บทถอดความฉบับเต็มของ Coverage Counts: Kids, Medicaid & CHIP

00:04:42.160 --> 00:04:48.720 So I would like to start by just saying that this podcast is going to be split in two for our listeners. 00:04:48.720 --> 00:04:57.199 So the first part is gonna talk a little bit more about Medicaid and the second portion about actions that we can take for our patients. 00:04:57.199 --> 00:05:02.399 Can you talk a little bit about the important role Medicaid plays, especially in the lives of children? 00:05:02.800 --> 00:05:07.519 Yeah, so it's impossible to overstate the importance of Medicaid. 00:05:07.519 --> 00:05:13.920 Medicaid and chip are covering nearly half of the children in this country and over 40% of the births. 00:05:13.920 --> 00:05:17.120 Uh, in some states, it's more than half of the births. 00:05:17.120 --> 00:05:28.240 So if you just think about that, you walk past a playground and you see a bunch of kids playing there, about half of them, their births, their childhood, they have health insurance because of Medicaid and CHIP. 00:05:28.240 --> 00:05:33.439 And I want to underscore something really important about that that people often overlook. 00:05:33.439 --> 00:05:38.079 You know, obviously 50% just jumps out at you as a huge statistic. 00:05:38.079 --> 00:05:41.439 But you also have to remember who those kids are. 00:05:41.439 --> 00:05:47.839 Um, they are in many cases kids growing up in poverty who have a host of other challenges, right? 00:05:47.839 --> 00:05:58.079 Lead in their water, malnutrition, maybe they have seen uh gun violence in their community, their guardians may have very low health literacy. 00:05:58.079 --> 00:06:05.040 So Medicaid isn't just taking care of a randomly selected cohort of 50% of the kids in this country, right? 00:06:05.040 --> 00:06:12.720 These are often kids that have major life challenges that translate into major developmental or health challenges. 00:06:12.720 --> 00:06:20.240 And so Medicaid is filling an incredibly challenging void and is very specially designed to do that. 00:06:20.240 --> 00:06:27.120 The long-term impact of Medicaid and CHIP can be felt in our society as these kids become adults. 00:06:27.120 --> 00:06:33.040 I don't think I need to explain to most medical providers that if children have health care, they will live healthier. 00:06:33.040 --> 00:06:42.480 They'll be more likely to overcome developmental delay or have better controlled asthma, better management of behavioral health conditions, higher quality of life. 00:06:42.480 --> 00:06:48.240 But for kids, what people sometimes forget that also translates into school readiness. 00:06:48.240 --> 00:06:51.360 With Medicaid, you get higher high school graduation rates. 00:06:51.360 --> 00:06:53.839 Kids are more likely to graduate on time. 00:06:53.839 --> 00:06:57.439 They're more likely to enroll in college, more likely to graduate from college. 00:06:57.439 --> 00:07:06.399 And so that means that we end up with a generation of adults that is fully prepared to be our future doctors and our future engineers and our future leaders. 00:07:06.399 --> 00:07:08.959 So it's just so, so, so important. 00:07:09.519 --> 00:07:16.319 And there's a lot of changes that have been occurring, and we are hearing about this bill called HR1. 00:07:16.319 --> 00:07:20.319 Can you tell our audiences a little bit about what is HR1? 00:07:21.199 --> 00:07:21.439 Sure. 00:07:21.439 --> 00:07:26.639 So HR1 is the legislation that passed in July of last year. 00:07:26.639 --> 00:07:32.319 It has many names: HR1, the One Big Beautiful Bill Act, the Budget Reconciliation Law. 00:07:32.319 --> 00:07:33.519 It's all the same thing. 00:07:33.519 --> 00:07:39.600 It was a broad law that did a lot of things and is incredibly consequential for Medicaid. 00:07:39.600 --> 00:07:46.720 It makes numerous changes to Medicaid law, some in effect already, others phasing in over the next three to four years. 00:07:46.720 --> 00:07:56.079 The Congressional Budget Office, CBO, estimated that HR1 will result in a cut of about a trillion dollars to Medicaid. 00:07:56.079 --> 00:08:03.199 And that is the largest cut in the history of the program and is predicted to result in 10 million people losing health coverage. 00:08:03.199 --> 00:08:10.959 That's about 7.5 million in Medicaid, 2.5 million in marketplaces, a smaller amount in Medicare. 00:08:10.959 --> 00:08:26.560 The other major contextual piece that we should overlay on that, which is also playing out right now, is that at the same time, Congress did not extend the enhanced subsidies that were in place for marketplaces. 00:08:26.560 --> 00:08:33.039 So it's estimated that four to five million more people will drop marketplace coverage for that reason. 00:08:33.039 --> 00:08:35.120 So a lot of challenges going on right now. 00:08:35.440 --> 00:08:40.480 Definitely sounds like at this point we're at a crucial turning point. 00:08:40.480 --> 00:08:43.440 And remind us why this coverage actually matters. 00:08:43.759 --> 00:08:48.480 The United States is a coverage-based system for healthcare, right? 00:08:48.480 --> 00:08:51.519 There are not generally public hospitals in this country. 00:08:51.519 --> 00:08:57.919 Only extremely wealthy people will willingly choose to self-insure out of their own pocket, right? 00:08:57.919 --> 00:09:01.519 If you meet a Wall Street lawyer, they have health insurance, right? 00:09:01.519 --> 00:09:02.720 And there's a reason for that. 00:09:02.720 --> 00:09:06.960 Without coverage, people have much less access in this coverage. 00:09:06.960 --> 00:09:16.080 And we can actually see that in the data showing much lower utilization, including for basic preventive care among the uninsured. 00:09:16.080 --> 00:09:20.320 And of course, worse health comes associated with that. 00:09:20.320 --> 00:09:38.559 I think the critical fact that we really have to shine a light on and grapple with is that in our system, if we look at the workers that are below 200% of the federal poverty

level, less than half of them are eligible for an insurance from their employer. 00:09:38.559 --> 00:09:46.879 So without these basic programs for kids, half of these kids in these families would have no coverage. 00:09:46.879 --> 00:09:50.240 And there's no way those families are going to pay for coverage out of pocket. 00:09:50.240 --> 00:09:54.639 No one does that in this country, much less people who are low who are low income, right? 00:09:54.639 --> 00:10:04.799 And so those people, if they don't have insurance, then they're stuck trying to find, you know, a public clinic that might do basic primary care on a low fee scale. 00:10:04.799 --> 00:10:10.960 And of course, they can use the ER when a problem gets totally out of control, but they're not going to have specialty care. 00:10:10.960 --> 00:10:14.879 They're not going to have, you know, advanced diagnostic testing. 00:10:14.879 --> 00:10:17.519 They're not going to have durable medical equipment. 00:10:17.519 --> 00:10:19.759 They're not going to have chronic care management. 00:10:19.759 --> 00:10:21.679 They're not going to get prescriptions. 00:10:21.679 --> 00:10:25.679 They're going to avoid the ER until things get really, really bad. 00:10:25.679 --> 00:10:32.320 And they're certainly not going to get all of the surgeries that they should be getting in the timeframe that they should be getting it. 00:10:32.320 --> 00:10:40.799 And one last thing that I'll just add is that it also means that uninsured adults who are sick are going to have trouble working. 00:10:40.799 --> 00:10:44.080 And many are going to run straight into medical debt, right? 00:10:44.080 --> 00:10:50.240 Either because they have trouble working or because they're uninsured and they can't pay for the care that they get at the ER. 00:10:50.240 --> 00:10:53.679 And that's the number one cause of bankruptcy in this country, right? 00:10:53.679 --> 00:10:57.440 This causes huge instability for families and their children. 00:10:57.440 --> 00:11:01.600 They skip groceries, they skip rent, they lose jobs, they lose housing. 00:11:01.600 --> 00:11:07.840 And it's a it can create a very challenging, harmful environment to raise a child or to be a child, right? 00:11:07.840 --> 00:11:17.840 So imagine that low-wage family, if they have Medicaid, they walk out of the ER totally stressed, but without a copay or with a very minimal copay. 00:11:17.840 --> 00:11:26.559 Without Medicaid, they would have a $30,000 bill for that appendectomy with minor complications, right? 00:11:26.559 --> 00:11:27.759 That's $30,000. 00:11:27.759 --> 00:11:32.639 That $30,000 might be more than their entire annual salary, right? 00:11:32.639 --> 00:11:36.399 So that's an existential difference for that family. 00:11:36.399 --> 00:11:38.159 And again, we're talking about working families. 00:11:38.480 --> 00:11:43.679 I mean, that just sounds unsurmountable for those individuals that don't have access to care. 00:11:43.679 --> 00:11:50.960 And

so how are we filling that gap that for the half that don't get coverage currently and then going forward? 00:11:51.360 --> 00:11:51.600 Right. 00:11:51.600 --> 00:11:55.279 So I mean, this is where the public programs become so important, right? 00:11:55.279 --> 00:12:02.879 And we kind of have a net of public programs, um, and they're covering a lot of people when you add it up, almost half of the people in this country. 00:12:02.879 --> 00:12:07.679 You've got, you know, the lowest income families being covered by Medicaid. 00:12:07.679 --> 00:12:15.519 Then you have CHIP, the children's health insurance program, covering a slightly higher tier of families just above the Medicaid cutoffs. 00:12:15.519 --> 00:12:23.840 And then the families that are above that can go into the marketplace where they can get subsidies if they are low to middle income. 00:12:23.840 --> 00:12:28.559 And then, of course, we also have the Medicare program providing coverage for seniors. 00:12:28.559 --> 00:12:44.720 And I just want to flag that even within Medicare, about a fifth of the Medicare population are low-income seniors who rely on Medicaid to actually reduce the cost sharing and premiums associated with their Medicare coverage, right? 00:12:44.720 --> 00:12:57.039 So that suite of public programs is what is stepping in and really covering half of the people in this country that are are not, we're not able to cover through the employer system. 00:12:57.279 --> 00:13:02.639 It does sound like it becomes a lot more complex, especially when we're talking about Medicaid. 00:13:02.639 --> 00:13:07.600 And you had talked a little bit about what it means to have Medicaid being tailored. 00:13:07.600 --> 00:13:09.519 So what do you mean by that? 00:13:09.519 --> 00:13:11.919 Like Medicaid is tailored to the needs. 00:13:12.240 --> 00:13:19.200 And this is one of the most important things to understand about Medicaid, because it's not just the number of people the program covers, it's what it does for them. 00:13:19.200 --> 00:13:21.279 So the Medicaid population is low income. 00:13:21.279 --> 00:13:24.240 In some cases, um, has special needs. 00:13:24.240 --> 00:13:26.720 So the insurance is doing special things. 00:13:26.720 --> 00:13:31.039 And in some cases, it's just straight up filling a national void. 00:13:31.039 --> 00:13:42.080 Probably the most significant financial and structural thing people don't understand is that for many, many people who need institutional level care and can't afford it, that's Medicaid. 00:13:42.080 --> 00:13:53.440 Seniors in poverty who need nursing homes, people of all ages with intellectual disabilities who need facility-based care, children with behavioral health issues who need facility-based care. 00:13:53.440 --> 00:13:57.440 Medicaid is our national solution for all of those problems. 00:13:57.440 --> 00:14:14.879 Medicaid also has, for example, very strict limits on cost sharing for medical services, and premiums are generally not allowed for the obvious reason that if if you have a $300 a month premium or $50 co-pays for services, it's just not going to work for these low-income families. 00:14:14.879 --> 00:14:22.000 Medicaid also covers transportation, including for non-emergency care, because that is a big barrier for low-income people, right? 00:14:22.000 --> 00:14:25.039 Most employment insurances don't have that. 00:14:25.039 --> 00:14:35.120 And a really, really important thing for providers to know about, and specifically pediatric providers, is the Medicaid early periodic screening diagnostic and treatment benefit. 00:14:35.120 --> 00:14:37.840 It's a long acronym, EPSDT. 00:14:37.840 --> 00:14:42.000 All of the words actually have a lot of meaning, but you don't have to learn the whole acronym. 00:14:42.000 --> 00:14:44.159 Maybe we could just talk a little bit about what it is. 00:14:44.399 --> 00:14:45.120 That would be great. 00:14:45.120 --> 00:14:54.240 So for our listeners, can you remind us a little bit about what this is and what it covers and how it actually plays a role, probably in our daily lives? 00:14:54.480 --> 00:14:58.559 So EPSDT is Medicaid's benefit for children. 00:14:58.559 --> 00:15:01.679 And it's really a gold star standard. 00:15:01.679 --> 00:15:05.200 Um, it's five-star coverage when it's done right and enforced. 00:15:05.200 --> 00:15:07.360 So I could talk about EPSDT for hours. 00:15:07.360 --> 00:15:16.559 It's one of my favorite things to talk about, but I want to just pull out two basic pillars that will give you a good understanding of what it's trying to do. 00:15:16.559 --> 00:15:27.679 First, from a system point of view, the theory of EPSDT is if we have these kids in poverty with all of these complicating factors, right? 00:15:27.679 --> 00:15:31.200 There might be malnutrition, there might be housing insecurity, et cetera. 00:15:31.200 --> 00:15:35.200 We want to be proactive about monitoring them. 00:15:35.200 --> 00:15:49.360 So there is going to be, there is a periodicity schedule in every state, and we're going to make sure that we check this kid and do screenings at, you know, five days, one month, two months, four months, six months, nine months, et cetera. 00:15:49.360 --> 00:15:52.080 And we're going to use formal screening tools. 00:15:52.080 --> 00:15:58.399 And when we get positives on screenings, we are going to refer to diagnostic and we're going to cover that. 00:15:58.399 --> 00:16:06.559 And when diagnostic comes back telling us there's something here, then treatment is going to be prescribed and happened. 00:16:06.559 --> 00:16:09.039 And so we're monitoring these kids. 00:16:09.039 --> 00:16:15.759 And when a kid falls off the expected developmental trajectory, we're going to figure it out quickly. 00:16:15.759 --> 00:16:21.840 We're going to get them back on track to the best of our ability and their ability, whatever their capacity may be. 00:16:21.840 --> 00:16:25.120 And so we're going

to catch that heart defect early, right? 00:16:25.120 --> 00:16:26.960 We're going to catch scoliosis. 00:16:26.960 --> 00:16:35.200 And kids are going to get the diagnostic, they're going to get the treatment that will ultimately lead to the right surgery they might need or whatever. 00:16:35.200 --> 00:16:37.279 So that's the system level. 00:16:37.279 --> 00:16:40.559 From the practice point of view, is the second pillar. 00:16:40.559 --> 00:16:43.600 And this is really important to a medical provider. 00:16:43.600 --> 00:16:53.360 And it's very, it was very important to me as a lawyer representing families against an insurer or state trying to deny, you know, a surgery you might have prescribed for them. 00:16:53.360 --> 00:17:01.039 Under APSDT, children must get any medically necessary service within the Medicaid universe. 00:17:01.039 --> 00:17:08.400 So states have a lot of discretion and flexibility in what Medicaid services they cover for adults. 00:17:08.400 --> 00:17:11.279 They don't have to cover every service for adults. 00:17:11.279 --> 00:17:15.359 Sometimes they place caps on services, all kinds of limits on services. 00:17:15.359 --> 00:17:24.160 For kids, there always, always has to be an exception to get the service if medically necessary. 00:17:24.160 --> 00:17:35.599 And so what this means is that Medicaid kids truly can get an incredible range of services that might not even be available under fancy employment insurances. 00:17:35.599 --> 00:17:56.240 And this is particularly true for, say, autism or mental health or topics that are cutting edge or sometimes expensive that other insurances don't want to cover, like hearing loss surgery or implants, things like cleft palate, scoliosis, vision-related corrective surgeries that might be denied as elective for adults. 00:17:56.240 --> 00:18:02.720 State Medicaid programs are going to be and managed care organizations, they might not want to go there, right? 00:18:02.720 --> 00:18:07.200 But for kids using EPSDT, we can actually make that happen. 00:18:07.200 --> 00:18:15.279 Now I want to be clear what I just described is not the actual reality on the ground everywhere, but that is the law everywhere. 00:18:15.279 --> 00:18:18.160 Those outcomes are possible everywhere. 00:18:18.160 --> 00:18:28.480 It's a place where advocacy, understanding how you can help patients, understanding systemic advocacy, connections to informed advocates can make a real difference. 00:18:28.799 --> 00:18:38.400 So some states may cover some of these services, whereas other states have limited them, or they it's just not on the docket to be covered. 00:18:38.799 --> 00:18:44.960 So again, for adults, states have to offer a benefits package that reasonably achieves its purpose. 00:18:44.960 --> 00:18:48.160 That does not mean you have to cover every single service. 00:18:48.160 --> 00:18:54.559 So for an adult in Medicaid, you might not get every single service. 00:18:54.559 --> 00:19:05.680 And in

particular, for example, right, if the state says for 95% of adults, two of these treatments a year is a reasonable amount. 00:19:05.680 --> 00:19:09.680 When you're an adult and you need number three, there's nothing to do. 00:19:09.680 --> 00:19:29.359 If you're a kid and you need number three, as long as the provider is willing to step forward and say, you know what, treatment number three is medically necessary for this child, EPSDT overrides, it trumps, it defeats the normal state limits and discretion to limit services. 00:19:29.359 --> 00:19:40.319 And so where providers will often run into this is um in the managed care context in Medicaid, where the managed care plan will tell you there is some coverage limit. 00:19:40.319 --> 00:19:49.920 And so the answer to that is number one, yes, the plan can have a prior authorization process, for example, right? 00:19:49.920 --> 00:19:56.079 They can do things to try and create system defaults in coverage. 00:19:56.079 --> 00:20:09.599 But for kids, due to EPSDT, that system default always has to have an override for a service that is in the Medicaid universe of potentially coverable services, right? 00:20:09.599 --> 00:20:20.720 So this is an incredibly valuable tool, and it's why um some cutting-edge things can happen in Medicaid that don't happen even in private, fancy private coverage. 00:20:21.039 --> 00:20:30.720 We've come a long way so far with discussions on where we are, and I'd love to know a little bit more about what's going on currently in the US. 00:20:30.720 --> 00:20:39.279 So Medicaid's been in the news a lot, and I'm wondering what's currently happening with the Medicaid coverage for kids and some of the changes that we're seeing. 00:20:39.680 --> 00:20:43.839 Yeah, so we are in a very particular moment. 00:20:43.839 --> 00:20:50.160 I will call it a moment of great uncertainty, a moment of great concern for children's coverage. 00:20:50.160 --> 00:20:54.559 To be honest, myself and my colleagues, uh, we are very worried. 00:20:54.559 --> 00:21:01.119 Um, and I'll try and explain how we got to this precarious uh moment that we find ourselves in. 00:21:01.119 --> 00:21:08.880 If we take a lot of steps back and look at a very macro timeline, we can start with actually some really great news. 00:21:08.880 --> 00:21:21.759 In the 20 years, from the mid-1990s to the mid-uh 20 teens, so to 2016, we saw incredible and remarkably consistent progress in children's coverage. 00:21:21.759 --> 00:21:32.640 We went from 15% of kids uninsured in the mid-1990s to dropping below 5% for the first time ever in 2016. 00:21:32.640 --> 00:21:36.240 Uh, and the graph in that time range is incredible. 00:21:36.240 --> 00:21:41.119 It's a slow, steady progress every single year without fail. 00:21:41.119 --> 00:21:42.960 It's the happiest graph you can imagine. 00:21:42.960 --> 00:21:45.680 Like on a day where I'm sad, I just pull up that graph, right? 00:21:45.680 --> 00:21:46.880 It's just amazing. 00:21:46.880 --> 00:21:59.759 Um, and and I want to highlight for everybody, because I think it's really important that those years, um, those take you through Republican presidents and Democratic presidents, and they take you through Democratic Congresses and Republican Congresses, right? 00:21:59.759 --> 00:22:03.200 This is a national bipartisan success story. 00:22:03.200 --> 00:22:05.759 We went from 15% to below 5%. 00:22:05.759 --> 00:22:19.839 And then from 2017 to 2019, you know, for the first time in 20 years, for three years in a row, every year the number went the wrong way to a statistically significant degree. 00:22:19.839 --> 00:22:23.599 And so we went from below 5% to back up to almost 6%. 00:22:23.599 --> 00:22:29.039 The pandemic then happened, and we have a lot of instability in the data. 00:22:29.039 --> 00:22:30.799 So it swings up and down. 00:22:30.799 --> 00:22:34.160 But we came out of it right here at 6% still. 00:22:34.160 --> 00:22:47.839 And so the story of what happened in 2017 is not that anyone was targeting children per se, but there was a combination of policies that hurt coverage at the family level. 00:22:47.839 --> 00:22:52.480 And we know from the data that every time you do that, it impacts the kids. 00:22:52.480 --> 00:23:07.200 The administration, you know, reduced enrollment windows, we decreased funding for healthcare navigators, we reduced outreach, we put up some extra barriers to enrollment and renewal in all of that stuff added up for families. 00:23:07.200 --> 00:23:14.799 And the concern we are seeing is that a lot of those things are being done again right now or being proposed again right now. 00:23:14.799 --> 00:23:19.519 And so we have this concern that coverage is going to move the wrong way for kids. 00:23:19.519 --> 00:23:29.359 And in fact, I'm quite certain that the uninsurance rate for kids is going to spike in a way we we literally have not seen in the last 35 years. 00:23:29.359 --> 00:23:32.640 So that's very heartbreaking for us. 00:23:32.640 --> 00:23:34.720 There's good news too. 00:23:34.720 --> 00:23:37.119 If you want to do some good news too. 00:23:38.000 --> 00:23:44.400 So let's talk a little bit how that pandemic impacted coverage and how do we come out of the pandemic? 00:23:44.960 --> 00:23:50.240 The chief thing that happened during the pandemic is Congress passed a continuous coverage requirement. 00:23:50.240 --> 00:23:56.400 Basically saying, you know what, during this pandemic, nobody can be terminated from their public health programs. 00:23:56.400 --> 00:24:07.039 So all of the kids who at every annual renewal get dumped by the program because there are paperwork problems or documentation problems, et cetera. 00:24:07.039 --> 00:24:08.960 And that's what terminates a lot of kids. 00:24:08.960 --> 00:24:11.200 All those kids stayed in the program. 00:24:11.200 --> 00:24:15.680 And so we saw the rates improve. 00:24:15.680 --> 00:24:23.759 And then when that

continuous coverage period ended, the rates dropped right back down to that six percent place that we're at. 00:24:23.759 --> 00:24:28.079 You know, the pandemic sort of created this wave up and down of coverage. 00:24:28.079 --> 00:24:36.480 But I do think we also got a fair amount of you know pent-up demand from the pandemic because there were a lot of kids going through a lot of things. 00:24:36.480 --> 00:24:39.920 More mental health, behavioral health issues popped up during that time. 00:24:39.920 --> 00:24:44.160 So I do think we also have sort of a cohort of children that has some more needs. 00:24:44.480 --> 00:24:50.960 Leo, you mentioned there's some positive um aspects that have come out with the after the pandemic. 00:24:50.960 --> 00:24:52.960 Can you talk a little bit more about those? 00:24:53.359 --> 00:24:57.759 Yeah, so we we did have some silver linings to the pandemic. 00:24:57.759 --> 00:25:06.240 And the really big one is that in the last few years, we've seen the development of some new policies that might be the keys to future success. 00:25:06.240 --> 00:25:20.319 As I hinted at earlier, one of the reasons we struggle to get kids on insurance rate to zero, even though we have programs where they should all fit, is that if you think of the program as a bag of grain, right? 00:25:20.319 --> 00:25:25.920 We're scooping kids into the program, but the bag has a hole in the bottom and kids are leaking out. 00:25:25.920 --> 00:25:30.400 And we scoop new kids in, but at the same time, current kids are dropping out. 00:25:30.400 --> 00:25:32.000 And so that bag never fills. 00:25:32.000 --> 00:25:33.680 We never get all the kids covered. 00:25:33.680 --> 00:25:41.279 And we know the vast majority of kids who fall out, it's because they get dropped due to excessive renewal policies. 00:25:41.279 --> 00:25:55.279 For example, imagine a family that one month, uh, say, you know, December holiday season, dad picks up some extra shifts at the um Amazon warehouse or the Walmart warehouse. 00:25:55.279 --> 00:25:59.599 And in that one month, family income goes up. 00:25:59.599 --> 00:26:04.720 And so the kid gets dropped from Medicaid just because of that one month. 00:26:04.720 --> 00:26:14.000 Um and so in 2023, Congress passed a law uh that started in 2024, and and that's what we call continuous eligibility. 00:26:14.000 --> 00:26:19.839 And what it says is that kids, once they get into Medicaid, their coverage gets locked in for the full year. 00:26:19.839 --> 00:26:29.519 So that mid-year fluctuation, that random month where income changes, we're not gonna cancel a kid's health insurance because family income changed one month. 00:26:29.519 --> 00:26:32.799 And we even so so that passed as law. 00:26:32.799 --> 00:26:34.240 So so that's huge. 00:26:34.240 --> 00:26:54.480 But we even had upwards of 10 states implement temporary pilot programs to do multi-year continuous eligibility where the kids would get continuous eligibility from birth until age six, age six being sort of when they start school and you can sort of start tracking them through school. 00:26:54.480 --> 00:27:06.480 And so what that means is that not only are families protected from that, you know, one month where their income goes up, but they also get protected from getting dumped at the annual renewal, which is a major driver of coverage loss. 00:27:06.480 --> 00:27:09.359 And I think this is really huge. 00:27:09.359 --> 00:27:18.480 It's the future of kids' coverage, um, it's the way that we actually could get that uninsurance rate down to zero with those kinds of policies. 00:27:18.480 --> 00:27:25.039 Um right now, the administration has said they're not going to approve any more of those multi-year pilots. 00:27:25.039 --> 00:27:30.400 Um, and they might let the current ones that are approved expire in the coming years. 00:27:30.400 --> 00:27:32.640 So we're waiting to see what happens with that. 00:27:32.640 --> 00:27:36.400 But we can sort of see the path ahead of us for kids' coverage. 00:27:36.400 --> 00:27:40.640 Um, we're gonna take several steps backward before that step forward. 00:27:40.640 --> 00:27:50.400 We have storm clouds on the horizon, but I think we also have on the drawing board the idea for how we can really solve kids' coverage. 00:27:50.960 --> 00:27:53.279 I'm excited to hear more about this. 00:27:53.279 --> 00:28:08.319 So we're now gonna transition into part two, and we will start off by talking a little bit about what's happening right now and what's coming next, and what has Congress been doing and what's the outlook. 00:28:08.319 --> 00:28:16.160 Tamar, can you talk a little bit more about um what's going on and some of the implications for both children and providers? 00:28:16.559 --> 00:28:16.880 Sure. 00:28:16.880 --> 00:28:19.440 So Congress passed HR1. 00:28:19.440 --> 00:28:22.880 We're coming up actually on a year anniversary of its passage. 00:28:22.880 --> 00:28:34.960 It's HR1, sometimes called the One Big Beautiful Bill Act, a very large piece of legislation with a lot of implications for healthcare, for the economy. 00:28:34.960 --> 00:28:58.559 At a high level, the bill now law permanently extends the 2017 tax cuts and partially offsets the spending for that by enacting a number of changes that will reduce healthcare spending, it will reduce spending on uh SNAP, the food assistance program, and increases significantly spending on immigration enforcement. 00:28:58.559 --> 00:29:03.359 For purposes of this conversation, though, I want to focus on the healthcare provisions. 00:29:03.359 --> 00:29:22.960 And, you know, according to the nonpartisan Congressional Budget Office, they estimate that we will see over a trillion dollars in net Medicaid, chip, and Affordable Care Act marketplace cuts over 10 years, which will increase the number of uninsured individuals by about 10 million over 10 years. 00:29:22.960 --> 00:29:42.240 One thing to note, although I

know I don't think we're going to talk too much about it today, but just to note that the Affordable Care Act, one of the things that the bill did not do, which is partially responsible for some of the increases in the uninsured rate, is that it does not extend the enhanced premium tax credits that were passed as we were coming out of the COVID-19 pandemic. 00:29:42.240 --> 00:29:53.359 And so that took effect this year, and we are seeing the implications of that throughout the country with uh decreases in enrollment in affordable care act plans throughout the country. 00:29:53.359 --> 00:29:57.519 But look forward to talking a little bit more about those Medicaid provisions uh in a minute. 00:29:57.839 --> 00:29:58.799 You mentioned SNAP. Can you tell our listeners what that stands for? 00:29:59.119 --> 00:30:02.559 Oh, sure. 00:30:02.559 --> 00:30:06.799 I know we I just uh violated the rule of no acronyms here. 00:30:06.799 --> 00:30:08.960 We are in Alphabet Soup here in Washington. 00:30:08.960 --> 00:30:11.759 It's uh the SNAP program, also known as Food Stamps. 00:30:11.759 --> 00:30:14.720 It stands for the Supplemental Nutrition Assistance Program. 00:30:14.720 --> 00:30:23.119 And changes to SNAP in the bill, much like the Medicaid ones, really represent a cost shift from the federal government to state government. 00:30:23.119 --> 00:30:35.839 So states are already facing really important fiscal implications from HR1 and having to do things like new cost sharing or higher administrative costs for these programs. 00:30:35.839 --> 00:30:42.640 And so that is partially why we're seeing some of the decisions that states are making right now to fill these budget holes. 00:30:43.039 --> 00:30:49.119 I know that we've already talked a lot about Congress's agenda, but are there things we have not talked about? 00:30:49.519 --> 00:31:00.720 It's an interesting time as we are in a midterm uh election year, and the closer we get to that, the harder it is to pass legislation in Congress. 00:31:00.720 --> 00:31:02.640 And that's a historical trend. 00:31:02.640 --> 00:31:12.480 Um, and you layer on top of that the fact that this has been a time where we've seen relatively fewer laws enacted in in our recent history. 00:31:12.480 --> 00:31:15.759 Um, that trend started in the last Congress, the 118th Congress. 00:31:15.759 --> 00:31:18.079 We're currently in the 119th Congress. 00:31:18.079 --> 00:31:31.279 So we've only seen a total of 98 laws passed by Congress in the 119th, and that is on a downward trend, which means it just becomes that much harder to get laws enacted. 00:31:31.279 --> 00:31:40.880 A reason for that is very tight margins for the majority party in the House and the Senate, uh, which makes it harder to get legislation through. 00:31:40.880 --> 00:31:45.440 There are a lot of ambitious plans for the remainder of this year, having said all of that. 00:31:45.440 --> 00:31:51.039 Um, one of the big things that Congress tries to do every year is pass an annual appropriations set of bills. 00:31:51.039 --> 00:31:54.559 Uh so for the year ahead, it's uh for fiscal year 2027. 00:31:54.559 --> 00:31:59.759 Uh, work is ongoing in the House right now to move various spending bills. 00:31:59.759 --> 00:32:02.720 The Senate is a little further behind them on that. 00:32:02.720 --> 00:32:05.440 Congress needs to do something by September 30th. 00:32:05.440 --> 00:32:11.279 Otherwise, we'll see a government shutdown if there isn't an extension of current funding levels. 00:32:11.279 --> 00:32:17.599 We are also hearing talk about a potential third budget reconciliation bill. 00:32:17.599 --> 00:32:22.880 So uh when I refer to HR1 before, that was uh budget reconciliation 1.0. 00:32:22.880 --> 00:32:28.160 Congress just enacted 2.0, which uh doesn't have direct implications for healthcare. 00:32:28.160 --> 00:32:32.000 It's more about spending for immigration enforcement. 00:32:32.000 --> 00:32:35.920 But budget reconciliation 3.0 is a very real possibility. 00:32:35.920 --> 00:32:44.000 There's a lot of push, particularly coming from the House of Representatives, to enact another bill that would have implications for healthcare. 00:32:44.000 --> 00:32:54.720 We don't know the exact uh details of that, but there's a lot of conversation about tackling uh waste, fraud, and abuse in various federal programs, including Medicaid and Medicare. 00:32:54.720 --> 00:32:56.880 So that is also a possibility this year. 00:32:57.200 --> 00:32:57.519 Wow. 00:32:57.519 --> 00:33:02.079 There's a lot on the docket, it sounds like, for them to uh try to get through. 00:33:02.079 --> 00:33:08.400 Can you give us a little insight on how the states are likely to respond to the cuts in Medicaid at the federal level? 00:33:08.799 --> 00:33:12.720 Well, this is a tricky position for states, uh, without question. 00:33:12.720 --> 00:33:17.279 You know, states, unlike the federal government, have to pass a balanced budget. 00:33:17.279 --> 00:33:25.200 So they are looking at their spreadsheets and looking at a huge loss of federal revenue coming their way because of HR1. 00:33:25.200 --> 00:33:38.160 So among the options that advocates for Medicaid and children should be kind of keeping an eye on, are look at cutting or limiting benefits within Medicaid that are considered optional. 00:33:38.160 --> 00:33:44.400 They can look at cutting provider payment rates, as we've definitely seen states do that in the past. 00:33:44.400 --> 00:33:59.440 They could think about closing or capping eligibility for Medicaid or imposing kind of red tape types of bureaucratic policies that make it harder for people to enroll or stay enrolled. 00:33:59.440 --> 00:34:02.960 They can think about increasing out-of-pocket costs for enrollees. 00:34:02.960 --> 00:34:07.119 And then on the flip side, some states are looking at ways to boost their revenues. 00:34:07.119 --> 00:34:25.840 This is by no means an easy effort, but I would

just note that there are two ballot initiatives very recently that passed in the state of California, most recently in Los Angeles County, to increase the sales tax in order to offset spending, particularly for safety net providers. 00:34:25.840 --> 00:34:39.039 And then I think the other thing to look at is just how states are going to potentially reduce spending in other parts of the budget or even enact cuts to programs that may be popular and folks who are listening may benefit from. 00:34:39.039 --> 00:34:42.079 So it's not a lot of great options, I'm gonna admit. 00:34:42.559 --> 00:34:48.880 Can you give our listeners some suggestions on ways they can advocate for their patients, even if they don't have a lot of time? 00:34:49.280 --> 00:34:49.519 Sure. 00:34:49.519 --> 00:35:05.599 Well, this is probably my favorite thing to talk to uh pediatric providers about is thinking about, and and look, and I know you are very busy, and your ability to engage beyond the clinic walls is probably very limited. 00:35:05.599 --> 00:35:21.920 Um, but I just wanted to give you a few ideas, even if you have very limited time of ways to really harness your power, your voice, your expertise as physicians, as surgeons, as provider, pediatric providers. 00:35:21.920 --> 00:35:33.840 If you only have a few minutes to engage, if you aren't already receiving, I encourage you to sign up for advocacy auction alerts from professional organizations that you are a member of. 00:35:33.840 --> 00:35:46.800 I'm thinking about the American Academy of Pediatrics, the American College of Surgeons, the American Medical Association, or their state affiliates where you live, and think about responding to one of those action alerts. 00:35:46.800 --> 00:36:00.239 Usually those organizations make it very user-friendly and a very quick process to be able to just click on an email, open it up, and then send it directly to your member of Congress on an important issue that's moving. 00:36:00.239 --> 00:36:09.119 You might think about a story you read recently or a headline that really moved you and what you might do about it. 00:36:09.119 --> 00:36:12.159 Same goes for thinking about a patient case you had. 00:36:12.159 --> 00:36:40.719 If you think about, you know, kind of the circumstances that led to that case being in front of you, and think about how that public policy impacted it, whether it's you know product safety or firearms or frankly not having a surgical device that was appropriate for use in a child, and and then think about what organization is doing advocacy around that issue and sign up for their newsletter or get on their uh lister so that you can be become aware of opportunities for advocacy. 00:36:40.719 --> 00:36:49.440 Uh and then most importantly, you know, because uh we have national elections and local elections that happen throughout the year, uh just make sure you vote kids. 00:36:49.679 --> 00:36:52.239 And what about contacting our representatives? 00:36:52.480 --> 00:36:52.719 Great. 00:36:52.719 --> 00:37:05.840 Well, if you have a little more time, I think it can be very effective to look into attending your local, state, or federal representatives, town hall meetings, or try to get a meeting with them in their district office. 00:37:05.840 --> 00:37:20.800 Every member of Congress has a district office or multiple district offices, and um they have they are staffed by staff who are there to meet with constituents, and so that's that's one thing to think it's a lot more local and accessible than coming to Washington, D.C. 00:37:20.800 --> 00:37:26.960 If you are employed in a hospital, get to know your government relations staff. 00:37:26.960 --> 00:37:39.920 I think that's a really key one because the government relations office for your institution is typically the main entry point for federal, state, local elected officials. 00:37:39.920 --> 00:37:53.519 And so making sure you're on their radar, making sure that if you are interested in advocacy, they'll they know they have you on speed dial so that you can be called upon when that member of Congress comes to visit your institution. 00:37:53.519 --> 00:38:10.960 Or if you are the beneficiary of a grant program from the federal government at your institution, it's really important for your government relations staff to know about that program and know why it's important to you so they can hopefully add it to the advocacy uh priorities that they engage in. 00:38:10.960 --> 00:38:15.760 If you like to write, think about writing an op-ed or a letter to the editor. 00:38:15.760 --> 00:38:21.599 If you read an article that really uh inspires you, think about writing a letter to the editor. 00:38:21.599 --> 00:38:31.119 And most of your the professional organizations are there to help their members, both with the drafting of those as well as helping to pitch and get them placed. 00:38:31.440 --> 00:38:31.760 Thank you. 00:38:31.760 --> 00:38:36.639 I'm not sure a lot of our listeners are aware of the hospital's government relations staff. 00:38:36.639 --> 00:38:42.320 So I think that's a great resource for providers to be able to reach out to become involved. 00:38:42.559 --> 00:38:42.880 Yeah. 00:38:42.880 --> 00:38:48.719 You know, and if you have a little more time, I always say it's it's a wonderful experience to come here to Washington, DC. 00:38:48.719 --> 00:38:50.800 Uh, there's really nothing like it. 00:38:50.800 --> 00:38:55.599 All of the professional organizations that I mentioned before all have fly-in days. 00:38:55.599 --> 00:39:10.719 Many have a combination of training on skills, training on issues, and most of them culminate with going to your actual elected member of Congress's office on Capitol Hill to talk about an issue that's uh relevant to your profession. 00:39:10.719 --> 00:39:16.559 Also, most of those organizations with state chapters also do something similar at the state capitol. 00:39:16.559 --> 00:39:21.599

So I think those do take a little more time, and so this is definitely an investment. 00:39:21.599 --> 00:39:34.880 I often hear from folks that do these how inspiring and fun, and how nice it is to step away from the clinic for a couple days to engage and see government in action. 00:39:35.199 --> 00:39:50.880 Well, I guess that brings me to given your time on Capitol Hill as a staffer and your time teaching advocacy to pediatricians, what tips can you offer pediatric surgeons for having a successful meeting with a member of Congress or their staff? 00:39:51.519 --> 00:39:54.480 I love this question because I've sat on both sides of it. 00:39:54.480 --> 00:40:03.280 I've sat as the staffer receiving information from a constituent, and I've also done uh lobbying and training physicians to do lobbying. 00:40:03.280 --> 00:40:09.920 So a few thoughts to leave your listeners with is to always be prepared. 00:40:09.920 --> 00:40:14.559 I think in knowing who your audience is is critically important. 00:40:14.559 --> 00:40:31.280 So uh ways to kind of figure out where your member or the staff person may be on a particular issue, a good place to look is the member's website and to kind of take a look at their press releases, see the types of press releases they've been putting out because that's an indication of that member's priorities. 00:40:31.280 --> 00:40:32.880 And maybe it isn't healthcare. 00:40:32.880 --> 00:40:47.440 So you're gonna go in maybe having to do a little more educating on some of the basics, or maybe it is, and so it's important for you to go in if the member has been supporting something already that you're going in to talk about, start with a thank you. 00:40:47.440 --> 00:40:58.159 Talk about the impact that that person's vote or the bill they introduced, how that is important to the care and to your to the care you give and the patients that you see. 00:40:58.159 --> 00:41:07.199 And then also if that member has voted in a way that you don't support, it's really important to be educated on that and think about the language you might use. 00:41:07.199 --> 00:41:12.320 Because I say every one of these conversations and meetings is the start of a relationship. 00:41:12.320 --> 00:41:25.119 You may not agree on everything, but it's really important to go in as a constituent to provide your perspective and to also explore where you might find areas of agreement, even if it's not the exact issue that you're in there to talk about. 00:41:25.119 --> 00:41:40.000 Having clear asks, though, I think is about the most important piece of advice I would give, which is that that staffer, when you leave the meeting, that staffer should know exactly why you came in and what exactly you want their boss to do. 00:41:40.000 --> 00:41:45.519 Because if they can't know that and they don't know that, that is an incredibly missed opportunity. 00:41:45.519 --> 00:41:49.440 So make sure that you start with your ask and you end with your ask. 00:41:49.440 --> 00:41:52.880 And then the last thing I would say is that follow-up really matters. 00:41:52.880 --> 00:41:56.320 So I am a big fan of the thank you note. 00:41:56.320 --> 00:41:58.639 It's hard to do those handwritten nowadays. 00:41:58.639 --> 00:42:00.400 So email is fine. 00:42:00.400 --> 00:42:11.760 And it's also an opportunity to both ensure that you're getting that staffer's email and providing them with your contact information so that if they have follow-up or want to engage you down the road, they know how to do that. 00:42:11.760 --> 00:42:18.960 But it also enables you to get their cards so you have their email and you can send a thank you and then reiterate your asks when you send a thank you. 00:42:19.280 --> 00:42:23.840 Now, Congress is of course only one of the three branches of the federal government. 00:42:23.840 --> 00:42:30.400 So I know there's advocacy work that we can also do with the executive and judicial branches. 00:42:30.400 --> 00:42:33.199 Can you share briefly your thoughts on that? 00:42:33.440 --> 00:42:41.920 I think people oftentimes, you know, they think about engaging with lawmakers and they they really think about the legislative branch, and I understand that. 00:42:41.920 --> 00:42:54.559 But we do have two other branches of government where advocacy can be very effective and needed, especially lending your expertise as medical and scientific experts. 00:42:54.559 --> 00:43:00.239 So in the executive branch, you know, there's so many policies that come out of the executive branch. 00:43:00.239 --> 00:43:09.519 They oftentimes start at a federal agency like the one where I worked, and then they make their way all the way up to the White House before getting published in the Federal Register. 00:43:09.519 --> 00:43:15.679 Oftentimes those rules usually are open for public comment before they become final. 00:43:15.679 --> 00:43:17.920 So that is really critical. 00:43:17.920 --> 00:43:23.039 And those comments become part of the administrative record. 00:43:23.039 --> 00:43:37.440 And so those are really important, both for the agencies that are seeking to finalize the rules, and then ultimately, if those rules are challenged and wind up in court, the judges in those cases oftentimes look at the comments that were submitted. 00:43:37.440 --> 00:43:47.760 So even if your comment doesn't change the outcome of the rule, it can still have an impact as part of the administrative record for the courts down the road. 00:43:47.760 --> 00:43:51.920 So highly encourage consideration of participation in that. 00:43:51.920 --> 00:43:59.440 And many professional organizations will provide templates so you don't have to know exactly how to. 00:43:59.440 --> 00:44:03.679 Submit it or what to say all on your own. 00:44:03.679 --> 00:44:21.280 Usually, you know, the organizations that you might already be a part of, whether it's the American Academy of Pediatrics or the American Medical Association or the

American College of Surgeons, will already kind of do the hard legwork of putting together a template that you can then personalize based on your expertise and your patients. 00:44:21.280 --> 00:44:30.960 And then switching to the judicial branch, just very briefly, obviously, if you are not a party to a lawsuit, there are more limited options for engagement. 00:44:30.960 --> 00:44:44.400 But one of the things I've seen very done very effectively by professional medical organizations is engaging in the filing or signing on to of an amicus brief or a friend of the court brief. 00:44:44.400 --> 00:44:55.920 And that can be an impactful way for physicians and organizations to ensure that their expertise is heard in the court, even if they aren't one of the two members of the lawsuits. 00:44:56.159 --> 00:45:01.280 I'm going to move on to a couple questions we had from our listeners. 00:45:01.280 --> 00:45:03.760 This is for both of you. 00:45:03.760 --> 00:45:07.599 And these were questions about Medicaid. 00:45:07.599 --> 00:45:09.280 This one's about Medicaid and chip. 00:45:09.280 --> 00:45:20.800 Are Medicaid and chip eligibility thresholds truly aligned with the cost of living in high-cost states, or are large numbers of near poor families still falling through the cracks? 00:45:21.360 --> 00:45:23.679 This is certainly one I can chime in on. 00:45:23.679 --> 00:45:27.519 We have some great news for kids in the Medicaid world. 00:45:27.519 --> 00:45:35.519 I will tell you some of the income limits for adults are preposterously low in some places. 00:45:35.519 --> 00:45:40.719 But for kids, we have had great success over the years. 00:45:40.719 --> 00:45:45.199 And again, that's because healthcare for kids is a bipartisan issue. 00:45:45.199 --> 00:45:52.079 And in red states and in blue states, you can get legislators to set high income limits for the program. 00:45:52.079 --> 00:45:59.119 So almost all of the states are up to 200% of the poverty level for Medicaid. 00:45:59.119 --> 00:46:12.960 And they are layering chip on top of that, where the average goes up to something in the range of uh 255, but you have some states going up as high as three or 400 for their chip. 00:46:12.960 --> 00:46:20.079 So the short answer is families that are just above the poverty level, their kids are going to be eligible for Medicaid in every state. 00:46:20.079 --> 00:46:27.039 And their kids, even if they're quite above that, are still very possibly going to be eligible for chip. 00:46:27.039 --> 00:46:29.679 The parents in the family might not have coverage. 00:46:29.679 --> 00:46:37.119 And as we said, that has huge implications for the economic security of that family, right? 00:46:37.119 --> 00:46:50.320 So if the parent is uninsured and because of that, the family ends up homeless because they can't, because they have a medical bankruptcy and can't make rent, then yes, that that child has a health insurance, but they're also living in a car, right? 00:46:50.320 --> 00:46:58.159 And so you have a whole bunch of bad outcomes related to what is happening at the family level, right? 00:46:58.159 --> 00:47:01.280 I always remind people kids live in families, right? 00:47:01.280 --> 00:47:04.159 They're not little automatons that are out there. 00:47:04.159 --> 00:47:17.440 Um the bad news is, even though we have these amazing income limits for children, we still have a lot of policies that make it really hard for those low-income families to keep their kids enrolled. 00:47:17.440 --> 00:47:30.800 Um, and so that's why we have this persistent um uninsurance rate for children that even though for many of these kids there is a program, we can't seem to keep them in the program. 00:47:30.800 --> 00:47:37.679 Um, and so that's why we really need to work on smart policies to help retain their coverage. 00:47:37.679 --> 00:47:41.440 And let's just get them in and keep them in, right? 00:47:42.480 --> 00:47:43.039 Thank you. 00:47:43.039 --> 00:47:54.960 I have a question from one of our listeners about HR1 and children's best health care, which provides specialized, holistic, and family-centered medical care and what states can do if there are federal cuts. 00:47:55.280 --> 00:47:55.760 Yeah. 00:47:55.760 --> 00:48:01.440 So I think this is where advocacy uh and relationship development is really critical. 00:48:01.440 --> 00:48:11.599 As I mentioned before, states are going to be faced with some really tough decisions based on their budgets because of the cuts coming to them from HR one. 00:48:11.599 --> 00:48:22.639 And so now is a really good time to be working in coalition with other partners and getting to know the staff that work in your state Medicaid office. 00:48:22.639 --> 00:48:30.960 These are very hardworking folks that are administering very large programs in most cases and have a lot coming their way. 00:48:30.960 --> 00:48:51.679 Um at the current moment, and I'm happy to talk more about this, but those staff are dealing with many things, but especially the implementation of the new Medicaid work requirement and some new guidance that just came out of the federal government that is going to cause a lot of changes to systems that they've built. 00:48:51.679 --> 00:49:00.880 So at the current moment, many Medicaid staff are really dealing with the aftermath of the federal government's latest thinking on the work requirements. 00:49:00.880 --> 00:49:21.360 So it is an important time to really shore up education and to do that as much as you can in coalition and partnership with others so that you can hopefully persuade the Medicaid staff to not put children's benefits in the crosshairs as they're trying to make these really difficult coverage decisions. 00:49:21.920 --> 00:49:31.519 Which brings me to what are both of your thoughts on is it time for a universal children's coverage program that eliminates Medicaid and chip fragmentation? 00:49:32.159 --> 00:49:40.639 I t's challenging to

think of how it happens outside of the context of our sort of current universe, right? 00:49:40.639 --> 00:49:50.960 So our current universe is half of half of the people in this country are getting insurance through their work, and that's a lot of kids who are getting coverage that their families are happy with, right? 00:49:50.960 --> 00:49:54.559 So um I don't think we're gonna upend that anytime soon. 00:49:54.559 --> 00:49:59.679 Um we have the programs, right? 00:49:59.679 --> 00:50:02.320 We have Medicaid, we have chip. 00:50:02.320 --> 00:50:10.079 Uh the the one group you can kind of you know put a pin in is the question of immigration status, right? 00:50:10.079 --> 00:50:15.519 Because as Tamara was talking about, there are some immigration statuses that are not eligible for for Medicaid and chip. 00:50:15.519 --> 00:50:19.440 And so what happens to those kids is a big question, Mark. 00:50:19.440 --> 00:50:30.400 But if if you look at the kids that have a qualifying immigration status, right, um Medicaid and chip income limits go up quite high. 00:50:30.400 --> 00:50:37.280 Um, so there we have a home, we have a health answer for these kids. 00:50:37.280 --> 00:50:40.559 We're just not making that answer workable. 00:50:40.559 --> 00:50:42.639 Um, so what does it look like? 00:50:42.639 --> 00:50:56.719 What it looks like, and this is sort of what we have um suggested as the policy concept, is when kids are born, they are enrolled into Medicaid, regardless of their income. 00:50:56.719 --> 00:51:03.679 Their parents have an employment insurance, great, that insurance is the primary insurance, it's gonna pay for everything. 00:51:03.679 --> 00:51:09.920 Medicaid doesn't do anything for that kid, it's just background music that's not doing anything. 00:51:09.920 --> 00:51:25.679 But when that kid whose family has an employment insurance, when mom or dad loses their job and suddenly they're low income, and the primary employment insurance disappears, the Medicaid insurance is already on. 00:51:25.679 --> 00:51:28.400 It's there, it's ready to go. 00:51:28.400 --> 00:51:31.840 So there's no breakup in their coverage. 00:51:31.840 --> 00:51:37.840 And the kids are covered continuously from birth until they turn, you know, whatever age, let's say 21. 00:51:37.840 --> 00:51:43.440 Um, and so what that means is you don't have the annual renewal problems. 00:51:43.440 --> 00:51:46.719 You don't have the problem of the family's income changing mid-month. 00:51:46.719 --> 00:51:50.159 Um, it's you know, it's kind of a pay and chase model. 00:51:50.159 --> 00:51:55.280 People get health care, and then we sort out who pays for it. 00:51:55.280 --> 00:51:57.760 And if there is an employer insurance, they pay. 00:51:57.760 --> 00:52:01.440 And if there isn't, then the public program pays. 00:52:01.440 --> 00:52:04.559 And which exactly which pro public program, right? 00:52:04.559 --> 00:52:05.360 We don't care. 00:52:05.360 --> 00:52:07.840 We'll we'll we'll we'll sort that out, right? 00:52:07.840 --> 00:52:14.400 That is what the model looks like to make sure that kids have coverage the whole way through. 00:52:14.400 --> 00:52:17.840 And I'll tell you one thing that will just kind of blow your mind. 00:52:17.840 --> 00:52:25.280 Um, uh I've I have been a practicing right um attorney most of my career. 00:52:25.280 --> 00:52:36.800 And so I'm more new in the world of working at a university, um, but I I meet a lot of um international healthcare people now who I talk to. 00:52:36.800 --> 00:52:52.320 And when you talk to somebody from one of these countries that actually does get a hundred percent of their population covered, they can't even understand the concept of eligible but not enrolled. 00:52:52.320 --> 00:53:01.840 It does it doesn't even exist in their systems that there could be a person who, yes, they qualify for this for the government to provide their health insurance. 00:53:01.840 --> 00:53:07.760 They just happen to not be in a status that allows them to get that coverage, right? 00:53:07.760 --> 00:53:12.639 It's it's like talking to a fish about what it's like to live outside of water. 00:53:12.639 --> 00:53:16.559 They just don't even, they can't even conceive of what it's like. 00:53:16.559 --> 00:53:26.320 We need to get to the point in our country where for our children, where it's eligible but unin unenrolled, doesn't even make sense for a kid, right? 00:53:26.320 --> 00:53:42.239 Let's let's let's design the system to bring them all in at birth, keep guarantee that they have a source of coverage the whole way through, and when primary coverage drops, we always have a backup. 00:53:42.239 --> 00:53:58.880 And once we do that, then tomorrow and I can spend our time figuring out how we make sure kids get all the services they should have while they're covered, and spend instead of spending all of our time spinning our wheels about these kids who are constantly dropping off of coverage, right? 00:53:58.880 --> 00:54:00.320 It just makes no sense. 00:54:00.320 --> 00:54:08.880 And obviously, for providers, you know, um, when it's one in 20 kids who are uninsured, that's one in 20 kids who show up to their appointment. 00:54:08.880 --> 00:54:12.880 And the last time you saw them, they had insurance, and this time they don't, right? 00:54:12.880 --> 00:54:21.679 And now you can't see them, and the front office has to make all these calls, and they have to come back on another day, and their treatment gets disrupted, and all of these problems happen, right? 00:54:21.679 --> 00:54:27.440 It's it's an inane system that should not exist for kids that way. 00:54:28.000 --> 00:54:33.760 Finally, I would love for each of you to share your top three takeaway points with our listeners. 00:54:34.239 --> 00:54:43.039 I would like to close just reminding providers that there are a lot of ways to be involved and a lot of ways to get involved. 00:54:43.039 --> 00:54:57.360 Um, you

know, if you can only get involved at the level of your patients, learning a little bit more about the rules of Medicaid and how you can advocate for your patients and get them the care they're entitled to, then bless you. 00:54:57.360 --> 00:54:58.159 Thank you. 00:54:58.159 --> 00:54:59.280 We appreciate you. 00:54:59.280 --> 00:55:07.280 You know, even that is you going above and beyond your job description to help kids. 00:55:07.280 --> 00:55:12.320 Um, but if you can do more than that, then there are a lot of ways to get involved, right? 00:55:12.320 --> 00:55:19.519 You can um work with provider associations at the state level to influence how states run their program. 00:55:19.519 --> 00:55:24.159 A lot of really consequential decisions get made by the states and you can influence that process. 00:55:24.159 --> 00:55:33.039 You can be a watchdog um talking to advocates um about the you know naughty things that you see managed care plans doing. 00:55:33.039 --> 00:55:39.760 Um, you know, so when someone like me tells you here's what the rules are supposed to be like, and then you see managed care plans are not doing that, right? 00:55:39.760 --> 00:55:46.000 You can be the person that goes to those advocates in your state and says, hey, this is what we're seeing, what can be done about it. 00:55:46.000 --> 00:55:50.880 Um and and those advocates might go to town on that issue with your help. 00:55:50.880 --> 00:56:00.400 Uh another really important role is that you can help improve the policies and practices of the hospitals that you work in. 00:56:00.400 --> 00:56:22.880 Um this is a really important way that doctors can be involved in ways that are supportive because hospitals, um other practice-level um institutions often have policies that the people who are making those decisions don't understand how they impact patients. 00:56:22.880 --> 00:56:25.840 Um, and and you can actually be a big part of that. 00:56:25.840 --> 00:56:29.679 You know, Tamar talked about um access to care for immigrants. 00:56:29.679 --> 00:56:31.039 That's a great example. 00:56:31.039 --> 00:56:49.280 Um the way that an emergency room, the way that a hospital talks to immigrants has massively outcome-determinative impact on whether those immigrants stay to keep to get care or just turn around and walk right out of the emergency room, right? 00:56:49.280 --> 00:56:50.639 Because they're fair afraid. 00:56:50.639 --> 00:56:55.039 Um so there are a lot of ways that you can influence policy that that impacts things. 00:56:55.039 --> 00:56:59.920 You can also be a public spokesperson for the um interests of your patients, right? 00:56:59.920 --> 00:57:10.719 When a state proposes a bad policy or somebody proposes a good one, um, you can speak publicly about um, you don't have to take a position on legislation per se. 00:57:10.719 --> 00:57:15.119 You can just say, here's how this is going to impact patients based on what I see as a provider. 00:57:15.119 --> 00:57:18.639 And I think providers often underestimate their importance. 00:57:18.639 --> 00:57:22.800 You know, I'm somebody who makes a lot of public statements, uh, but guess what? 00:57:22.800 --> 00:57:27.760 There are a lot of people who don't trust me the way they trust you as a provider. 00:57:27.760 --> 00:57:28.960 You know, I'm a lawyer. 00:57:28.960 --> 00:57:30.719 That's strike one right there. 00:57:30.719 --> 00:57:33.679 Um that might even be a strikeout right there. 00:57:33.679 --> 00:57:36.079 Um I'm perceived as an advocate. 00:57:36.079 --> 00:57:40.559 Um, and some people think I have, you know, some agenda, right? 00:57:40.559 --> 00:57:45.599 I'm I'm trying to follow the evidence to get care for people, but some people think I have an agenda. 00:57:45.599 --> 00:57:53.920 When people hear providers talk, when they hear doctors talk, um, they know you are speaking out for your patients. 00:57:53.920 --> 00:57:57.039 You are a trusted leader, you have a trusted voice. 00:57:57.039 --> 00:58:02.960 So you have a power that you may not realize you have until you start using it. 00:58:02.960 --> 00:58:07.679 And you might realize, oh wow, people actually listen to me. 00:58:07.679 --> 00:58:09.679 People care about what I think. 00:58:09.679 --> 00:58:20.480 Um I have the ability to, you know, get people to listen who might not listen to other people bringing the same evidence forward, right? 00:58:20.480 --> 00:58:23.119 Um, so that's what I would ask you to lean into. 00:58:23.440 --> 00:58:25.840 So a few thoughts in closing. 00:58:25.840 --> 00:58:31.840 I would say that uh it is important to remember that advocacy is a marathon and not a sprint. 00:58:31.840 --> 00:58:42.000 So you may not see the benefit of your activities and your actions right away, but just know that persistence does lead to progress. 00:58:42.000 --> 00:58:48.480 And then I also would just say that it is important to remember the power that you have as physicians. 00:58:48.480 --> 00:59:01.119 And I love to remind physician organizations about this uh Gallup poll that Gallup does every couple of years just to remind you of the power that you have within. 00:59:01.119 --> 00:59:08.239 So Gallup polls Americans and their views on honesty and ethics in various professions. 00:59:08.239 --> 00:59:13.920 So they ask Americans how they feel about honesty in a whole range of professions. 00:59:13.920 --> 00:59:27.920 And I would say, and just to note that nurses and doctors uh consistently rank in the very top, always among the highest, where Americans view their honesty and ethics high or very high. 00:59:27.920 --> 00:59:37.679 And consistently at the very bottom, this year it is only beat by telemarketers, is members of Congress. 00:59:37.679 --> 00:59:48.480 So there's a lot of power in that, and reminding yourself that as doctors, as physicians, you are the trusted voices in the room, and there's a lot of power in that. 00:59:48.480 --> 00:59:56.639 And then as physicians, I know that you are dealing with a lot, a lot of stress, a lot of moral injury. 00:59:56.639 --> 01:00:06.480 And I have had physicians tell me on so many occasions that engaging in advocacy feels like an antidote to what they're dealing with clinically. 01:00:06.480 --> 01:00:17.280 The stress of the profession, the added administrative burdens on you as physicians, and so many challenges that you're facing, that engaging in advocacy can be a real antidote to that. 01:00:17.280 --> 01:00:25.360 Being around other people who are advocating for policies that will benefit their patients can be really helpful at supporting that work. 01:00:25.840 --> 01:00:31.280 Thank you very much, Leo and Tamar, for a wealth of information and resources on Medicaid. 01:00:31.280 --> 01:00:33.679 I want to thank you both for your time today. 01:00:33.679 --> 01:00:38.480 Our next podcast will be E-Bikes, Kids, and the Speed of Change. 01:00:38.480 --> 01:00:59.599 We will have guest speakers Romeo Ignacio, a pediatric surgeon from San Diego, a member of the Southern California ACS Advocacy Committee, and Sigrid Burres, an acute care trauma surgeon from Irvine, California, who was awarded the American College of Surgeons Advocate of the Year in 2025. 01:00:59.599 --> 01:01:02.159 Thank you for listening to Operation Advocacy. 01:01:02.400 --> 01:01:03.280 Thanks for listening. 01:01:03.280 --> 01:01:05.199 Make a difference in the life of a child. 01:01:05.199 --> 01:01:08.400 Advocate, but also please like and subscribe to our podcast. 01:01:08.400 --> 01:01:12.480 And if you want to make your voice heard, one way to do that is contacting your policymakers. 01:01:12.480 --> 01:01:14.559 There are some links below that can help.