When the CHIPS Are Down
Texas nurse leaders and advocacy organizations seek support to restore health coverage for the state’s impoverished children
By Steve McLinden
August 16, 2004
Rosalind Bryant, RN, a pediatric nurse practitioner in the hematology / oncology clinic at Texas Children’s Hospital in Houston, says she’s seen firsthand how recent cuts in the Texas Children’s Health Insurance Program (CHIP) program are heaping new miseries on kids who have suffered too much already.
Bryant, who treats many sickle cell anemia patients, has watched as an increasing number of financially strapped families are forced to forgo such preventive measures as routine eye exams that could determine if disease-related retinopathy is advancing in their children.
One distraught mom told the nurse that her son had suffered respiratory symptoms at home and later complained of ear pain, symptoms she had tried to treat with home remedies because there was no money in the budget for a doctor visit. “Well, he woke up in the middle of the night screaming in pain a few nights later and then she had to take him to the ER,” Bryant said.
The child recovered, “but because he had a hematological problem … his care requirements were much greater and the bill was tremendous,” Bryant said. “That’s just one example of how these cuts are going to come back to bite us. And in the meantime, theyjust going to do more harm to children.”
A dubious ranking
According to 2002 Census data, 22.6% of Texas children — about 1.4 million — lack any type of health care coverage, the highest rate of any state in the nation. The Texas CHIP program, instituted in 1999, has served as an insurance safety net for children whose family’s income exceeds Medicaid limits but remains too low to afford private health insurance. But hikes in copays and a litany of other new fees and restrictions imposed in the last year have winnowed down the state-reported CHIP enrollment numbers from 507,000 last September to about 358,000 today.
Several grassroots coalition groups, many with nurses leading the charge, have formed in the past year to stem the rollback against Texas children, and restore CHIP funding to previous levels.
Margie Dorman-O’Donnell, RN, MSN, cochair of governmental affairs for the Texas Nurses Association and a nurse with a Dallas/Fort Worth area health care provider, says the cuts strike at the very foundation of good health: preventive care.
“We are shortchanging tomorrow’s citizens in the state of Texas with limited care today,” she said. “Kids will miss school because they’re sick, their parents will miss work and miss wages, and employers will suffer lost productivity.”
Dorman-O’Donnell says the cutbacks are disheartening for nurses “because they can’t find the resources these children need and it’s exasperating to see the shortsightedness of it all. Public health nurses and pediatric nurses are especially frustrated because they are all seeing the direct consequences of these children being shortchanged.”
The CHIP cuts are part of wholesale spending reductions in the Texas Health and Human Services Commission designed to alleviate a $10 billion general fund budget shortfall the Legislature tackled last year.
The changes that were pushed through included changing the $15 annual CHIP program fee to a monthly $15 charge; eliminating vision, dental, hospice, and most mental health benefits; and removing child support, child care, and work-related expenses from coverage guidelines. Formerly annual eligibility reviews for families enrolled in CHIP coverage now will take place every six months.
This month, a new asset test will reportedly knock another 5,000 children off CHIP rolls. Families with more than $5,000 in total assets – which include savings and checking accounts – would be disqualified if their income exceeds $28,275 a year, or 150% of the poverty level. The new CHIP asset policy is more restrictive than Children’s Medicaid.
Leaving money on the table
What frustrates many advocates is that Texas is losing far more in matching federal funds than it saves in withholding state money, say Dorman-O’Donnell and other Texas caregivers.
About $550 million in matching funds will go unused because of the 2003 budget cuts of about $206 million from the program. “Texas has left money on the table that could have been matched because it was unwilling to find money in the budget,” Dorman-O’Donnell said. “And we are going to be paying a lot more as a society in the future than we will be saving in the present.”
A July report from the Kaiser Commission on Medicaid and the Uninsured stated that the state saved a total of $1.6 billion through cuts and stricter eligibility standards.
Beth Schlechter, RN, MSN, a practicing clinic nurse in Austin and a member of the Central Texas Regional Children’s Health Insurance Coalition, said the preventive care cuts will mean that many developmental problems will go undiagnosed. “This is one of those things that will have great repercussions in the life of a child and the life of a family. It is trickle-down in the truest sense of the world.”
She said nurses are seeing more kids coming to the ED for primary care “who shouldn’t have to be there, but they don’t have a medical home now,” she said. “It is essentially the state shifting the burden. We are seeing big increases in the percentage of uncompensated care, and that burden always cycles back to the community.”
Schlechter, who is working with the statewide Campaign to Restore CHIP, said she plans to help such advocacy groups quantify how much harm the CHIP cuts are inflicting for presentation to the Texas Legislature at the January session.
In a six-county North Texas region that includes the heavily populated Dallas and Tarrant counties, CHIP rolls have been reduced by 32% since Sep-tember, according to Sara Neese, RN, vice president of administration for Cook Children’s Health Plan.
Neese adds that CHIP, for the first time, will begin removing families in September for failure to pay their premiums. “More and more, these families have a choice,” she said, “and that’s: ‘Do I put food on the table or do I pay these premiums?’”
Fighting back
Sustaining CHIP funding “is just the right thing to do,” she said. “You don’t turn your back on kids that need you. They have no voice. They are vulnerable. So we have to try to speak for them. The way things are now, they are not going to get screened for diabetes and other diseases … so the effects of this are going to be felt for years and years.”
The Texas Nurses Association has joined a bipartisan coalition of elected officials and advocacy organizations that are calling on Gov. Rick Perry and the Legislature to restore CHIP funding.
Others joining the effort include the Texas Medical Association, Texas Catholic Conference, the Mental Health Association, Cook Children’s Medical Center, The United Way, and The Texas Hospital Association.
State officials involved with the CHIP program say some issues surrounding the program have been overhyped. The steep drop in CHIP enrollment is partially due to some families’ failure to send in renewal forms, said Linda Dalton, an administrator for the East Texas CHIP Coalition, which is based in Longview. “It is the families’ responsibility to take ownership of their own health care, and we encourage that. That’s something that gets left out of a lot of the op-ed pieces and news stories.”
Additional families have been dropped off because they lost income and rolled over into the Medicaid program, or their children have aged out of the program, she added.
Russell Smith, press officer for the Texas Health and Human Services Commission, said the $15 monthly fee enables families to “insure their kids for about the price of a meal at McDonald’s. It is very much the best deal out there.”
Some families are misinterpreting the recent spate of publicity on CHIP “as a sign that it’s going to go away and it’s not worth their money,” he said. “We have tried to counter that by urging people who have CHIP coverage to stay with the program … and reinforcing the fact that we are still signing up eligible people.”
New people signing up for CHIP are not doing it, however, through referrals from the state itself. Texas also has stopped spending money to promote CHIP at clinics and other care and community venues to the families who might benefit.
The CHIP program also has been under fire after a state auditor reported in July that poor oversight at the Health and Human Services Commission allowed a $20 million overpayment to a third-party insurance provider, a move that forced the removal of 17,000 children from the CHIP rolls, according to Texas Comptroller Carole Keeton Strayhorn.
Future on the line
The state’s insistence that it balances its budget without raising taxes is deceptive, Dorman-O’Donnell said. “We are going to be paying more in the long run in insurance or through the communities in [property] taxes,” she said.
Bryant, of Texas Children’s in Houston, said increases in copays (an extra $2 or $3 a visit) “may seem small, but for families on strict budgets with multiple kids suffering from chronic illness, that’s a big burden.” She said one nurse devised a plan to defray expenses for CHIP families by soliciting contributions to help patients pay for hospital-area parking.
Cuts in mental health treatment also are taking their toll, Bryant said. Those who have had cancer and lost their hair or lost a limb and who suffer from mental health comorbidity problems as a result, “need to be helped with their ability to cope,” she said. “I have kids right now who can’t get those services because of CHIP cuts.”
Bryant said she encourages nurses and other caregivers to write to their congressional representatives to restore CHIP funds. “Nurses and the whole interdisciplinary team are saddened by these cuts and what they are doing to sick children,” she said. “Even though these are chronically ill children, these are our children and our future.”