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And the Medicaid Rolls Just Keep Growing and Growing….. We have been watching the rolls increase for several months now, waiting for the recession to take full effect. From what we’re seeing in Arizona and Colorado, it looks like the impact of job losses is starting to show up in Medicaid. Colorado‐ The CO Medicaid rolls are growing fast, with more than 72,000 people added in the last year. The current total enrollment of 457,000 people is a new record for the state. 1 Officials are trying to increase it to nearly 600,000 with recent legislative efforts. The expansion effort seeks to raise the FPL ceiling to cover 100,000 more citizens. If the bill gets federal approval, it will be the largest Medicaid expansion for CO since the beginning of the program. 2 In order to
12 Month Increases in Medicaid Enrollm ent (April 08 - April 09)
fund the CO Medicaid expansion, Gov Ritter has signed
1,200,000
into law a new hospital tax that will be used to get federal
1,000,000
fund matching.
3
800,000 600,000
Arizona‐ Medicaid rolls in AZ have surged by almost
400,000
102,000 people over the last 12 months (11%). Projected
200,000
cost increases are in the $250M range for next year. AZ
0
currently is short about $3B for next year. 4
AZ Enrollment before surge
CO 12 month increase
Planned expansion
3
Hospitals Fighting to Survive in the Economy: Medicaid and the Summer Squeeze of 2009 We take a look at some on the ground examples in 7 states: Washington‐ Hospitals in WA say the state owes them money for patients whom Medicaid should have covered and who received services from 1994 to 2009. 18 hospitals are suing the state for $31M in back payments. This case is one of many across the country that seeks similar payments, but it is considered to be the strongest one
According to a survey conducted by the American Hospital Association (AHA), hospitals across the country are taking drastic measures to survive in the recession, including reducing services like patient education and clinics. Key financial metrics like days cash on hand are "slipping" and may signal a time in the near future when creditors call in chips.
out there currently. If the hospitals win this one in WA, expect many
http://www.aha.org/aha/content/2009/p
more to follow across the nation. In 1995, Medicaid accounted for
df/090427econcrisisreport.pdf
about 90% of WA hospital revenues ‐ now its about 83%. 5
Nevada‐ Hospitals are phasing out services to deal with the economic recession. University Medical Center of Southern Nevada has closed its mammography center and plans to start shutting down its outpatient cancer program in 4Q09. The $30M in overall state Medicaid cuts are seen as a contributing factor. 6
Impact of Recession on US Hospitals
Illinois‐ According to a survey of hospitals Stopping building projects
80%
Seeing more uninsured patients
60%
conducted
by
the
Illinois
Hospital
Association, facilities in the state are reporting some scary numbers: increases
Cut staff levels
50%
Expect losses in 2009
40%
in ER visits (47% of hospitals); longer delays to get paid by Medicaid (78% of hospitals); longer delays to get paid by private
Reduced services
20%
insurers (30% of hospitals); and plans to fire staff (30 % of hospitals). 7
4
Idaho‐ Medicaid hospital rehab providers
Some MA hospitals report no decline in
got a stay of execution in late April when a
volume, but have seen less waiting time for
judge blocked reimbursement cuts (some as
patients. 10
high as 55%). The judge gave a 3 week
reprieve, and arguments were scheduled to
Pennsylvania‐ PA hospitals are getting
resume in late May. 8
crushed as the state reckons with a $3B
deficit. Profit has dropped 13% for the
Utah‐ Medicaid is slashing hospital
average PA hospital since December 2007,
reimbursement this July 1, with most
and the proposed $75M in cuts for FY 2010
facilities staring down the barrel of a 25%
are expected to turn a crisis into a
cut. Making it worse is the fact that most
catastrophe for hospitals. Most of the cuts
hospitals are not really prepared ‐ a
are to supplemental payments above and
temporary plug was found to avoid the cut
beyond standard PA Medicaid rates. Stories
last year so it did not hit the radar. Hope
of decline at individual hospitals give a
still persists, with some lawmakers
sense of the state as a whole:
suggesting the use of tobacco tax increases
Univ of Pittsburgh Medical Center has seen
or perhaps raiding a special fund for about
revenue decrease 3% and fired 500
$9M. 9
employees.
Massachusetts‐ Nearly 2/3 of MA hospitals
West Penn Allegheny Health System had a $9M loss in 2Q09. 11
are reporting drops in profit margins, largely due to reductions in elective
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surgeries and other delayed care. The average facility has lost more than 50% of its margin‐ plummeting from 0.7% in 4Q08 down to 0.3% in 1Q09. Jobs are disappearing and new clinics and other expansions are on hold. Caritas Christ is laying off 160 people. Lahey Clinic has tabled plans to build a new $100M facility.
FREE The fine print: all you have to do is write an article for an upcoming issue, or join our blog team. Paid ads also available at low rates. Email us for more info info@mostlymedicaid.com
5
More news over at the Mostly Medicaid Blogs
blog.mostlymedicaid.com where the best Medicaid minds mingle.
recent entries New use of the old healthcare fraud statute It’s getting ugly‐ cuts across the states Provider taxes everywhere! CMS should reconsider Colonoscopy decision Stimulus strings attached EHR updates Medicaid fraud news
Now we’re on Facebook and Twitter, too! Look us up searching “medicaid” or “mostly medicaid”
6
The Great Healthcare Reform Debate: The 4 Critical Obstacles to Reform that No One is Taking Seriously Enough Everyone is all abuzz with the possibility that the full‐scale, national health reform dream will happen give convergence of key current events. A President has been elected that will push for it. We learned from Hillary’s mistakes 15 years ago, and she is on today’s team to make sure we don’t forget. The global economic crisis has brought the middle class to the brink of actually facing the costs of their own coverage and maybe even losing it. And – in an astounding move – major stakeholders who profit from US healthcare spending have gone on record volunteering to take a $2T hit to make the reform plans work. It all seems to add up to a slam‐dunk. But there are key problems and obstacles that we are not engaging in the debate. And by “we”, we mean the vast majority of us who make our living from being connected to the U.S. healthcare industry – and happen to also be predominantly Democrats. There’s no denying it (and no need to). But sometimes the political ideology keeps our heads in the sand when confronted with real barriers to our goals. The 4 Critical Obstacles We Need to Take More Seriously #4 – No one really believes the industry will sacrifice trillions in profit. Trust is key to getting the nation to provide the faith needed to embark on a reform journey that will take at least decades. The surprising announcement that key US health industry players would forego $2T in revenues (via spending cuts) to make Obama's health care proposal work was, well, surprising. Voices on both sides of the aisle are skeptical. Besides the fact that these same groups have historically fought the very same
An Overview of Where the Debate is Today – Read this Report Whitepapers and primers on healthcare reform are popping up everywhere. The folks at Healthjournalism.org have done a good job of boiling the debate down to 3 main issues ‐ 1. Coverage‐ Roughly 1 in 7 people were without it in 2007 and Americans in general are starting to care. 2. Cost and Spending ‐ It's eating up GDP (16% in 2008) and its scaring retirees. 3. Quality ‐ American medicine is in the middle of the global pack on this one, despite the high price tag.
This is a 20 page report that covers the role Medicaid may (or may not) play in any reform plans. The report points out the impact Medicaid costs play in the overall trends, but also that a whole separate set of issues emerge when reformers realize that Medicaid may need to be "folded into new insurance arrangements." The report also makes the key point that the line between public and private coverage has often become blurred in America. Finally ‐ the report covers lots of ground, including an overview of the reform bills (and related committees) already in play. This report is a great way to get up to speed quickly on the reform talk today.
Other Sources The Washington Post also started a new section on the healthcare reform debate‐ http://voices.washingtonpost.com/health‐care‐ reform/
Marilyn Werber at the National Journal threw out 2 key topics to several heavy hitters in health economics today. In addition to asking if the estimated $2.7B in savings from increased fraud prevention efforts are realistic, she also asked commenters to weigh in on the plausibility of the now famous health industry‐volunteered $2T in savings to make health reform work. The comments come from the likes of John Goodman, Uwe Reinhardt, Denis Cortese, and Chuck Grassley. For anyone interested in various perspectives on the industry's claims to put some skin in the game ‐ this read is a gold mine. http://healthcare.nationaljournal.com/2009/05/poli cing‐medicare‐fraud‐worth.php
8
Its (one of) the elephant(s) in the healthcare room. Innovative fixes whose effectiveness is unknown and won't be for decades aside ‐ Medicare is broke and we all know it. We
proposed savings measures, analysts just don't believe that insurers, providers and others will sacrifice their own economic self‐interest to make this all work. Others feel that the announcement itself was the accomplishment (or tactic depending on who you listen to). In other words, they believe the press conference showing the American Medical Association, American Hospital
have for a while now, and we
Association, the Pharmaceutical Research and Manufacturer's Association all
just have to simply face it.
reaching consensus on a voluntary $2T pay cut sent a strong message of progress ‐ whether or not its impossible to actually achieve. 12
#3 ‐ The reimbursement system is completely misaligned and fixing it will take decades (just like it took decades to screw it up so royally). Take for example the concept of reducing re‐admissions. Reducing re‐admit costs are great for Medicare. Terrible for hospitals. If all unnecessary re‐admits were eliminated for Medicare patients, CMS would save about $17B. But hospitals lose money because patients are not coming back for follow‐up care and beds are left empty. It's not that they want patients to have complications. They don't. And in fact here are a few examples of hospitals that have tried to do the right thing, but can't afford to keep it going: Park Nicollet Hospital (Minnesota) spent $750 k to get nurses and the electronic tools needed to track cardio patients once discharged home. The readmit rate dropped from 16% to 4%. CMS pocketed about $5M in savings each year from the Park Nicolett program ‐ but the most CMS sent back to the hospital in the form of enhanced reimbursement for higher quality of care was $250k in one year (not enough to cover the program). The program is still in place but is losing money according to the chief exec at the facility.
Costs of Running Redmit Avoidance Program at One Hospital
$5,000,000
$750,000 $250,000 1
-$500,000
Expenses to run cardio follow -up program
Reimbursement from CMS for program
Park Nicollete Net
CMS savings
Catholic Health Partners ran a similar cardio follow‐up program with grant funding for 5 years, but when the grant dried up the hospital tried to find other financial backers (such as insurance companies), but no one would put any skin in the game and the program was ended. 13
9
Medicaid Managed Care 17th Annual
Congress
Next Gen Medicaid Managed Care – Optimizing Quality, Access and Efficiency
20+ States Represented!
What is Changing for 2009
CONFIRMED: Senator Tom Daschle to Speak at MCC Senator Tom Daschle, Former Senate Majority and Minority Leader, has confirmed his keynote session on Solving the Healthcare Crisis for Tuesday, June 9, 2009.
• M edicaid Reform Roundtable with representation from the Obama Administration • M edicaid 101 Workshop for Healthcare Executives New to Medicaid, Managed Care or in Need of a Refresher
Keynote and Featured Speakers
• S trategies to Improve Health Literacy to Affect True Behavioral Change
P hilip M. Bonaparte, MD Vice President of Clinical Affairs, Horizon Blue Cross Blue Shield of New Jersey, Chief Medical Officer HORIZON NJ HEALTH
• T ools to Implement a Comprehensive Program to Track, Report and Reduce Never Events
Carolyn Ingram Director, Medical Assistance Division NEW MEXICO DEPARTMENT OF HUMAN SERVICES
• O pportunities to Leverage the Medical Home Model in Medicaid • E xpanded State Medicaid Director and Health Plan CEO Panels
Accreditations PTi international is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Anthony Rodgers Director ARIZONA HEALTH CARE COST CONTAINMENT Bruce Johnson Technical Director, Division of Benefits, Eligibility and Managed Care CMS
This event is jointly sponsored by CME LLC and the Institute for International Research.
Special Thanks to Featured Media Partner
www.MostlyMedicaid.com
‘09
June 8-10, 2009 Hyatt Regency, Baltimore, MD
www.MMCCongress.com
#2 Thinking that US taxpayers might pay more than they do now to cover other people may ignore a growing lower‐my‐taxes movement. It certainly ignores that the recession is hitting taxpayers just as hard as everyone else. One health reform proposal in the US Senate would have taxpayers paying even more to fund Medicaid, albeit indirectly. The Senate Finance Committee is considering whether to remove the current tax‐exempt status of employer‐sponsored health coverage. Obama opposes this (largely due to labor unions ties) as way to achieve reform, but advocates like the Kaiser Commission on Medicaid and the Uninsured say 21M more Americans could have health insurance if another $19B can be found somewhere in the budget. Other advocacy groups like the Center on Budget and Policy Priorities (CBPP) further elaborate the fiscal justice position. The director of CBPP believes the current tax‐exempt status of employer‐sponsored health coverage "gives the greatest benefit to . . . the group that needs the least help paying for health insurance." Max Baucus brings the debate back to reality when he reminds us that mechanisms that increase the burden on taxpayers (like raising the price of their own healthcare by 30% by taxing it) are of little use for forging healthcare reform that works. 14 Don’t count on taxpayers taking this one sitting down. #1 – It just may be that the numbers really don’t add up and maybe never will. As much as advocates, academics, Democrats and those who profit from the US healthcare industry believe that reform (and ultimately universal coverage) should happen, it may not be actually possible from a fiscal viewpoint. Until this harsh possibility is at least considered possible, efforts making the should match the is will continue to waste time and resources that could be geared toward a different movement with similar objectives. Think its really just a simple exercise in finding the money or moving it around? Take a look at Medicare and SSI. Fundamental deficiencies in the basic financing model of these two programs have made one thing clear to the average American – you can not keep spending money you do not have forever. The economic meltdown has reinforced this. Asking Americans to believe anything different will eliminate credibility. Reform’s best hope –maybe it’s only hope – is if we can be transparent and simple enough in our reform efforts to win back the faith of an American populace who will be paying for this thing for
11
generations. The Americans who signed off on SSI and Medicare and Medicaid 70 and 40 years ago were much less jaded than Americans today. Not only is Medicare going broke (and broker), Social Security is set to be bust in 2016. The insolvency dooms‐day for each of these programs is now projected 2 years closer than was projected last year. The WSJ makes a mind‐blowingly simple observation. If $13T (the current Medicare hospital deficit) were put in an interest bearing account today, Medicare would be funded until almost the next century (2084). That was just the Medicare hospital fund. When you look at all parts of Medicare (doctors services, drugs, etc) the amount of money Medicare owes but does not have is almost $38T. According to one analyst, that is more than twice the size of the entire U.S. economy. Spread to each household, each US family owes about $325k to cover Medicare. Social Security is bad off, but not as bad as Medicare. (SSI owes about $5.3T over the next 75 years). According to Geithner, once healthcare reform is completed, SSI reform is next. 15 The recently released Medicare Trustees report just could not go
Current Unfunded Obligations of Medicare and SSI Compared to Size of US Economy (all in $ trillion)
unanswered. HHS Secretary Sibelius issued an official commentary on the
$38
underlying message of the report. She $19
calls it a "wake‐up call" for people concerned
about
healthcare
in
$5
America, and vows (on behalf of Obama) that "whatever it takes to
Medicare Unfunded Obligations
US Economy
SSI Unfunded Obligations
Net
protect it" will be done. You have to wonder if that is actually possible.
-$24
Sibelius covers the more ominous data from the report. Medicare is in the hole today. Not ten years from now. It is spending more than it takes in and government officials are using fund balances to fill the gap. In 2017 they will run out of band‐aids and Medicare retirees will face premiums that more
12
realistically reflect the cost of their care. No one has admitted yet that they may just lose coverage alltogether. If we sound skeptical, its because we are. We agree that this is a crisis (it's easy to agree with the obvious). We just don't believe rhetoric and vague new funding mechanisms will generate the cold, hard cash needed to get us out of the mess. 16 Now get out there and come up with some better ideas.
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FREE The fine print: all you have to do is write an article for an upcoming issue, or join our blog team. Paid ads also available at low rates. Email us for more info info@mostlymedicaid.com
13
What if you could identify your frail members? For the first time in health care, an objective and evidence-based resource is available to accurately determine high-risk members and manage their risks associated with frailty. SeniorMetrix, pioneers in predictive modeling, introduces its newest technical solutions – HRAPlus and HomeSafe – designed with caregivers and health plans in mind.
The Power of Information • • •
A web-based tool, the HRAPlus screens and identifies in-home, high-risk members The tool generates a reliable and objective measure of function and risk to establish someone’s specific needs on a daily basis Such information helps care managers allocate appropriate member management resources which allows for early intervention in maintaining a safe living environment
The Clout of Evidence • • •
Based on 400,000+ clinical cases in this web-based tool, HomeSafe is a comprehensive in-home assessment of identifying members for risk factors With 350 different data elements, the HomeSafe assessment produces a detailed summary for care planning The HomeSafe application includes automated reporting for identifying individual risk factors and care needs
To see how others have benefited from this one-of-a-kind technology, email msandwith@seniormetrix.com or call 866.755.3374 www.seniormetrix.com
CHIP UPDATE SUMMER 2009 We look at what 4 states are doing with their CHIP programs: North Dakota‐ North Dakota shut down
afford insurance anyway. Dems in the Hawaii
attempts to expand its CHIP using an increased
legislature are looking for ways around a veto
Federal Poverty Level ceiling of 200%. Right
this time around, inserting about $600k in the
now 150% of FPL is the cut‐off. 17
state budget for Keiki Care in FY 2010. 19
Texas‐ Dems are trying to double the current TX
Iowa‐ With one piece of legislation, Iowa just moved to the front of the line in terms of states with the highest percent of kids covered. In fact its just about 100% now that the 53,000 remaining uninsured kids are covered under a bill passed with widespread and bi‐partisan support. The initial price tag was about $10M, but with CHIPRA (see the sidebar below) putting more cash on the table, its more like $7.5M. 18 Hawaii‐ Usually CHIP programs face challenges like caps in enrollment or funding shortfalls.
CHIP coverage period (from 6 to 12 months) to try and ensure 250,000 kids would be covered. Right now their parents have to re‐apply every six months to prove they are still eligible, and advocates claim this "beaurocratic hurdle" reduces the rolls unnecessarily. Opponents say that without the required reapplication, you can't be sure that only the neediest kids get care. Doubling the time that beneficiaries can go without re‐applying is estimated to cost TX another $300M in state funds (but would leverage the match to get another $500M in federal funds). 20
Hawaii's Keiki Care is fighting just to exist. It got started in mid‐2008 but was shut down by the Governor who felt it covered families who could
Under the CHIP Reauthorization Act (CHIPRA), states can get a higher federal match if they exceed their enrollment targets AND implement 5 of 8 policies near and dear to the feds. The enhanced FMAPs can be as high as 92%. The strings attached include continuous enrollment targets, not having asset tests and other items. The days of exceeding your CHIP enrollment goals and then being punished with an enrollment cap or funding 15 shortfall may just be over. Check out the full report for more details‐ www.kff.org/medicaid/upload/7884.pdf
Mostly Medicaid LinkedIn Group Has Passed 450 Members! In less than 10 months the Mostly Medicaid group on LinkedIn has skyrocketed to 450+ members. This makes the Mostly Medicaid group the largest group on LinkedIn that connects Medicaid industry professionals for sales opportunities, job openings and knowledge sharing. Our members include Medicaid directors, hospital executives, industry analysts, government officials, consultants, and many other leading professionals in the Medicaid industry. Mostly Medicaid is a group of hundreds of Medicaid industry professionals who network and share information. If you are involved in the Medicaid industry, we have a spot for you at our ever‐growing table! Go to linkedin.com and search groups using “Medicaid” to find us and join.
16
Medicaid Crossword Summer 2009
Across 3. One of the 4 obstacles to reform, according to Mostly Medicaid 4. Medicare _______ Report. Report that recently predicts Medicare will be insolvent in 8 years 8. State that does not have a CHIP program 9. Big word in Medicaid policy today, and focus of this issue of the MM newsletter 13. State where hospitals just received a 25% cut in Medicaid reimbursement 14. State where one hospital is closing a mammography center 15. The word for when the enrollment increase is planned
Down 1. 2. 3. 5. 6. 7. 10. 11. 12.
North ________. State that just pulled out of efforts to increase the CHIP FPL floor to 200%. State where hospitals are suing Medicaid agency for back payment for services to the indigent % of US hospitals who have reduced services during the recession One word for what has occurred in Medicaid enrollment in the past 12 months The act that brought CHIP back _______-sponsored coverage. the senate finance committee is considering taxing this for the first time % of US hospitals who expect to post a loss in 2009 One of the 3 keys to the reform debate, according to healthjournalism.org State with the highest % of kids covered
17
Job Listings
Hey‐ We know it’s tough out there.
Here’s a few Medicaid‐specific opportunities. If you are interested in more specific details about any of the positions below, please contact Eve Crane & Associates Inc via email: eve@evecrane.com
Clinical Product Designer
interface with medical management such as provider
Location: South
relations, member services, benefits and claims
Licensed RN with a minimum of a bachelor's degree
management, etc. Assists in short and long range
(masters' preferred) OR a Masters' level professional
program planning, total quality management (quality
with public health background and extensive
improvement) and external relationships. Works
experience in behavior change and health education.
with Corporate Health and Medical Affairs for
Project Management
support, assistance and direction in overall medical
Product Development
management effectiveness. Reports all issues of
Knowledge of Technical healthcare systems
clinical quality management to the health plan CEO,
COO, the Board and the Chief Medical Officer (CMO)
of Corporation. Collaborates with the CMO and
other health plan medical directors on national
Medical Director
medical policies and carries out national medical
Location: East Coast
policies at the health plan in collaboration with the
JOB SUMMARY: Oversees all medical care for
health plan CEO or COO
Company products and services. Oversees the health
care needs of the membership and serves as the
principal medical manager and policy advisor to the
VP of Proposal Development
company and health plan CEO or COO. Is
JOB SUMMARY: Under the direction of the SVP
accountable for and provides professional leadership
Business Development, the VP is accountable for the
and direction to the utilization/cost management
production of a high quality proposal response that
and clinical quality management functions. Works
incorporates COMPANY marketing messages and
collaboratively with other plan functions that
win themes with the required elements of the
18
technical requirements. The VP plans, organizes, and
the Senior Vice President of Health Plan Services.
manages the work of the Business Development unit
This position collaborates with leaders at the highest
to support business acquisition in new and existing
level of the company and with internal customers
markets for COMPANY with a primary focus on the
and business partners.
proposal development process, tools and the
This position requires a strong proven ability to lead,
integration of COMPANY marketing messages within
with strong functional skills in technology, business
the technical response.
process engineering and business planning and
execution. Experience includes a blend of strategic
and
VP of Health Plan Services
communications and a strong background in the
Location: East Coast
healthcare IT industry. Essential responsibilities
JOB SUMMARY: The Vice President of HPS serves as
include overall leadership and management of a
a significant contributor to the senior leadership
regional market.
operational
experience
with
effective
team of Health Plan Services and reports directly to
19
Crossword Answers
20
1
“Number on Medicaid sets record for state.” Allison Sherry. The Denver Post. May 16, 2009
2
“Federal funds will help enroll more people in Medicaid.” Tim Hoover and Jennifer Brown. The Denver Post. April 22, 2009
3
Colorado Governor Signs Bill To Expand State Medicaid Program. Medical News Today. April 27, 2009
4
“Economic slump leads to 11% jump in Az Medicaid.” Tucson Citizen. May 7, 2009
5
Tim Klass. AP. 4/24/09
6
“Hospitals cutting services, staff amid recession” Las Vegas Sun. Apr 26, 2009
7
“Illinois Hospitals Hit Hard By Recession.” Medical News Today. April 10, 2009
8
“State Medicaid Developments.” Idaho Statesman, 4/28 "Medicaid Cuts Leave Hospitals Strapped.” Salt Lake Tribune. May 1, 2009
9
10
“Hospitals, patients suffer from decline in elective surgeries.” Megan Woolhouse. Boston Globe
May 4 2009 11
“Hospitals fear Pennsylvania spending cuts in Medicaid.” Mike Wereschagin. Tribune Review
April 28, 2009 12
“Kaiser Daily Health Policy Report Feature Highlights Recent Blog Entries.”Kaisernetwork.org 5/12/09
13
“Hospitals Pay for Reducing Costly Readmissions.” NYT. May 8, 2009
14
Reuters May 12, 2009
15
“Social Security, Medicare bleeding faster ‐ Washington Times. 5/29/09; WSJ. David Dickson
May 13, 2009 16
“Sebelius Statement On New Medicare Trustees' Report.” CMS and Medical News Today. 5/15/09
17
Wetzel. AP/ Rockford Register Star. 4/25/09
18
“Iowa Legislature approves health expansion.” USA Today. Mike Glover. 4/24/09
19
“Hawaii Democrats Look To Put Funding for Children's Insurance Program in Several Appropriations Bills To Sidestep Veto.”
Kaiser Daily Health Policy Report. Apr 30, 2009 20
“Advocates push for children's Medicaid expansion in Texas Legislature.” Dallas News. May 12, 2009
21