Articles from June 2024

Arizona and Florida — whose rates of uninsured children are among the highest in the nation — set goals last year to widen the safety net that provides health insurance to people 18 and younger.

But their plans to expand coverage illustrate key ideological differences on the government’s role in subsidizing health insurance for kids: what to charge low-income families as premiums for public coverage — and what happens if they miss a payment.

“It’s a tale of two states,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

That divergence represents more than just two states taking their own path. It showcases a broader breakthrough moment, Alker said, as the nation rethinks how government works for families following the covid-19 pandemic.  The divide also underscores the policies at stake in the 2024 presidential election.

Republican-led legislatures in Florida and Arizona worked across party lines in 2023 to pass bills to expand their states’ Children’s Health Insurance Program — widely known as CHIP — which covers anyone younger than 19 in families earning too much to be eligible for Medicaid.

Florida Republican Gov. Ron DeSantis and Arizona Democratic Gov. Katie Hobbs then signed bills into law last year that increased the amount of money a family can make and still be eligible for their states’ CHIP programs. That’s where the similarities end.

Arizona began to enroll newly eligible children in March. That state has adopted policies that align with the Biden administration’s efforts to apply Affordable Care Act-style protections to CHIP, such as eliminating annual and lifetime limits on coverage and lockouts if families don’t pay premiums.

Arizona’s CHIP plan, called KidsCare, suspended its monthly premiums in 2020 and has yet to reinstate them. State officials are considering whether it’s worth the expense to manage and collect the payments given that new federal rules forbid the state from disenrolling children for nonpayment, said Marcus Johnson, a deputy director for the state’s Medicaid agency.

“We’re trying to understand if the juice is worth the squeeze,” he said.

By contrast, Florida has yet to begin its expanded enrollment and is the only state to file a federal lawsuit challenging a Biden administration rule requiring states to keep kids enrolled for 12 months even if their families don’t pay their premiums.

A judge dismissed Florida’s lawsuit on May 31, saying the state could appeal to federal regulators. The state’s CHIP expansion now awaits federal regulatory approval before newly eligible children can be enrolled.

“No eligible child should face barriers to enrolling in CHIP or be at risk of losing the coverage they rely on,” said Sara Lonardo, a spokesperson for the federal Department of Health and Human Services.

Florida’s CHIP expansion calls for significantly raising premiums and then boosting them by 3% annually. The state estimates expansion will cost an additional $90 million in its first full year and expects to collect about $23 million in new premiums to help fund the expansion of what it calls Florida KidCare.

But Florida officials have said that complying with a provision that bars children from being disenrolled for unpaid premiums would cause the state to lose $1 million a month. The state’s 2024 budget allocates $46.5 billion to health care and projects a $14.6 billion surplus.

Florida officials have flouted federal regulations and removed at least 22,000 children from CHIP for unpaid premiums since the rule banning such disenrollments took effect on Jan. 1, according to public records obtained by the Florida Health Justice Project, a nonprofit advocacy group.

DeSantis’ office and Florida’s Medicaid administration did not respond to KFF Health News’ repeated requests for comment about CHIP. But in legal filings, Florida said its CHIP plan is a “personal responsibility program.” It is “a bridge from Medicaid to private insurance,” the administration said on social media, to get families used to premiums, cost sharing, and the risk of losing coverage when missing a payment.

For some Floridians, like Emily Dent in Cape Coral, the higher premiums proposed in the state’s expansion plan would create a financial burden, not open a path to self-sufficiency.

Dent, 32, said her 8-year-old son, James, was disenrolled from Medicaid in April because the family’s income was too high. Although James would qualify for CHIP under Florida’s proposed expansion, Dent said the $195 monthly premium would be a financial struggle for her family.

Leaving James uninsured is not an option, Dent said. He is severely disabled due to a rare genetic disorder, Pallister-Killian syndrome, and requires round-the-clock nursing.

“He has to have health insurance,” she said. “But it’s going to drain my savings, which was going to be for a house one day.”

Research shows the cost of premiums can block many families from obtaining and maintaining CHIP coverage even when premiums are low.

And premiums don’t offset much of a state’s costs to operate the program, said Matt Jewett, director of health policy for the Children’s Action Alliance of Arizona, a nonprofit that promotes health insurance coverage for kids in the Grand Canyon State.

He noted that the federal government pays 70% of Florida’s program costs and 75% of Arizona’s — after deducting all premiums collected.

“Premiums are more about an ideological belief that families need to have skin in the game,” he said, “rather than any practical means of paying money to support the program.”

Republican-leaning states are not alone in implementing monthly or quarterly premiums for CHIP. Twenty-two states, including Democratic-leaning states such as New York and Massachusetts, charge premiums.

States have had wide discretion in how they run CHIP since the program became law in 1997, including the ability to charge such premiums and cut people’s access if they failed to pay. That’s been part of its success, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF.

“Especially in more conservative states, the ability to create CHIP as a separate program — independent from Medicaid — enabled and fostered that bipartisan support,” Tolbert said.

But in the decades since CHIP was enacted, government’s role in health insurance has evolved, most significantly after President Barack Obama in 2010 signed the Affordable Care Act, which introduced coverage protections and expanded assistance for low-income Americans.

Former President Donald Trump didn’t prioritize those things while in office, Tolbert said. He has suggested that he is open to cutting federal assistance programs if reelected, while the Biden administration has adopted policies to make it easier for low-income Americans to enroll and keep their health coverage.

Just as for Dent, the question of CHIP premiums in this debate isn’t abstract for Erin Booth, a Florida mom who submitted a public comment to federal regulators about Florida’s proposed CHIP expansion. She said she would have to pay a high premium, plus copayments for doctor visits, to keep her 8-year-old son covered.

“I am faced with the impossible decision of whether to pay my mortgage or to pay for health insurance for my son,” she wrote.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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For Diana Perez, a medical resident at the Family Health Center of Harlem, the handwritten thank-you note she received from a patient is all the evidence she needs that she has chosen the right training path.

Perez helped the patient, a homeless, West African immigrant who has HIV and other chronic conditions, get the medications and care he needed. She also did the paperwork that documented his medical needs for the nonprofit that helped him apply for asylum and secure housing.

“I really like whole-person care,” said Perez, 31, who has been based at this New York City health center for most of the past three years. “I wanted to learn and train, dealing with the everyday things I will be seeing as a primary care physician and really immersing myself in the community,” she said.

Few primary care residents get such extensive community-based outpatient training. The vast majority spend most of their residencies in hospitals. But Perez, who is being trained through the Teaching Health Center Graduate Medical Education program, is among those treating patients in federally qualified health centers and community clinics in medically underserved rural and urban areas around the country. After graduating, these residents are more likely than hospital-trained graduates to stay on and practice locally where they are often desperately needed, research has found.

Amid the long-term shift from inpatient to outpatient medical care, training primary care doctors in outpatient clinics rather than hospitals is a no-brainer, according to Robert Schiller, chief academic officer at the Institute for Family Health, which runs the Harlem THC program and operates dozens of other health center sites in New York. “Care is moving out into the community,” he said, and the THC program is “creating a community-based training environment, and the community is the classroom.”

Yet because the program, established under the 2010 Affordable Care Act, relies on congressional appropriations for funding, it routinely faces financial uncertainty. Despite bipartisan support, it will run out of funds at the end of December unless lawmakers vote to replenish its coffers — no easy task in the current divided Congress in which gaining passage for any type of legislation has proved difficult. Faced with the prospect of not being able to cover three years of residency training, several of the 82 THC programs nationwide recently put their residency training programs on hold or are phasing them out.

That’s what the DePaul Family and Social Medicine Residency Program in New Orleans East, an area that has been slow to recover after Hurricane Katrina in 2005, has done. With a startup grant from the federal Health Resources and Services Administration, the community health center hired staff for the residency program and became accredited last fall. They interviewed more than 50 medical students for residency slots and hoped to enroll their first class of four first-year residents in July. But with funding uncertain, they put the new program on hold this spring, a few weeks before “Match Day,” when residency programs and students are paired.

“It was incredibly disappointing for many reasons,” said Coleman Pratt, the residency program’s director, who was hired two years ago to launch the initiative.

Until we know we’ve got funding, we’re “treading water,” Pratt said.

“In order to have eligible applications in-hand should Congress appropriate new multi-year funds, HRSA will issue a Notice of Funding Opportunity in late summer for both new and expanded programs to apply to be funded in FY 2025, subject to the availability of appropriations,” said Martin Kramer, an HRSA spokesperson, in an email.

For now, the Teaching Health Center program has $215 million to spend through 2024.

By contrast, the Centers for Medicare & Medicaid Services paid hospitals $18 billion to provide residency training for doctors in primary care and other specialties. Unlike THC funding, which must be appropriated by Congress, Medicare graduate medical education funding is guaranteed as a federal entitlement program.

Trying to keep THC’s three-year residency programs afloat when congressional funding comes through in fits and starts weighs heavily on the facilities trying to participate. These pressures are now coming to a head.

“Precariousness of funding is a theme,” said Schiller, noting that the Institute for Family Health put its own plans for a new THC in Brooklyn on hold this year.

The misalignment between the health care needs of the American population and the hospital-based medical training most doctors receive is a long-recognized problem. A 2014 report by the National Academies Press noted that “although the GME system has been producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas.”

The Teaching Health Center program has demonstrated success in these areas, with program graduates more likely to practice in medically underserved areas after graduation. According to a study that analyzed the practice patterns of family medicine graduates from traditional GME training programs vs. those who participated in the THC program, nearly twice as many THC graduates were practicing in underserved areas three years after graduating, 35.2% vs. 18.6%. In addition, THC graduates were significantly more likely to practice in rural areas, 17.9% vs. 11.8%. They were also more likely to provide substance use treatment, behavioral health care, and outpatient gynecological care than graduates from regular GME programs.

But the lack of reliable, long-term funding is a hurdle to the THC training model’s potential, proponents say. For 2024, the Biden administration had proposed three years of mandatory funding, totaling $841 million, to support more than 2,000 residents.

“HRSA is eager to fund new programs and more residents, which is why the President’s Budget has proposed multi-year increased funding for the Teaching Health Center program,” Kramer said in an email.

The American Hospital Association supports expanding the THC program “to help address general workforce challenges,” said spokesperson Sharon Cohen in an email.

The program appeals to residents interested in pursuing primary and community care in underserved areas.

“There’s definitely a selection bias in who chooses these [THC] programs,” said Candice Chen, an associate professor of health policy and management at George Washington University.

Hospital primary care programs, for instance, typically fail to fill their primary care residency slots on Match Day. But in the THC program, “every single year, all of the slots match,” said Cristine Serrano, executive director of the American Association of Teaching Health Centers. On Match Day in March, more than 19,000 primary care positions were available; roughly 300 of those were THC positions.

Amanda Fernandez, 30, always wanted to work with medically underserved patients. She did her family medicine residency training at a THC in Hendersonville, North Carolina. She liked it so much that, after graduating last year, the Miami native took a job in Sylva, about 60 miles away.

Her mostly rural patients are accustomed to feeling like a way station for physicians, who often decamp to bigger metro areas after a few years. But she and her husband, a physician who works at the nearby Cherokee Indian Hospital, bought a house and plan to stay.

“That’s why I loved the THC model,” Fernandez said. “You end up practicing in a community similar to the one that you trained in.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).