Another study revealed that $9 mil uninsured kids - $7 mil are eligible for other programs.
If KS is like that, of 15K uninsured in KS, 11.5K would be eligible for another program.
Biggest problem of uninsured: Don't receive appropriate care at appropriate time in appropriate place. (Give detailed examples.)
Study: 50% of care in Emergency rooms are not emergencies.
School nurses are becoming Primary care for some kids.
BC/BS has endorsed national policy, health care coverage for the uninsured. Everyone seems to be looking at taking a kids' initiative first. one suggestion they make is perhaps for Medicaid/HealthWave - look at opportunities to sign kids up when they sign up for other programs (e.g., school lunch program).
Maybe need to do evaluation of what we have now. Before we think about expanding programs, think about why we are not getting eligibility kids in now:
-education - now aware of programs
-complacency - don't want to take time to do
-administrative - too difficult to go through process
-fear - stigma of government care, immigration issues
-access - maybe not enough providers (particularly dental)
Healthy Kansas First Five initiative - insurance industry has no concerns about putting health care in hands of people who don't have, but need to be careful. Subsidy programs squeeze something. Identification of who's in need may come into question. 300% of poverty - family of 4, about $60K per year. How will taxpayers feel about this? There are policies available out there. Base level – BC/BS policy for $96/month. If child health, could be as low as $60/month. Take in all information, make decisions together. Be cautious as we find solutions.
Certainly we support and participate any efforts that are being done for uninsured. Have participated in programs for uninsured.
Biggest concern - issue called crowd out. People currently covered have incentive to take another program that is subsidized by state funds.
* Parent Perspective - Valetta Striblin *
Mother of 3 children. After former husband started doing subcontracting, for Medicaid, went by gross wage so they did not qualify.
Her daughter's delivery put in her name.
Daughter got sick and spent week in the hospital.
Doctor allowed her to take her daughter home. Set up tents, etc. in home instead of staying in hospital.
...various problems with insurance. Told her story. (Will not record all details here due to confidentiality.) Many challenges!! Nearly all were related to the system itself, falling through cracks due to various reasons. Listed implications on her children's health.
** On Break **
* Discussion *
Dennis Cooley - Early childhood is key time in children. Very important to realize when a child is not getting healthcare in this period of life, tremendous impact later on. Key time for neuro-development.
Nick Rogers: How are we defining health care? Dental home at early age is just as important as medical home.
How are we defining health? Including dental?
Dennis Cooley: I would say yes. If child has problems with oral health, will affect in other ways, too. Dental health problems affect on diabetes, etc.
Nick Rogers: I would like to make sure...however it comes out on paper, dental home is a part of this.
When a child needs care, will make sure they have care no matter what. But often not accountability for these programs. See problems at 2 years old, educate, have access, don't see again until 5 years old with worse problems. Expensive care. Would like to see accountability built in.
Mary Murphy: This is an issue. Not sure how to go about addressing this. We work very hard with our families in head start to make sure follow-up, case management.
Most children I work with who are connect with program are better off.
Dennis Cooley: 20-30% Medicaid, some uninsured, some private insurance. As a whole, low socio-economic status (SES) has higher rate of non-compliance, but not as much as you might think. If Dr. Shaw was here, she would probably tell you that compliance rate is dismal. Compliance is a problem.
Penney Schwab: As a Community Health Center, we have found that the no show rate for uninsured is lower than Medicaid/S-CHIP. Enrollment rate for S-CHIP is dismal, not sure why. It is difficult.
How do we get the number of those who are eligible on the roll? State has about 35K on S-CHIP, another 40K uninsured of which majority are probably eligible. 70% of those eligible for another program.
Penney Schwab: We ask, if we think you might be eligible for something. Would you like assistance filling about paper work. In many cases, answer is no. Mentioned Benefit Bank program. As this gets rolling, may be helpful.
Nick Rogers: premise received on paper is great. If we have it, will it be used?
Shannon Cotsoradis: Dealing with 2 different populations. Majority of children uninsured...eligible for some program. Potentially talking about capturing a different population of children that might be easier to capture. (more middle income with jobs.)
Valetta Striblin: Barriers could be transportation. Huge barrier. For both rural and urban populations. Barriers are a big issue for getting health care, even though eligible.
Paul Getto: Tweaking one of my problems. Easy for a bunch of white middle class people to talk about problems. But there are a lot of barriers. Sympathetic to fact that it is hard to get continuity built in. But I don't think most of us have a clue the barriers some of the uninsured face in their lives.
Gerard Lozada: Any ideas - of those 40K, are these urban, rural?
Paul Getto: Probably more rural poverty in Kansas, even though this is not noticed.
Shannon Cotsoradis: I think largest number of uninsured were on Barb's list because most people live there, but pretty dispersed.
Paul Getto: Rural access is huge issue.
Valetta Striblin: Barriers - in Jetmore there is only one doctor, hospital, but no dentist or optometrist. I see issues now that uninsured have.
Paul Getto: More than making appointment. Need to consider transportation and other barriers. This is difficult, but when presented, need to deal with these barriers.
Rand O’Donnell: Agree with comments. approach we take needs to incorporate best existing programs. Medicaid does take this into account (case management, transportation). There will be issues, even if take 40K or so and give inexpensive co-pay...some people may be able to spend $35/month, but choose not to. For most part, people will respond to this. They will tend to do the right thing for their child. I endorse the Governor’s approach and KPHA document.
Nick Rogers: I, too, have no problems supporting this. Another variable..15% of headstart kids are homeless by federal definition. How does this affect the issue? Any facts on homeless or highly transient?
Dennis Cooley: If covered by Medicaid, can get transportation usually...but others fall through.
Penney Schwab: And many areas have no public transportation.
Linda Kenney: School lunch program does not require income verification, so couldn't really do dual applications.
Dennis Cooley: Maybe not automatically sign up, but send info to them so they could.
Vicki Hoffman: It is already on letter to parents.
Linda Kenney: I think school nurses and schools have done a good job, but it's tough.
Shannon Cotsoradis: Kansas Action for Children (KAC) did a study to look at this. Matching free/reduced school meals but not on Title 19 or 21. It was possible to do the match, found 25% on free/reduced not on Title 19 or 21. On national level, has been success with free/reduced lunch sign up, then part of application goes on to have eligibility determined for Title 19 & 21.
Mary Murphy: But this misses younger kids.
Shannon Cotsoradis: Did find could potentially access through siblings.
Gerard Lozada: Combined database to follow children and see what happens? ...seems to be a common theme across multiple issues. Should we address this as a committee?
Dennis Cooley: It is being addressed somewhat, but Lt. Gov committee...looking at Emergency Medical Records...shared information for children. This is down the road. But there is a group in the state working on this type of information and agree it really ties in to what we are doing.
Tom Ostrander: Middle and high school students do not ask for free/reduced meals (see comment to side).
Barb Gibson: With families who have multiple children, some eligible, some not, we have had to caution families not to sign up the wrong child because this could be seen as fraud.
Shannon Cotsoradis: Also afraid may lose kids on free/reduced lunches if they know it will be submitted on for verification.
New verification requirements - have to verify citizenship - enormous backlog at state level. For some families difficult to get documentation simply because they don't have it. Created large number of children in the system waiting to have application processed.
This is a federal requirement.
Current estimate is 18K-20K backlog. No light at the end of the tunnel.
Nick Rogers: In time, how long are they backlogged?
Shannon Cotsoradis: Not sure, but this is since July.
Barb Gibson: And office of Vital stats never meant to verify birth cert at that rate.
Shannon Cotsoradis: A huge burden on multiple agencies. And most will be eligible.
Presumptive eligibility is still on the table - is a pilot, but families don't follow-up when get form. (whatever the barriers to enrollment are).
There are many barriers to getting families enrolled.
Linda Kenney: Must be tremendous burden for families to have to deal with this.
Linda is passing out SOBRA information.
SOBRA - provides emergency coverage for non citizens and others.
(To those joining by phone, we will post. This handout has SOBRA statistics.)
State Fiscal Year 05:
For Medicaid, SOBRA clients by age.
There were 1892 SOBRA deliveries in SFY2005. There were 475 non-delivery SOBRA clients.
Has to be life-threatening condition to pay for. Really has to be admission to hospital, not just visit to emergency room.
Barb commented on SOBRA, challenges for hospitals filing. There MAY be a lot more SOBRA deliveries than are recorded.
Think numbers on handout are lower than what is really going on.
Three things we can make recommendations on
1. Agree that health care coverage of all children 0-5 should be a goal for the state.
2. Look at programs to increase eligibility numbers.
3. Make a recommendation on the Healthy Kansas First Five Initiative.
Regarding 1st one, shouldn't we support insurance for all kids, not just kids 0 to 5?
Yes. Everyone agrees.
1. Recommend - health care coverage for all children 0-18 should be goal for state.
Include dental.
Does anyone disagree?
No disagreements voiced.
2. Increase eligibility numbers.
How to do?
Do we need to encourage studies?
There have been some. Would be good to review, know why.
Mim Wilkey: What is the growth? Have we plateaued?
Yes, maybe a little lower.
Mim Wilkey: I would support really looking at problems, true need. Need more information on how to support.
Nick Rogers: But think it should be addressed by studies or other. Need to recommend that we address in some way today.
Dennis Cooley: State look at ways, develop programs for state to increase utilization for unenrolled eligibles.
Shannon Cotsoradis: Pockets across state that are successful, but these groups have not gotten together.
Yes, joint planning, come together and have discussion on how to solve.
Recommend task force, another group to come together and look at all of these.
Enormous interest in this.
Recommend Task Force look into unenrolled eligibles and make recommendations for urban and rural.
New contractors would also be interested. May have information.
Paul Getto- need two areas:
(1) successful urban experiences AND (2) successful rural experiences.
Undocumented challenges. Interesting irony that some people we find may say, sorry, not eligible.
Literacy issue built into this. Just because someone is literate at a certain level, doesn't mean that they have health literacy or are literate for filling out forms, etc.
Some from Mexico may not be literate in Spanish or English.
Mim Wilkey: having conversation would be helpful.
Penney Schwab: Kansas Children's Service League might have helpful information. Think good data here.
Paul Getto: Look at Ford and Finney county.
2. Consensus on this. Creating task force or group to study and make recommendations on non-covered eligibles.
3. Healthy Kids First Five Initiative. Shannon's point - this is potentially a different group, better chance of reaching.
Does anyone feel negative?
No. We endorse.
Paul Getto: Little far afield, but will have to get some type of non-tax revenue to make sure we provide access to children.
Also issues with access of children are enrolled.
Next Meeting April 12
| Meeting 4 Discussion Board is now closed.
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