LetterOn February 13th, Michigan Governor Rick Snyder’s administration submitted a Medicaid 1115 waiver proposal concerning children and pregnant women in Flint. After the lead water disaster was exposed and information came to light about how many children tested with high blood lead levels, questions arose as to how those children could access the services and care they would need in the future. The state’s proposal seeks to provide Medicaid coverage for the children and pregnant women affected by the lead in Flint’s water.

About 30,000 people in Flint currently receive Medicaid or Children’s Health Insurance Program (CHIP) coverage an this waiver proposal would give access to about 15,000 more.

Many states have applied for and received 1115 waiver demonstrations – there are examples all across the board. This one, though, is a little different. The other waivers often apply to the whole state and everyone lives under the same rules of the waiver. What Governor Snyder is asking for would not apply to everyone in Michigan, but the “individuals up to age 21 who are served by the Flint water system or were served by the Flint water system between April 2014 and the date on which the Flint water system is deemed safe by the appropriate authorities.”

The waiver seeks to waive “statewideness,” which is the offer of Medicaid coverage to all individuals in Michigan. This waiver proposes to include any children born to the pregnant women who are served by the Flint water system between the date of the waiver approval up until the water in Flint is deemed safe. Those children would retain full Medicaid eligibility until age 21, and pregnant women would receive it through their pregnancy and for two months afterward.

Governor Snyder’s proposal would allow children (up to age 21) and pregnant women who are or who have been exposed to Flint’s lead poisoned water to access Medicaid coverage if they have an income up to 400 percent of the Federal Poverty Level (FPL), which is $64,080 for a family of two.

Pregnant women and children up to age 21 who were/are exposed to Flint’s water, but whose income is above 400 percent FPL, could buy into the program to access Medicaid. That cost per month is between $446 per person per month and $500 per person per month.

Currently, the Medicaid program in Michigan covers children up to 1-year-old with household income up to 195 percent of (FPL). Children ages 1-18 with household income up to 160 percent of FPL qualify for Medicaid. Children with household income up to 212 percent of FPL qualify for MICHILD (Michigan’s CHIP program). Pregnant women with household income up to 195 percent of FPL are currently covered by Medicaid in Michigan.

Michigan does not offer Medicaid or CHIP coverage to lawfully present immigrant children and pregnant woman, though this option is available to states, and 29 states opted to do so.

Questions and ideas for improvements in the Michigan waiver proposal:

When CMS approves 1115 waivers, they are typically for an initial five year period and then extended for an additional three years. The questions here are:

  • How long will this waiver be extended?
  • Will it be renewed so that newborns who have been born in Flint recently, or are born before the “Flint water system is deemed safe by appropriate authorities,” have Medicaid coverage for the full 21 years?
  • Will all the future governors of Michigan renew this waiver?
  • Will every federal U.S. Department of Health and Human Services administration renew this waiver?
  • Can these promises truly be kept for the children of Flint?
  • Is that really a certainty?
  • Is it possible to guarantee coverage for decades to come for this population?
  • What stipulations have to be made for that to hold true?
  • how will immigrant children and their families access needed coverage and ongoing services?

The waiver request states that children and pregnant women who are covered by Medicaid through this waiver will receive Targeted Case Management (TCM) services. Those services are defined as “services furnished to assist these individuals within the target population in gaining access to needed medical, social, educational, and other services.” The state will provide face-to-face TCM services in a manner consistent (with their state code) though a Designated Provider Organization (DPO).

The qualifications to be a DPO include the capacity to provide comprehensive assessment and care plan management, as well as linking, coordination, and long-term monitoring of services. The DPO will serve as a case manager to the family and be either a Licensed Registered Nurse with at least one year of experience in community health, pediatric, or maternal or infant health nursing services, or a Licensed Social Worker with at least one year of experience providing social work services to families.

These are appropriate descriptions and I think a good start. However, when you look at the type of symptoms a lead affected child or youth could show, I recommend that these DPOs receive ongoing, specific training on the needs their clients will have now and in the future.

Lead poisoning symptoms 

  • Tiredness or loss of energy
  • Hyperactivity
  • Irritability or crankiness
  • Reduced attention span
  • Poor appetite
  • Weight loss
  • Trouble sleeping
  • Constipation
  • Aches or pains in stomach

The waiver talks about referrals to Early On (Part C), Head Start, and Great Start (state-funded four year old preschool) in Michigan, all appropriate for the youngest children. However, questions remain:

  • What about school age children?
  • What about a fourth grader with hyperactivity or a reduced attention span? Irritability?
  • What about a teenager with those symptoms?
  • What will be the best, most effective referrals for those children over the years to come?
  • Can this waiver assure that services will exist for all of these children, for the coming decades, and that the services will be provided by case managers who are trained in these specific issues?
  • Will they have appropriate referral agencies and services at the ready?
  • Will the school administrations and staff be trained in how best to teach and discipline the kids of Flint so that they can stay in school and reach their educational goals?
  • How about school-based health clinics? They could be a big support to the schools and to the students and staff. They should certainly be seen as essential Designated Provider Organizations.
  • What if the children who were affected by Flint’s water system move to other areas in Michigan, away from Flint? Will the TCM follow them? Will there be services for them in Marquette or Grand Rapids or Benton Harbor?
  • Are the children and youth assured that access no matter where they live in Michigan throughout their childhoods?

Another area that could use further refinement in the proposal is the evaluation of the demonstration. Right now, it appears to be an evaluation only of how many people utilize services and what those services are. Of course, those numbers are important, but this is also a critical time to evaluate if the services provided work:

  • Did children gain skills?
  • Were symptoms alleviated?
  • How long were services used?
  • Were all children given access to the needed services?
  • Were new or additional services created to meet the needs of the children as they grew up? Were there services in the schools?
  • Were providers given specific training?

There are many ways this evaluation could be designed to help guide and improve this waiver for years, decades to come as well as to offer information for other lead impacted communities.

The idea of this waiver is a good one to provide coverage and targeted services to a specific population who needs it now and will into the years ahead. It can and should be done well, on behalf of the children and families in Flint. With thought and careful design, this can be managed in ways that give the right help to those who need it the most.

Michigan Governor Asks CMS for Medicaid Coverage for Children from Flint http://bit.ly/1U8DGAQ #InvestInKids #FlintWaterCrisis
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