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43–021—PDF 2007

S. HRG. 110–439

CHILDREN’S HEALTH INSURANCE PROGRAM IN

ACTION: A STATE’S PERSPECTIVE ON CHIP

HEARING

BEFORE THE

COMMITTEE ON FINANCE

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

(BILLINGS, MT)

APRIL 4, 2007

(

Printed for the use of the Committee on Finance

COMMITTEE ON FINANCE

MAX BAUCUS, Montana, Chairman

JOHN D. ROCKEFELLER IV, West Virginia

KENT CONRAD, North Dakota

JEFF BINGAMAN, New Mexico

JOHN F. KERRY, Massachusetts

BLANCHE L. LINCOLN, Arkansas

RON WYDEN, Oregon

CHARLES E. SCHUMER, New York

DEBBIE STABENOW, Michigan

MARIA CANTWELL, Washington

KEN SALAZAR, Colorado

CHUCK GRASSLEY, Iowa

ORRIN G. HATCH, Utah

TRENT LOTT, Mississippi

OLYMPIA J. SNOWE, Maine

JON KYL, Arizona

CRAIG THOMAS, Wyoming

GORDON SMITH, Oregon

JIM BUNNING, Kentucky

MIKE CRAPO, Idaho

PAT ROBERTS, Kansas

RUSSELL SULLIVAN, Staff Director

KOLAN DAVIS, Republican Staff Director and Chief Counsel

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C O N T E N T S

OPENING STATEMENTS

Page

Baucus, Hon. Max, a U.S. Senator from Montana, chairman, Committee

on Finance ............................................................................................................ 1

Cantwell, Hon. Maria, a U.S. Senator from Washington ..................................... 5

WITNESSES

Schweitzer, Hon. Brian, Governor, State of Montana, Helena, MT .................... 4

Miles, Joan, Director, Montana Department of Public Health and Human

Services, Helena, MT ........................................................................................... 8

Lyons, Dr. Barbara, vice president and deputy director, Kaiser Commission

on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation, Washington, DC ............................................................................................................. 10

Anderson, Melissa, representing her family, Helena, MT .................................... 12

Langohr, Janis I., M.D., pediatrician, the Children’s Clinic, Billings, MT ......... 20

Windy Boy, Hon. Jonathan, council member, Chippewa Cree Tribe Business

Committee; and Montana Representative, House District 32, Box Elder,

MT ......................................................................................................................... 22

Stewart, Judy, Director of Strategic Partnerships, Yellowstone City-County

Health Department, Billings, MT ....................................................................... 23

Wright, Rev. F. Vernon, Plymouth Congregational Church, United Church

of Christ, Helena, MT .......................................................................................... 25

Rencher, Dr. Kevin, pediatric dentist, Helena, MT .............................................. 33

Simon, Lori, March of Dimes, Billings, MT ........................................................... 35

Sauers, Clark, senior, Project for Alternative Learning, Helena, MT ................. 35

Thompson, Eran, Montana People’s Action, Billings, MT .................................... 35

Brown, Russ, on behalf of State Representative Arlene Becker, Vice-Chair,

Montana House Committee on Health and Human Services, Billings, MT .... 37

Callbeck-Harper, Pat, associate State director of AARP, Helena, MT ................ 38

Riutta, Olivia, representative of WEEL, Helena, MT ........................................... 38

Rockroads, Dolly, Northern Cheyenne Tribe, co-founder of the National Indian

Child Development Institute ............................................................................... 39

Lankford, Carole, vice chair of the Salish-Kootenai Tribe ................................... 40

ALPHABETICAL LISTING AND APPENDIX MATERIAL

Anderson, Melissa:

Testimony .......................................................................................................... 12

Prepared statement .......................................................................................... 43

Baucus, Hon. Max:

Opening statement ........................................................................................... 1

Becker, Hon. Arlene:

Prepared statement .......................................................................................... 45

Brown, Russ:

Testimony .......................................................................................................... 37

Callbeck-Harper, Pat:

Testimony .......................................................................................................... 38

Cantwell, Hon. Maria:

Opening statement ........................................................................................... 5

Langohr, Janis I., M.D.:

Testimony .......................................................................................................... 20

Prepared statement .......................................................................................... 47

Lankford, Carole:

Testimony .......................................................................................................... 40

Page

IV

Lyons, Dr. Barbara:

Testimony .......................................................................................................... 10

Prepared statement .......................................................................................... 49

Miles, Joan:

Testimony .......................................................................................................... 8

Prepared statement with attachments ........................................................... 66

Rencher, Dr. Kevin:

Testimony .......................................................................................................... 33

Prepared statement .......................................................................................... 80

Riutta, Olivia:

Testimony .......................................................................................................... 38

Rockroads, Dolly:

Testimony .......................................................................................................... 39

Sauers, Clark:

Testimony .......................................................................................................... 35

Schweitzer, Hon. Brian:

Testimony .......................................................................................................... 4

Simon, Lori:

Testimony .......................................................................................................... 35

Stewart, Judy:

Testimony .......................................................................................................... 23

Prepared statement .......................................................................................... 84

Thompson, Eran:

Testimony .......................................................................................................... 35

Windy Boy, Hon. Jonathan:

Testimony .......................................................................................................... 22

Prepared statement .......................................................................................... 87

Wright, Rev. F. Vernon:

Testimony .......................................................................................................... 25

Prepared statement .......................................................................................... 93

COMMUNICATIONS

Fight Crime: Invest in Kids .................................................................................... 97

Melbourne, Gary James, letter to Chairman Baucus, dated April 4, 2007 ........ 102

The Urban Institute ................................................................................................ 105

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CHILDREN’S HEALTH INSURANCE PROGRAM

IN ACTION: A STATE’S PERSPECTIVE ON CHIP

WEDNESDAY, APRIL 4, 2007

U.S. SENATE, COMMITTEE ON FINANCE, Washington, DC.

The hearing was convened, pursuant to notice, at 2:10 p.m., in

the Student Union Building, Montana State University-Billings,

Billings, MT, Hon. Max Baucus (chairman of the committee) presiding.

Present: Senator Cantwell.

OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR

FROM MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

The CHAIRMAN. Good afternoon, everyone. We are now convening

the Senate Finance Committee hearing in Billings. It is not often

that we get to have a hearing outside of Washington, DC and come

to where the rubber meets the road, where the real decisions are

made. We are very honored to be here at MSUB, the Finance Committee is, to have this hearing on the Children’s Health Insurance

Program.

Also, I want to begin by thanking our Governor, Governor

Schweitzer, for joining us here today. [Applause.]

The Governor has been a great friend to Montana’s children in

lots of different ways, helping them, and having the legislature do

the right thing on CHIP, for example.

In addition, we are very honored to have Joan Miles here with

us. Joan is the Director of the Department of Public Health and

Human Services to represent the technical level of all that is happening in Montana as we improve our outreach for children. Also,

a big, big welcome, a big Big Sky welcome, to Senator Maria Cantwell, who has joined us here today. [Applause.]

Senator Cantwell is a member of the Finance Committee, one of

our most valuable members. Of course, all members are valuable.

She is very active in lots of areas, very effective, not only for the

people whom she represents from the State of Washington, but also

on national issues. I could just go down the list. One of the issues

is energy. She is very forward-looking in trying to figure out how

to make sure we become more independent of OPEC. Another is

just basic investment decisions and how we have the wherewithal,

the economic wherewithal and the capital of our country to invest

in areas that help make our country stronger. And, clearly, Seattle

as the gateway to Asia is an extremely valuable part of the country

in terms of trade with Asian countries and America, and she is a

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very, very smart, good, and effective Senator. So we thank you,

Senator Cantwell, for all that you do.

Sir Thomas Browne, an English physician and philosopher, once

wrote: ‘‘There is no road or ready way to virtue.’’

Well, Sir Thomas Browne wrote this long before we had the Children’s Health Insurance Program. In my view, the program has

paved the clearest road to improve the lives of our Nation’s children in recent years.

It is only fitting that we here today in Montana join to discuss

our journey this past decade with the Children’s Health Insurance

Program. Today’s hearing gives the Finance Committee a great opportunity to hear directly about how it has worked at the State

level and, again, as I mentioned earlier, where the rubber meets

the road.

I am proud of the role that so many of us have played in Montana’s journey with CHIP so far. It was in 1997, frankly, that this

got off the ground, and it was a great idea. It was championed by

Senators on both sides of the political aisle, and Senator Hatch

from Utah was extremely active, and the late Senator John Chafee

of Rhode Island, another very active Senator. They are the two—

and there were a couple more—that were really the major prime

movers in 1997. I was there, I was pushing it, but to be honest,

it was Senator Hatch and Senator Chafee who really led the effort,

and we all owe them a deep debt of gratitude for all that.

I was also at that time, prior to coming to our legislature, back

then helping Montana get started with CHIP, testifying at a committee because of its importance. I am very happy that we have

moved, and I am very hopeful that the State legislature now will

take the next step as it moves coverage beyond the 150 percent up

to a higher level.

The number of children in our State who have been helped by

low-income programs is at least 13,000, and it has also improved

the enrollment of Native Americans, a segment which is often forgotten, and we are not going to let that happen. And I think we

can be proud when the legislature finally enacts an increase in coverage.

But we cannot rest on our laurels. There is always much more

to be done, and that clearly is the case here.

Too many children who are eligible for the Children’s Health Insurance Program and for Medicaid remain uninsured. That is, they

just do not get the benefits in the law. Nationwide, three-quarters

of the 9 million uninsured children are eligible for either CHIP or

Medicaid, but they are not enrolled.

Of our State’s 37,000 uninsured children, more than half—that

is, 19,000—are eligible for either Medicaid or CHIP. But they remain uninsured. Many of those who remain uninsured live in Indian country. Clearly, that is an area that we have to address. And

the number of uninsured children in Montana unfortunately has

been rising, even as the number of uninsured children nationwide

has been falling. The largest increase in uninsured children is

among children under 5 years of age. Those are the kids, clearly,

who need access to health care the most. This is simply unacceptable.

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Not having health insurance means one accident, one broken leg,

or one major life-saving surgery could drive these families into

bankruptcy.

Today, we will hear from Melissa Anderson. Melissa will tell us

how not having health insurance coverage can mean choosing between making payments to keep her business from sinking and

paying for prescriptions to keep her son from having seizures.

These are decisions no Montanan or any American should have to

face.

And while Montana’s recent Children’s Health Insurance Program expansions are positive, we still in our State rank second to

last in coverage. We need to ensure that Montana, therefore, has

the funding that it needs to cover kids at levels provided by most

other States. In fact, in my personal view, I think we need to see

that Montana can cover kids up to twice the poverty level, even

more than we are contemplating in the legislature.

Looking at the road ahead for CHIP, there are at least five principles that I will pursue.

First, we must provide adequate funds to maintain coverage for

those already on the program. According to the Congressional

Budget Office, we will need at least $13.4 billion over the next 5

years just to maintain coverage.

Second, we must reach the 6 million children who are eligible for

coverage either under CHIP or Medicaid but not enrolled.

Third, we must support State efforts to expand coverage to children through the Children’s Health Insurance Program.

Fourth, we must improve the quality of health care that children

receive. I do not think enough emphasis has been given to quality.

Quality is something which we should certainly focus on in reauthorizing legislation.

And, finally, we must not add to the numbers of the uninsured

as a result of our legislation. There are some, unfortunately, who

would like to see the numbers of uninsured actually rise due to restricting of coverage under the program. I am totally on the opposite side of that one. I think we should expand and not let anybody

fall between the cracks. Again, there are some who have a contrary

view in Washington, DC.

There will be challenges on the path to passing our bill. First

among them is how to finance the cost of renewing the program.

It is going to cost about $50 billion over the 5 years.

Let me state right here that this is the major initiative taken by

the Congress when we passed the budget resolution just a short

while ago: expanding CHIP by this amount. It is by far the most

significant new addition that we have passed in the budget resolution, and it is because of its need. We are moving in this country

toward universal coverage. [Applause.]

We are the only industrialized country in the world without universal coverage. That is not right. Every American should get

health insurance. When I say universal coverage, I mean that we

have to find our own unique American solution through a combination of private and public programs that results in universal coverage. Again, it is public and it is private. It is working together.

It has to be a uniquely American solution. But we must move agVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
4

gressively in this to provide universal coverage. And expanding the

Children’s Health Insurance Program is a step in that direction.

I plan to move on this very quickly and work with the Ranking

Republican on the Committee, Chuck Grassley. I would like to

move this legislation without delay. After this second hearing this

committee is now holding, we will be getting down to brass tacks

in the coming months. We will have a committee bill ready for

markup I think by late spring of this year. I want to move it, and

we will vote on the bill before September 30th, when funds expire.

Again, the program expires September 30th, and I am not going

to tempt fate by waiting close to the deadline. Rather, we have to

move early, as I said, markup by late spring. The fall schedule depends significantly on the decisions made by the Majority Leader

and other extraneous issues that we cannot now foresee. So my

view is let us get started, let us move.

This afternoon I very much look forward—and I know I speak for

the Governor and for Senator Cantwell—to hearing from people

who really know what is going on. It has been a great journey for

us, and you can help us so very, very much.

We are honored today to have our Governor. Governor Schweitzer has been moving the ball forward to get health care for Montana’s children since he was elected. In the past 2 years, he has

led State efforts to expand eligibility and lift enrollment levels. He

has improved outreach that is so critical to the program and making progress toward reaching our State’s uninsured children.

Thanks for all of you. It is a real honor to have you here. Thanks

for taking the time to come from Helena. I expect, though, it is

probably a little bit of a respite. It is kind of joyful to leave Helena

these days, in all fairness to the legislature. [Laughter.]

This might be an excuse for you to leave Helena and come on

over. In any event, we are very honored to have you here and

would love to hear your comments. [Applause.]

STATEMENT OF HON. BRIAN SCHWEITZER, GOVERNOR,

STATE OF MONTANA, HELENA, MT

Governor SCHWEITZER. Thanks, Max. I do that all the time. It is

actually ‘‘Senator Baucus.’’ I make that mistake all the time, and

I know people all over Montana make that same mistake. And

so——

The CHAIRMAN. What do you mean, ‘‘mistake?’’ [Laughter.]

Governor SCHWEITZER. I have decided, you know how sometimes

when you try to remember someone’s name, it is better to remember what they do and then that triggers your mind to what their

name is. So in my mind, I will always think of you as ‘‘Senator

CHIP’’ because no one has done more for the Children’s Health Insurance Program than Senator Baucus. So from now on it is ‘‘Senator CHIP.’’ [Applause.]

The CHAIRMAN. Except for those wonderful children who made

those chocolate chips out here.

Governor SCHWEITZER. Those are great.

The CHAIRMAN. They have done more for CHIP than anybody.

Governor SCHWEITZER. And, Senator Cantwell, welcome to Montana, and I know that after you have more of a chance to travel

5

across Montana, you will be back many times to enjoy the splendor

of Montana.

For those of you who do not know, Senator Cantwell really has

led on the national scene in energy independence, so I think of her

as ‘‘Senator Energy.’’ And for those of you who—I have the same

problem with Senator Tester. I always think of him as ‘‘Jon,’’ like

you do. So Jon, Senator Tester, has taken on the cause of veterans,

and so I just think of him as ‘‘Senator Vet.’’ Now we have this all

taken care of.

Healthy communities start with healthy families, and a healthy

start is healthy children. Montana has 13,300 of our children enrolled in the CHIP program that gets the families a healthy start.

And some people think of the Children’s Health Insurance Program

as being intended for indigent families. It is not. In Montana, 92

percent of the people who are enrolled in the CHIP program have

one or both of the parents working. These are working families,

and, ‘‘Senator CHIP,’’ there is nothing more important to working

families than a healthy child, because all over Montana there are

young families who say a prayer with their children as they tuck

them into bed, and after they tuck their children in, they go down

the hall and they kneel again and they say a prayer. And this time

the prayer is that none of their children gets sick because they do

not have health insurance.

These are working families. These are members of our community. So thank you for providing the Federal funds so that 13,300

kids have coverage. We have asked the legislature to increase coverage in the CHIP program in Montana to 175 percent of the poverty level, and, Senator, if you can find the resources in Washington, DC, if you could help us, we will take it to 200 percent and

above in the future.

The CHAIRMAN. Well, Governor, it is my goal to help make that

happen. That would be the right thing to do.

Governor SCHWEITZER. So, again, thank you very much. There is

nothing more important than healthy families, healthy communities. It starts with healthy children.

Thank you very much.

The CHAIRMAN. Thank you very much. [Applause.]

Thank you for your time. Go back and straighten them out over

there.

Governor SCHWEITZER. Honestly, when I leave Helena while the

legislature is in session—Nancy and I have three teenagers—it is

like going on vacation and leaving the kids at home. [Laughter.]

Senator CANTWELL. Well, thank you, Chairman Baucus.

The CHAIRMAN. I would like to introduce you first.

I have already introduced Senator Cantwell once, but I always

like to do it again. I meant it when I said it. She is just a great

person, a super Senator. We are very lucky that she is able to find

time to come over and visit us in Billings. Let us give a huge, huge,

huge Big Sky welcome to Senator Maria Cantwell. [Applause.]

OPENING STATEMENT OF HON. MARIA CANTWELL,

A U.S. SENATOR FROM WASHINGTON

Senator CANTWELL. Thank you, Chairman Baucus. Thank you for

the introduction and certainly for that Big Sky welcome. We have

6

been at several events today already, and I certainly feel welcome

every time I hear, ‘‘Welcome to Big Sky country.’’

I am sorry that the Governor left because I have been spending

time in Montana, mostly fly fishing, and I will come back for many

other activities. I want to thank him for his leadership with the

State legislature because part of the challenge for SCHIP is to

make sure that the State legislature does its job in matching the

Federal program, enrolling children and making SCHIP a priority.

I thank the Governor for that and for his leadership on energy policy issues as well.

Max and I had a chance this morning to talk about the common

interests of our States in growing canola, and how that might be

used for biodiesel in the future. And, I applaud Max for his creation of an Energy Subcommittee on the Finance Committee to explore how we can put the Washington and Montana farmer in the

energy business as opposed to the Saudi OPEC cartel. So thank

you very much for your work on these issues.

It is my pleasure to tell you what a tireless advocate the chairman of this committee is for your State—for farmers, for trade, for

economic development, for jobs, for education, and, as has already

been mentioned, for the CHIP program. I also personally want to

thank Caden and Ethan Berg. I do not know where they went, but

they are the two most darling young people. And I love the way

they gave us this cookie, Max. It actually says ‘‘60 billion’’ on it.

[Laughter.]

The CHAIRMAN. I like that.

Senator CANTWELL. So the price is being communicated well

through these children.

The CHAIRMAN. With the high inflation rate in this case.

Senator CANTWELL. Besides getting to your stomach, they definitely got to my heart, and so I am glad that they were here.

I want to thank Chairman Baucus for visiting Seattle last year

and having a similar hearing at Children’s Hospital to talk about

the SCHIP program in Washington State. We are a State that in

1994 expanded our Medicaid program to cover families that earned

too much to qualify for Medicaid but could not afford private insurance. Today, we cover over 140,000 children.

Like you, I believe that we need to use our States’ experiences

to help inform good Federal policy. That is why we are here

today—to hear from you about how we can do that. Without health

care coverage, children do not have access to the basic health care

services that we all take for granted, including things like well

child visits, treatment for asthma—and simply just the security of

knowing that you have a physician, a doctor on call.

Health insurance costs are skyrocketing, and many families cannot keep up. Last year, the premiums for employer-sponsored

health care coverage rose 7.7 percent. Now, that is twice as fast as

workers’ wages and twice as fast as inflation. You can see how that

is a huge challenge. Family health insurance coverage costs an average of $11,500 a year. When you are talking about family incomes, you are talking about a sizable part of their income going

to health insurance.

The average worker is paying about $3,000 a year towards those

premiums, which is almost a $1,300 increase from what they paid

7

in 2000. If you think about that increase and the fact that you have

not seen a similar increase in wages, you have to wonder where

somebody is going to come up with an extra $1,300 in such a short

period of time.

Wages simply cannot keep pace with these increases, and businesses are obviously feeling strained by health care costs. I know

that we are going to hear from Dr. Lyons. Her organization, the

Kaiser Family Foundation, issued a report analyzing how these

changes in employees’ health care coverage are impacting the system. They found that in 2000, 66 percent of non-elderly Americans

were insured through the workplace, but by 2004 only 61 percent

were covered through the workplace.

Part of finding solutions through CHIP is addressing the fact

that more and more employers are not able to cover their workforce

in the community. Both children and adults experienced the steady

declines in job-based health care coverage, and that is something

that we have to get serious about.

It is Medicaid and the Children’s Health Insurance Program that

have provided the backstop, to prevent the number of uninsured

children from growing. Unfortunately, I understand from Dr.

Lyons’s testimony that the number of uninsured children may be

on the rise again. That is why it is so important that Senator Baucus is leading this charge in the Senate to reauthorize the CHIP

program.

It is reauthorization of this Federal-State partnership that brings

us here today. But, it is also to recognize the great strides that

have already been made in the program. It has been a key driver

in cutting the percentage of low-income children without health

care coverage by a third over the past decade. We need to celebrate

that as well.

But our work is far from done because 9 million children in the

United States remain uninsured, and it will not be news to the people in this room that there are real consequences to lacking insurance. In the American Journal of Medicine this month, researchers

found that the uninsured receive less care and have poorer outcomes than those who have insurance.

We need to do better, and that is what this hearing is about, to

make sure that we continue to focus on giving the resources to all

children in America, to make sure that they are covered, not only

that they get good health care but that they get a good start in life.

So thank you for being here. It is a pleasure to be in Big Sky

country. I hope I get asked back a lot.

The CHAIRMAN. You will.

Senator CANTWELL. Otherwise, I am just going to come on my

own. But it is a pleasure to see so many people in Billings turn out,

and I want to also thank the MSUB for hosting this forum for us

and thank all of those who are testifying.

The CHAIRMAN. Thank you, Senator, very much. Thank you. [Applause.]

We have three panels. The first panel I will introduce, and then,

when they are finished, I will introduce the second panel. The third

panel is all of you. We have reserved time—not a lot of time, but

about 20 minutes—for people who want to speak to go to the microphone. So when we are going through the first two sets of witVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
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nesses, and Senator Cantwell and I will ask questions, I would encourage you to think of points you want to make. Maybe somebody

said something that needs to be clarified, or maybe somebody said

something that maybe is not quite right, or maybe somebody did

not say something that needs to be said. So you are all the third

panel.

The first panel includes Joan Miles, Director of Montana’s Department of Public Health and Human Services, and Joan will talk

about how the State has implemented CHIP and the challenges our

State faces in reauthorization.

Next is Dr. Barbara Lyons, deputy director of the Kaiser Family

Foundation’s Commission on Medicaid and the Uninsured. Dr.

Lyons will talk about how Montana’s experiences fit with those of

other States implementing their programs, and she will give us a

lot of new ideas.

Finally, Melissa Anderson, on the first panel, is a single, selfemployed mom from Helena. She will talk about how CHIP has

helped her family through a very difficult health crisis.

So why don’t all three of you come on up here, and, Joan, when

you are ready, you can begin.

Again, welcome, Joan, and thanks for all that you do for all of

us in our State.

STATEMENT OF JOAN MILES, DIRECTOR, MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES, HELENA,

MT

Ms. MILES. Thank you, and thank you for having all of us here.

This is an honor to be part of the national discussion on CHIP reauthorization, and we really appreciate it.

I would like to introduce Jackie Forba, who is sitting back here.

She is the Bureau Chief in Helena for our CHIP program, so if you

do have any questions for me, she might be able to help me.

I am going to jump right into the testimony because there is a

lot to say, but again, thank you, this is a wonderful opportunity.

Our motto for our CHIP program in our State is ‘‘Health insurance for children, peace of mind for parents.’’ And I can tell you

from firsthand experience, working 11 years at a local public health

department before I became director of this department, that the

CHIP program truly does give parents peace of mind.

I was working there when the program started, and we saw year

by year the number of people come in, and we would say, ‘‘Do you

have insurance?’’ And they would say, ‘‘Yes. As a matter of fact, I

do have insurance. I just got on the CHIP program.’’ So it really

has been not only peace of mind, but I think a source of pride for

families in Montana.

Montana has less than 1 million people, and that is approximately 6 people per square mile as compared to 8,800 per square

mile in DC. That is why you are feeling a little crowded. The median household income in Montana ranks 48th in the United

States. However, Montanans are fiercely independent and very

proud, and they do not see themselves, we do not see ourselves as

a State that is a relatively poor State. The rate of uninsured children in our State is higher than the national average, and we have

9

7 reservations in Montana with a disproportionate share of lowincome children.

I am giving you some of these statistics not to point out so much

the uniqueness of Montana. I think you could have all 50 States

here talk about the uniqueness of their own States. What has been

the hallmark of the CHIP program is the ability for States to look

at their own situations and design the program to meet their

needs. And we certainly encourage that in the reauthorization that

this is one of the things that we can continue to do, to look at our

own situation and design a program to fit our needs.

As a result of that, in Montana we chose to do a stand-alone insurance program, and as the Governor talked about, 92 percent of

the CHIP children have parents who are employed. By the way, the

single-largest employer is self-employed. It is people who are selfemployed. That is the category of employer that is the largest of

these families.

We fund a lot of our program through tobacco settlement dollars

and the tobacco tax increase. Two years ago, we increased the tax

on cigarettes in Montana by $1 a pack and dedicated a lot of those

funds to be able to go to the CHIP program. We stand ready to increase our eligibility. We have the funding in the budget if the legislature does approve this bill to expand eligibility up to 175 percent of poverty. We are one of 10 States, however, that has not yet

been able to insure children up to 200 percent of poverty.

We have 13,350 kids as of the end of April on our program. However, we do not cover any expanded populations. We are still working on getting our uninsured children covered. We have worked

hard in the past year to increase our enrollment, and we have been

successful in increasing enrollment among Indian children by 20

percent, statewide by 9 percent, and by the way, Yellowstone County, you have increased your enrollment by 20 percent. You certainly

brought up the State average.

In terms of the reauthorization, I think we have four issues that

I want to bring up. They are detailed in my testimony because I

know I will not be able to get into all of them. A lot of it is based

on some equity issues.

We would like to see the priority be to really focus on children,

and particularly those States that have not yet been able to get up

to that 200 percent of poverty.

We do need dependable, predictable funding. That has been a

problem in our State. Our legislature meets every other year. They

have been reluctant to do things like CHIP expansion because we

do not know what the level of funding is going to be. We do not

want to have waiting lists. We do not want to start something and

then have to cut kids off. So the ability to have dependable, adequate funding and not be dependent on redistribution funds after

the fact is very critical for us.

We would urge, I think, basically a two-pronged approach: that

Congress should first designate funding to support State efforts to

fully cover all uninsured children up to 200 percent of the Federal

poverty level; and then additional funds could be used by the

States to cover expanded populations. But we really hope that the

priority will be to get kids under 200 percent of poverty, to get

enough funding in the States for those children.

10

I will have probably the more boring testimony here. You are

going to hear some wonderful stories from some of the other panelists. You were right. I have the technical comments.

The 10-percent administrative cap has been a problem because

things that the State has to consider administrative when we do

it are not considered administrative if you have a fully insured program. In other words, things that Blue Cross Blue Shield used to

do for the State of Montana were not considered administrative.

They were considered benefits. For us they are considered administrative. We did switch to a self-administered program, but we almost were prohibited from doing it because of the 10-percent cap.

We would like to see the prohibition on State and university employees lifted. Right now they are not eligible for CHIP coverage.

And yet that same prohibition is not there for Federal employees.

It is just as difficult for a low-paid State employee to pay monthly

premiums as it is for a low-paid Federal employee. We would encourage that.

It looks like my time is up.

The CHAIRMAN. We will give you an extra minute.

Ms. MILES. An extra minute, thank you. I have two more quick

things.

The PERM Project, the Payment Error Rate Measurement, that

CMS is having the States do for both CHIP and Medicaid this year,

we would encourage that PERM-related costs either be 100-percent

federally funded or be excluded from the 10-percent administrative

cap so that we could at least obtain some Federal matching funds

in order to do those audits.

By the way, we have to do as many audits in our State as some

of the larger States have to do, so it will be proportionately very

costly for Montana to do this project.

Finally, we would urge you to look at the Child Support Enforcement Program. Right now, if there is a child support enforcement

order and a parent is required to provide insurance, they cannot

use the CHIP program. They have to do it through private insurance. However, divorced families who are not under the State Child

Support Enforcement can access CHIP. So, again, it is an equity

issue. We think that children of divorced families should have that

same access to CHIP whether they are under an enforcement order

or not.

The CHAIRMAN. Thank you very much, Joan. That is very helpful.

[The prepared statement of Ms. Miles appears in the appendix.]

The CHAIRMAN. Dr. Lyons?

STATEMENT OF DR. BARBARA LYONS, VICE PRESIDENT AND

DEPUTY DIRECTOR, KAISER COMMISSION ON MEDICAID

AND THE UNINSURED, HENRY J. KAISER FAMILY FOUNDATION, WASHINGTON, DC

Dr. LYONS. Thank you, Chairman Baucus, Senator Cantwell. I

am pleased to be here today in Billings, MT, to testify on the importance of a State Children’s Health Insurance Program. I am

going to get right to it.

First and foremost, CHIP is a success story. Today CHIP covers

6 million children nationwide, as you have heard repeatedly today,

over 13,000 in Montana. The investment in CHIP has paid off beVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
11

cause children have better access to the care they need. They have

improved health. They are performing better at school as a result

of this program.

Over the past decade, CHIP and Medicaid have reduced the uninsured rate among low-income children by one-third. That is a

fantastic accomplishment given the falling rates of employer-sponsored coverage, the rising health care costs we had during this period, and the fiscal strain that States were under during the economic downturn.

Since the enactment of CHIP a decade ago, the need for the program has grown substantially. Fewer firms today are offering

health coverage, and, as Senator Cantwell said, health insurance

premiums have skyrocketed in the past couple years.

CHIP is literally a lifeline for low-income, working families who

have been hardest hit by these changes. Without CHIP, the overwhelming majority of these children would be uninsured.

Why has CHIP been so successful? I am going to tick off three

reasons.

First, all States expanded eligibility. As was noted earlier today,

41 States provide CHIP for children and families at or above 200

percent of the Federal poverty level. A number of States have recently broadened eligibility. Here in Montana, Oklahoma, and

Ohio, there are proposals on the table to increase eligibility that

would raise these States up as well.

Second, CHIP established a new priority on enrolling eligible

children and keeping them covered once they are in the program.

Montana has adopted many of the enrollment simplifications in its

CHIP program, including no asset test, no required face-to-face

interview, permitting self-declaration of income, and using 12-

month continuous eligibility to keep kids covered once they are enrolled.

Importantly, many States have carried these improvements in

CHIP over into the Medicaid programs as well so that poorer children could also benefit from streamlining activities. Unfortunately,

the new citizenship documentation and identity rules in Medicaid

that are being implemented by CMS run counter to these simplifications and create barriers to enrollment for eligible children.

The third point that has been very important is outreach. Outreach is an essential tool to inform families about the availability

of coverage. It works best when program eligibility is broad and the

enrollment procedures are family-friendly and easy for families to

navigate.

Children’s participation in CHIP and Medicaid is high, reflecting

the value that parents place on coverage and their positive experiences with the program. Building on the success of CHIP, more

needs to be done to reach the 9 million children nationwide who

remain uninsured. These children are missing out on valuable

health benefits. Parents of uninsured children do live in constant

fear that an accident or medical emergency could just wipe them

out financially, and they worry that they are passing this stress

onto their children.

Unfortunately, many do not know that their children qualify for

CHIP or Medicaid, or they have difficulty applying for coverage.

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Outreach and streamlined enrollment are key to overcoming these

hurdles.

Successful outreach, however, depends on adequate financing

being available to support the coverage when children do enroll,

and the biggest challenge in CHIP throughout its history has really

been the program’s financing. Throughout the program’s history,

the capped financing has not lined up well with program needs.

The distribution of Federal dollars across States has also been

problematic.

As Congress prepares to reauthorize CHIP, a number of issues

will be discussed, including who can be covered and the level of

Federal financing that is available to States. CHIP’s experience

over the last decade suggests three lessons to keep in mind as

these discussions go forward.

First, I will just reiterate that States attribute much of the success of CHIP to the flexibility that they have had over eligibility,

benefits, and program design. This flexibility has enabled States to

design programs that meet their residents’ needs, the local health

insurance market, and the political environment in that State.

Second, the level of Federal financing and how these funds are

allocated across CHIP will be pivotal to the program’s future success. And States are poised to move forward. They really are. There

is much enthusiasm to do more to reach uninsured children. It is

mounting in States across the country. The outcome of the CHIP

reauthorization debate will be a key factor in whether States across

the country can go forward.

So I will just close by saying that the health and health coverage

of millions of children depend on reauthorization of CHIP. Unless

Congress acts, the program will expire in less than 6 months. And

without additional Federal financing, more children will become

uninsured, jeopardizing a decade of progress that we have made in

covering kids.

So thank you for the opportunity to testify, and I look forward

to your questions.

The CHAIRMAN. Thank you.

[The prepared statement of Dr. Lyons appears in the appendix.]

The CHAIRMAN. Next we have Melissa Anderson.

STATEMENT OF MELISSA ANDERSON,

REPRESENTING HER FAMILY, HELENA, MT

Ms. ANDERSON. Thank you, Senator Baucus. My name is Melissa

Anderson, and I would just like to say thanks for allowing me to

come share my story today about the CHIP program and how it

helped my son and me during a crisis period in our lives.

To give you a little bit of background, I have been self-employed

for the last 11 years, and I can tell you from experience that it is

nearly impossible to find affordable health insurance. I did not

think that was a problem until I needed it.

In 2005, our family situation changed, and I got a divorce, and

it was during this transition period that my son, Kasey, age 9 at

the time, had a grand mal seizure. Now, the news itself was shocking, and he had to undergo extensive testing and was diagnosed

with a seizure disorder. But perhaps even more traumatic was

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wondering how I was going to pay those bills because, like I said,

we had no insurance.

It was about that time that Kasey’s neurologist suggested that

we apply for the CHIP program, and I said, ‘‘Well, I do not think

we are going to qualify for that. That is probably for low-income

people.’’ And he said, ‘‘Well, you never know until you try.’’

So I filled out the paperwork, and I can tell you honestly right

now that that is the best filling out of paperwork I have ever done

in my life because, much to our surprise, we did qualify. And I cannot tell you what a relief it was getting to know that we were going

to have help for these medical bills.

Kasey had MRIs, EEGs, expensive blood work, and then he had

to be placed on seizure medications, which were not cheap, either.

You know, basically what it did for us is it gave us peace of mind

knowing that I could go back to work and concentrate on making

more money, and he could concentrate on getting well. And that

right there made all the difference in the health of our family.

I truly believe there are many others out there just like us who

do not realize that they qualify for this program. They probably

think it is for low-income people, and I am here to tell you it is for

low- to middle-income people.

We received the CHIP program for about 10 months, and then

I overqualified because I worked very hard that year to try to get

myself back up. And I am here to tell you that it was almost a

seamless transition going from the CHIP program to another insurance program, which I was very worried about because they accepted us even though most insurance companies would have said, ‘‘Oh,

this is a pre-existing condition.’’ We had no problem with that

whatsoever, and for that we are very thankful because that is what

we call ‘‘bridging the gap,’’ so to speak.

I am not embarrassed to have received these benefit. I am a very

hard-working person, and I think there is a problem in our society

today with American workers, people who are blue-collar workers

or people like myself who go out and work hard every day to pay

my fair share of taxes and then find out I do not have enough

money at the end of the day to buy insurance. And insurance is always at the bottom of the list. I do not care who you are. That is

always going to be last. You either put food on the table, pay your

mortgage, or buy insurance. Well, what would you do?

So I am not embarrassed to accept the benefits that were there

in our time of need because to me it is a ‘‘hand up.’’ And I have

actually been helping to advocate this program ever since. As a

matter of fact, I am a video producer, and I helped to produce the

CHIP commercials.

The CHAIRMAN. Good for you.

Ms. ANDERSON. So I am giving back, and I am giving back today

by my testimony.

In my opinion, I would just like to say that kids should not have

to feel guilty about being sick. And parents should not have to

worry about how they are going to make enough money to pay

those doctor bills or worry about whether they can afford to take

their kids to the doctor. That is just not right. And we have to do

the right thing in America to help people like me and other people

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to find insurance for our kids. Actually, I think it should go further,

because I still do not have health insurance for myself.

So I am just here to say thank you to all of the advocates and

supporters of the CHIP program, and I would like to say thank

you, and I want to leave you with one last thing. I do believe that

prevention is the best medicine, and I can testify for that right now

because, as of 3 months ago, my son no longer has to be on his seizure medications. So prayers have been answered, and thanks to

the CHIP program and the medication that he received. We are

very grateful for that. Thank you very much.

The CHAIRMAN. Thank you very much, Melissa. [Applause.]

[The prepared statement of Ms. Anderson appears in the appendix.]

The CHAIRMAN. I would like to do something a little bit different

instead of being so formal. When we have these hearings in Washington, DC, generally each of us on the committee takes 5 minutes,

and it goes to the next person, 5 minutes and so forth. It gets to

be a little bit formal sometimes, and so what I would like to do,

if you do not mind, Maria, is just kind of open it up, and the two

of us can talk with all the three of you, and you can talk with us,

and we can have a little conversation here as we try to advance the

ball. I will ask a couple of questions. You may want to pipe in with

something to ask. Or you may want to add on to it or maybe you

have something different. We have allotted 15 minutes for us with

this panel.

I am going to jump right into what I think is a very vexing problem that we are going to face, and that is financing. Dr. Lyons, you

talked about it a little bit. It gets to the allocations among States,

maybe some population changes and formula changes as we reauthorize this. It gets a little bit to the coverage that some States

have compared with some other States.

I know that New York is looking at 400 percent of poverty, and

I think New Jersey is 350 percent, if I am not mistaken, or something like that.

Then it gets a little bit into the shortfalls that we face this year.

Some States just ran out of money and came running to Congress

for some help, and some other States had some surpluses. They did

not use it all.

I would just like some guidance from all of you as to how we get

at that in a way that assures predictability and can help States

fashion their programs in a way that is fair to them and fair

among States. So just your thoughts, please.

Dr. LYONS. I will start and say that the most important issue,

I think, facing the reauthorization is making sure that there are

adequate funds on the table. The program has been struggling for

the past several years.

The CHAIRMAN. Adequate funds for the current coverage?

Dr. LYONS. Well, adequate funds, I would say, beyond current

coverage. If we really want to do something about uninsured children in this country, we have to go beyond current coverage.

So there is more money needed to just maintain the coverage

that is there. In addition to that, if we are going to do something

to reach those kids who are eligible for the program, for CHIP, as

well as Medicaid, but not enrolled, more money needs to be put toVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
15

wards that coverage. States could cover those kids now. They are

not. They need incentives to go out and bring those kids in, to

streamline their enrollment processes so that they can be covered

and that they can stay covered. And that is, quite frankly, going

to take some financing from the Federal Government to support

those efforts.

The Federal Government could also help by providing additional

financing so that States can do that in an efficient way, so they can

use automatic enrollment procedures, where if a child was eligible

for one program and they are likely to be eligible for CHIP or Medicaid as well, the State can get them enrolled easily. States need

help with information technology and data-sharing systems. We are

in the 21st century, yet some of the computer systems that we are

using in these programs do not talk to each other. Those kinds of

things would be very helpful for States.

So the bottom line is, I think there needs to be additional Federal money there. The $50 billion that you have included in the

budget resolution is a great, great start to help States get there,

if we can keep that money in the budget. But when we talk about

differences across States, States are in very different places across

the Nation, and their decisions on who they cover and what levels

they cover I feel really need to be individual State decisions. The

cost of living varies dramatically in different places across the

country, and so one State’s decision to be at 200 percent of poverty

may make sense. In another State, like New Jersey, 350 percent

of poverty is going to give you the same purchasing power for a

family living there.

So I think to set arbitrary limits on a percent of poverty could

actually inhibit the work that States are trying to do to cover more

uninsured kids.

The CHAIRMAN. Right. Could you explain in a little more detail

why dollars are necessary to reach out and find the children who

are eligible but not covered?

Dr. LYONS. Because once those kids are covered, it will cost

money to provide the coverage for those kids. Most uninsured

kids—three-quarters—are actually eligible for CHIP or Medicaid

but are not enrolled. Because CHIP is a block grant program, the

funds are limited. So if you bring in more kids, under a block grant

program you will not necessarily have more money.

The CHAIRMAN. As opposed to Medicaid.

Dr. LYONS. In Medicaid, financing is tied to the individual child.

So the more kids a State enrolls—the State gets paid for each one

of those kids. You get matching Federal dollars for each one of

those kids.

When folks have looked at the formula to distribute CHIP funds

to States, one of the options that they are looking at is whether to

tie the distribution of funds to actual enrollment, which would get

you——

The CHAIRMAN. And your thoughts on that?

Dr. LYONS. I think that makes sense. I think tying it to the number of kids whom you are enrolling in the program is a good way

to make sure that the dollars follow the kids who are getting coverage. There are a whole slew of problems with the current CHIP

financing formula which we are not going to have time to go into

16

today, but definitely keeping the dollars tied to the kids makes

sense.

The CHAIRMAN. In your view, what is one of the largest problems

with the current program? You said a whole slew of them we cannot go into.

Dr. LYONS. Oh, I am talking about the formula. The biggest challenge facing the program is really raising that total level of Federal

dollars going into the program. That would help with a lot of the

problems with even the distribution of funds across States if there

is just more program money there. And I would reiterate that the

need for the program has grown so dramatically since CHIP was

enacted, while Federal financing has stayed relatively flat over the

past 10 years on a year-by-year basis.

The CHAIRMAN. I would just remind everybody we are talking

about how it is a matching program.

Dr. LYONS. Right.

The CHAIRMAN. It is Federal-State.

Dr. LYONS. The State spends money to cover children and then

the Federal Government matches that.

The CHAIRMAN. Yet it is a block grant, so there is a cap.

Dr. LYONS. It is capped. The original program was capped at $40

billion over the 10 years, and that is different from Medicaid where

the spending goes up the more kids you cover.

The CHAIRMAN. Would you say quality is a factor in allocation?

Dr. LYONS. On quality, I would say that we definitely have seen

that covering kids with CHIP or Medicaid makes a big improvement in their access to care and their quality of care. During the

first 10 years of the program, the focus really was on looking at enrolling those kids and seeing what works to enroll kids. Now that

we are 10 years into it, it probably makes sense to look a little

harder at the quality standards that are applied to the program.

The current standards are voluntary and pretty minimal in terms

of what States have to report.

Having said that, if there is going to be more requirements and

more standardization of data that States are required to provide,

again, I think the Federal Government has to help pay for that and

provide money in additional administrative funds so that States

are not bearing the burden of that.

Secondly, I would say that it would be good for the Federal Government to provide some technical assistance to States in reporting

so that the data that actually is reported is meaningful.

The CHAIRMAN. Senator Cantwell?

Senator CANTWELL. Thank you, Chairman Baucus. I would like

to follow on the same line of questioning. It seems like one of our

challenges is that various States have different commitments, different economies, different fluctuations. The Washington State

economy is very, very cyclical, so a couple years ago we thought we

were going to lose our ability to cover about 100,000 children in

Washington State because we had a downturn in the economy.

Dr. Lyons or Ms. Miles, how do you think that we standardize?

I know you are saying we want flexibility in the program, but if

we know how much insurance is going up, and we know what family income is, thereby showing how difficult it is to get access or

coverage, why can’t we set some national goals of what we would

17

like to see? And then, it is up to States to decide whether children’s

health care is a priority. Are there not some things that we should

be doing there? I understand what you are saying about New Jersey because it is obviously a much more expensive place to live, but

isn’t the real equation here that we think at some level of income

or some level of buying power, the availability of insurance for Ms.

Anderson is not there? It is just not there in the marketplace. And

so she would buy it if she could. She cannot.

I am getting at the question of how do we set a Federal standard

or goal so that States know how to plan for that? Because I think

they have the same dilemma in their fiscal policies and budgets.

I am assuming, Ms. Miles, you have this dilemma here. You want

to plan probably for 175 percent of the poverty level, but you want

to know the Federal dollars are going to be there to match that,

or else you will have a shortfall in the next biennium. Well, I do

not know if you do it on a biennial basis here.

The CHAIRMAN. We do.

Ms. MILES. I would just comment that you have pointed out, I

think, a very difficult problem, and one that we really struggle

with in our State. When we start counting the uninsured and the

people who have coverage, there is no quality indicator in there or

comprehensive—I mean, insurance is not always insurance is not

always insurance. I mean, some can be very catastrophic and you

count them as covered, and some can be really aiming at the preventive type of insurance that Melissa was talking about.

So we do struggle with that, and I guess it would be interesting

to see an analysis of what kind of coverage some of the States have

and if there are some goals to get to some minimal floors, not just

in terms of who is eligible but what kind of insurance and what

kind of coverage does that provide. I think that would be a challenge to try to balance that, but I think that that is probably getting at a very key issue that should probably be of great concern

to Congress.

Senator CANTWELL. Well, I would think, too, that a State like

Montana or Washington could then plan for what we expect the potential impacted population will be over the next 10 years.

Senator Baucus has been a big leader on health care IT. We hope

we make medicine more efficient. We hope we get coverage for

many people, for working families like Ms. Anderson, to afford. But

at the same time, we know this challenge we are going to be facing

for the next 10 years. We are going to see an increase in health

care insurance. We are going to see that cost go up.

So it would seem like you could probably pencil out for Montana

exactly what that population increase is likely to be, could you not?

The CHAIRMAN. Isn’t part of the problem because it is a block

grant program? That is the problem, and that sort of begs whether

it is worth even considering changing to an entitlement program.

I think that is probably not in the cards in Congress given the history of it, but a block grant has its advantages—flexibility and so

forth—and it has its disadvantages, too, in terms of budgeting.

Ms. MILES. Right.

The CHAIRMAN. You know, there is churning problem here, too.

They are on for a while, then they are off, and that is obviously

18

a problem. There are immunizations, check-ups, and all those

kinds of things.

What changes would you suggest in the authorizing legislation to

help discourage churning, kids on and off all the time, so we keep

kids covered for a longer period? Any ideas on all that?

Dr. LYONS. Well, I will agree with you totally, you cannot have

quality, monitor quality, you cannot improve quality when you

have kids popping on and off. You cannot hold anyone accountable.

The 12-month continuous eligibility that you have in the CHIP

program in Montana, States have found that to be very, very useful

in terms of keeping kids covered. That has not always been employed in the Medicaid program across States. It is much less likely

to be used. That is a very important lever to keeping kids covered.

We have found that in most cases, when kids go off the program,

it is really not because they are not eligible anymore. It is more

because the paperwork did not get completed.

So, again, coming back to some IT help, if there was technology

being applied to keeping kids enrolled, kids were enrolled for

longer periods of time, that would help a lot with that churning.

The CHAIRMAN. Let me just touch on IT for a second here, information technology, health information technology. There is room

for huge, huge improvement in productivity in the health care sector, especially with more dedication to information technology. I remember a couple years ago then-Chairman Alan Greenspan said

that the one area that is lagging way behind and that has the

greatest potential for productivity increases is health care, and a

lot of it is because of all the paperwork and it is just a very inefficient system we have in this country.

The question is: How do we get better information technology?

How do we get doctors and hospitals and everybody more electronically hooked up with compatible software, compatible systems and

interoperability and so forth? But it does not happen because the

doctors do not take it up and invest in it. It is not in their best

interest in the short term to do so. Hospitals do not because it is

not in their short-term interest to do so. A very small portion of

the Medicare budget is dedicated to this. HHS does quite little.

I am just thinking out loud here. Is there a place for a requirement somehow that a certain percentage of these dollars that go

to Medicare, Medicaid, CHIP, or something in reimbursement to

doctors and hospitals, a certain percentage that they have to dedicate to IT? We have to have something here to kind of move the

ball here, because there has been a lot of talk about information

technology, but not a lot has been done about it. I am just trying

to figure out some way to advance the ball. Your thoughts, any of

you?

Dr. LYONS. Again, I think there needs to be some Federal leadership here because you have States at very different places around

the country.

There has been some attempt through some of the Medicaid

transformation grants in the Medicaid program to try to facilitate

IT and electronic medical records. And I think that those demonstration projects will be very helpful in advancing the conversation, but, at the end of the day, I still think there needs to be more

19

Federal leadership, because there are just so many different parties

involved.

Ms. MILES. Senator Baucus, I was going to thank you for the

leadership you have shown on this whole health information technology issue, and one of the problems that we have in Montana, I

think, is that the technology is changing so much faster than we

are able to organize around. And every time we think we have

some people talking the same language and looking in one direction, things change.

I think you are right that at some point there needs to be leadership saying that this is what we expect or this is what we want

you to start looking at, because it has been very difficult for us to

try to—it is a moving target, and we are jumping around, and we

are not getting anywhere on it.

The CHAIRMAN. We have been trying, and by ‘‘we,’’ I am speaking

very generally. There was a fellow named Dr. Brailer at HHS, and

this was his job. But he got discouraged, frankly. He was not supported, so he bailed out.

Ms. MILES. I am not surprised.

The CHAIRMAN. But it is our job just to pick up the pieces and

get it moving.

Ms. ANDERSON. I would just like to say something. As a working

person, you know, I, like she said, would love to go out and get

some health insurance if I thought I could afford it and pay my

taxes. I think there is a big squeeze that is bigger than this health

care issue right now going on in America that is squeezing the

working-class families to where they cannot afford to even buy that

health insurance.

And so if you have a health insurance program, I know in the

past they have had HMOs where you have had copays, but if you

offered or extended an insurance similar to this for adults, I bet

you would get a lot more takers.

The CHAIRMAN. I think it is clear as we move to universal coverage, probably we are going to expand programs like CHIP and

Medicare and Medicaid, and also private incentives, tax incentives

for more individual and group market coverage. We do not know

exactly what it is going to be, but it is probably going to include

some of them.

Ms. ANDERSON. Because right now all I have is accident insurance.

The CHAIRMAN. That is not right.

Ms. ANDERSON. And that is all I can afford, and that is $100 a

month. Fortunately, it worked for me. A couple months back I had

a shelf fall down, and I broke my nose, and it was 100-percent coverage at the emergency room, and I had to have a CAT scan, which

was $775. But I am just telling you it is very expensive. Health insurance is very expensive. And so if we can work on the cost——

The CHAIRMAN. This begs a whole deeper issue, and that is

health care costs in this country.

Ms. ANDERSON. They are very high.

The CHAIRMAN. And we have to get a handle on that sooner rather than later, or else this system could possibly collapse. We have

to get started.

20

Senator CANTWELL. Well, Mr. Chairman, I know you want to go

to the next panel.

The CHAIRMAN. Okay. Thanks very, very much. We appreciate it.

Thank you. [Applause.]

The next panel is Dr. Janis Langohr of the Children’s Clinic. Dr.

Langohr will talk about her work as a pediatrician and the role

that CHIP plays.

Also Representative Jonathan Windy Boy, who is Tribal Council

Member of the Chippewa Cree and a Representative over in Helena. He can tell us what is going on over there, give us some guidance.

And Judy Stewart, a nurse, Director of Strategic Partnerships,

Yellowstone City-County Health Department.

And Rev. Vernon Wright, from Helena. Rev. Wright is the Minister of Plymouth Congregational Church, and he will talk about

his work in the community and also the moral imperative of providing health care for kids.

Let us start out here, and, I guess, Dr. Langohr, you are first.

STATEMENT OF JANIS I. LANGOHR, M.D., PEDIATRICIAN,

THE CHILDREN’S CLINIC, BILLINGS, MT

Dr. LANGOHR. Thank you, Chairman Baucus and Senator Cantwell, for the opportunity to testify on a topic that is close to my

heart: children and health care. As a pediatrician practicing in

Montana, I can give a view from the trenches, so to speak, of the

importance of the Children’s Health Insurance Program to children

and their families. Pediatrics, by its nature, is a profession that is

highly reliant on government insurance programs such as CHIP.

Our patients and their families are young. They do not have the

resources to own expensive private health insurance.

Conservatively, 40 percent of the patients at our clinic in Billings

are covered under CHIP or its larger companion program, Medicaid. In some pediatric practices around the State of Montana, the

percentage is even higher. On top of that, there are 37,000 children

in Montana who have no health insurance at all. Many of these uninsured kids are probably eligible for CHIP or Medicaid, but are

not enrolled. In short, there is a very large number of children in

Montana who need these programs in order to receive basic medical services. That number will grow as the escalating cost of

health care and insurance continues to outpace Americans’ income.

If one truly wants to know the value of CHIP, the question must

be asked: What is life like for a child who does not receive medical

care? Unfortunately, I have a lot of examples from my practice.

One is the plight of a toddler with such rotten teeth and infected

ears that he went on to develop mastoiditis, an exquisitely painful

and life-threatening infection of the bone behind the ear. Or there

is the teenage diabetic who shared her insulin with her uninsured

diabetic family member to the detriment of them both. Another situation is one of an asthmatic teenager who made annual trips by

life flight for about 3 years to a Billings hospital to spend a couple

of days on life support before picking up a new supply of asthma

medication, which he had depleted long ago. That is an expensive

trip to the pharmacy.

21

All of these cases have common elements. First, loving but economically challenged families were involved. Secondly, all cases

represent common childhood maladies that were left unattended

and became life-threatening. Third, the cost of these cases to our

health care system and our State was staggering. And, finally, the

single most important element in all these situations is that they

could have been prevented by providing these children with regular

access to routine medical surveillance and care. In the decade since

its inception, CHIP has been resoundingly successful in providing

children with a medical home and improving their access to care.

Dollar for dollar, the CHIP program represents one of the best returns on investment our society can make.

Yet access to care for children remains a critical problem in

America. Dental services, mental health care, and services for children with special needs are woefully lacking. The parade of children with painfully decayed teeth that marches through our clinic

each week is a testament to the crisis in dental care. Repeatedly,

we also see children with significant behavioral and mental health

problems who have nowhere to turn other than their primary pediatrician. And a recent survey of Montana families of children with

chronic developmental and physical impairments, such as autism

and cerebral palsy, overwhelmingly revealed that access to health

care is their number one concern. These families feel isolated in the

day-to-day struggle to care for their child. Poor reimbursement by

Medicaid and CHIP to providers is the root of these problems. Providers must make difficult business decisions and limit or even exclude patients on Medicaid and CHIP, leaving families stranded.

Montana, with its small population sprinkled over a vast area,

presents yet another unique challenge to providing care. Probably

the best example here is of Montana children who are critically ill

or injured. Fortunately, children rarely need such extreme care, but

when they do, they need very expensive and highly specialized

services specific to children. These complex services are difficult to

coordinate in a rural State. Pediatric sub-specialists and surgeons

generally migrate to well-endowed children’s hospitals in large

metropolitan areas. Critically ill children and their families must

follow them there. Hundreds of Montana children are medically

evacuated to larger pediatric medical centers each year at enormous cost to the State.

Senators, children and the problems they face are my personal

passion. But, quite frankly, most Americans feel the same way I do.

After all, children are our future. A country with such wealth, medical expertise, and advanced information technology has the ability

to create a comprehensive health care system for children even in

challenging States such as Montana. Ultimately, achieving that

goal makes good economic and social sense. Although many challenges remain, CHIP is a model for achieving this worthwhile goal.

Thank you.

The CHAIRMAN. Thank you, Dr. Langohr, very much. That was

very good. [Applause.]

[The prepared statement of Dr. Langohr appears in the appendix.]

The CHAIRMAN. Representative Windy Boy?

22

STATEMENT OF HON. JONATHAN WINDY BOY, COUNCIL MEMBER, CHIPPEWA CREE TRIBE BUSINESS COMMITTEE; AND

MONTANA REPRESENTATIVE, HOUSE DISTRICT 32, BOX

ELDER, MT

Mr. WINDY BOY. Thank you, Mr. Chairman, Senator Cantwell. I

have about 20 pages here.

The CHAIRMAN. Well, if you want, we can put it all in the record.

Do you want that?

Mr. WINDY BOY. Actually, I think that I do have this in for the

record.

The CHAIRMAN. Well, we will put your whole statement in the

record.

Mr. WINDY BOY. Mr. Chairman, one of the things that I would

like to focus my testimony on is some of the underfunding that IHS

has had. You are aware of how underfunded the IHS has been. The

reason why it is so important to keep the funding levels more at

a parity level is because right now, using my tribe for an example,

I only have enough contract health service dollars to be able to

take care of emergency level 12, which is a life-or-death situation.

The CHAIRMAN. And that is all-year-rounders.

Mr. WINDY BOY. That is all-year-rounders, and right now, with

the amount of money that we have, it is not even close to where

we need to be, because, as you heard earlier, preventive medicine

is probably more feasible in mainstream America.

One of the things that I would like to also go into as well is a

couple years ago, during the last legislative session, I had the opportunity to put in House Bill 452, which calls for a demonstration

project between the tribes, the State, and the Federal Government,

which is coming along pretty well right now, and I have a couple

staff in Garfield, and the IHS has also been instrumental on that

part. And what that did—I always think of wanting to think outside the box on situations and how this would work. Right now

some of the Indian children who are under the current CHIP program—and others use hypothetically the number 3,000—and if we

had 3,000 Indian kids who were on the CHIP program, what this

bill would do is to move them over to the Medicaid program. And

the reason why that would be—the advantage of doing that—is

that once you move them away from CHIP, put them under the

Medicaid program, Medicaid fully reimburses the State 100 percent

under the FMAP, and by doing that, that would free up those slots

for other people who are eligible for the CHIP program.

So there are some things that I think will be advantageous as

far as where we are going with the CHIP program, and I think that

we need to be more proactive about things. We can throw billions

of dollars into a program like we threw billions of dollars into Iraq,

and it is not going to solve the problem. We need to come up with

situations and ideas and things that are going to solve the problems, and I think that thinking outside the box is the way to go.

One of the things that I would like to point out, Mr. Chairman,

is that we mentioned some of the road blocks, and the last couple

of years I have been thinking about the Federal poverty level. I

have a graph here, Mr. Chairman, about the current poverty level.

In a family size of two, $20,535 is considered poverty level, and at

200 percent it is $27,380, and the Federal poverty level in the forVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
23

mula has been in place since the Eisenhower days, and I think that

if we were to take a look at the Federal poverty level and the formula, how it has been, and putting the numbers—nowadays, the

cost of living, the cost of health care, and all of these other rising

costs that we are faced with today as opposed to what was in place

back in the days of Eisenhower—I bet you would probably have a

lot more real picture because, you know, $27,000 20 years ago was

a lot of money and $27,000 at 200 percent 40 years ago was a lot

of money. And if we continue to raise the Federal poverty level, like

you mentioned that New York and New Jersey are considering, to

350, 400 percent, you know, that is unreal. And if we are to go that

route, I think that with the existing Federal dollars that are coming down for IHS, I think we would probably be at 800 percent. So

I think, you know, the difference of the parity of the levels of dollars is coming down. I think that we need to take a look at the

whole system of care.

Thank you.

The CHAIRMAN. Thank you very much, Jonathan. Thank you very

much. [Applause.]

[The prepared statement of Mr. Windy Boy appears in the appendix.]

The CHAIRMAN. Okay, Judy. You are next.

STATEMENT OF JUDY STEWART, DIRECTOR OF STRATEGIC

PARTNERSHIPS, YELLOWSTONE CITY-COUNTY HEALTH DEPARTMENT, BILLINGS, MT

Ms. STEWART. Good afternoon, Senator Baucus and Senator

Cantwell. I am sitting here trying to be nonchalant about this, but

this is really an honor to be participating in this, and I thank you

for the opportunity and the invitation.

The CHAIRMAN. The honor is ours, believe me.

Ms. STEWART. Thank you.

As the Director of Strategic Partnerships for the Yellowstone

City-County Health Department, I have the opportunity to collaborate with multiple stakeholders in our community to create and implement viable solutions to problems that are too difficult, if not

impossible, to solve individually, and the issue of the uninsured is

certainly one of these issues. With the rapidly growing number of

uninsured people in our country, this can no longer be considered

an individual problem. It is a community, State, and national problem, and has and will continue to require a collaborative, creative,

and cooperative approach in solving.

There is a direct cause and effect between not having health insurance and poorer health outcomes, and it has been proven that

the uninsured live sicker and die quicker. Without insurance, people avoid preventive health care. Routine illnesses, left untreated,

may progress to serious and potentially chronic conditions. An example of this recently made headlines when an 11-year-old boy

died of an untreated dental abscess. And this did not happen in a

Third World country. This happened in the United States of America, and I think that is unacceptable.

Why is reauthorization so important, especially for the residents

of Montana? As compared to the other States, Montana has the

14th-highest uninsured rate in our Nation. Montana’s per capita

24

income ranks 48th in the Nation, with only West Virginia, Arkansas, and Mississippi having lower incomes; 14.2 percent of Montana’s population falls below the Federal poverty level, and 19.2

percent of our children do, and that is compared to 12.5 percent nationally. Without CHIP, these children will have very limited options for preventive care, dental services, mental health care, and

assistance with prescriptions and vision care.

On March 1st, there were almost 13,300 children enrolled in

CHIP. That is a 9-percent increase in the number of children enrolled over this time last year. Even with this increase, there remain an estimated 35,000 uninsured Montana children, many of

whom would be eligible for CHIP, and there is currently no waiting

list for those who qualify.

I think there are three priority areas that must be addressed in

order to utilize and maximize CHIP.

The first is education. Communities need to take a leading role

in educating about the availability and the benefits of CHIP while

dispelling the misconceptions about CHIP eligibility. For example,

one common misconception is that being a working parent automatically disqualifies your child from being eligible for CHIP, or

that if you are Native American you are ineligible for CHIP. Providing parents with this correct information is the first step in insuring more children.

The second priority is that communities must work to decrease

barriers for families that need to apply for CHIP. Over the past 5

years, Billings Clinic, St. Vincent Healthcare, and the Yellowstone

City-County Health Department have worked together to highlight

issues of the uninsured during ‘‘Cover the Uninsured Week.’’ Recognizing CHIP as one of our most valuable resources in combating

the growing number of uninsured, it has been a top priority for this

partnership to increase CHIP enrollment over the past 2 years. We

identified that the stigma attached to being uninsured continues to

be a significant barrier for families. Even now, when one in five

Montanans are uninsured, people are embarrassed by the fact that

they are unable to provide health insurance for their children.

In response to this, we have hosted two CHIP Champion luncheons where people from a wide variety of organizations come together and they are trained in how to assist families in completing

the CHIP application. Our hope is that in our community parents

will experience ‘‘no wrong door’’ when they are accessing information on CHIP. People will not be ‘‘referred’’ on. They will be assisted by the first person they talk to about CHIP, someone they

already have a trusting relationship with.

We have also promoted CHIP at local enrollment fairs at schools.

Our first one was a couple weeks ago at Lockwood School, and our

second one is planned for Laurel in April. The intent is to offer the

information and assistance in an environment that is safe and familiar to the family. These activities, combined with the traditional

access to CHIP enrollment, have resulted in a 20-percent increase

in CHIP enrollments in Yellowstone County over the past year.

The third priority needs to be improved access to services for

those who have CHIP. Unfortunately, there are providers that do

not accept children covered by CHIP, especially in the area of dental care, and improved access to a full complement of health servVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
25

ices is vital, and I encourage you to support increased funding for

the expansion of community health centers that offer access to

health care services not only to CHIP recipients, but to everyone,

regardless of their inability to pay.

I have a job that falls outside what most people would consider

the ‘‘conventional’’ nursing career, in that I do not work in a clinic

or a hospital. And at times it has made it very difficult when my

children have tried to explain to their friends what I do for a living.

So I am always kind of interested to hear what they are telling

people, and they have come up with some interesting things.

One day I overheard my 11-year-old talking to a friend of his

who had just asked him that question, ‘‘What does your mother

do?’’ And so I kind of listened, and he said, ‘‘Well, she is a nurse

and she helps people who are poor and they cannot go to the doctor

because they do not have any money to pay.’’ And, you know, I was

pretty impressed. That is fairly close, probably closer than a lot of

times what they get to. But it was his next statement that stopped

me in my tracks, and this is coming from an 11-year-old. He said,

‘‘Can you believe there are kids out there who cannot go to the doctor when they need to because they do not have insurance?’’

It is my hope that in the very near future every Montana child

will have health insurance and they, like my 11-year-old, will find

it incomprehensible that there are children living in our great

country who do not have access to health care.

Reauthorization of CHIP is imperative if we are to meet this

goal, and I thank you today for allowing me to be a part of this

very important discussion, and I very much appreciate you making

this a highlight of your work in Washington, DC.

The CHAIRMAN. Thank you, Judy, very, very much. Thank you.

[Applause.]

[The prepared statement of Ms. Stewart appears in the appendix.]

The CHAIRMAN. Rev. Wright, that is a good name. [Laughter.]

STATEMENT OF REV. F. VERNON WRIGHT, PLYMOUTH CONGREGATIONAL CHURCH, UNITED CHURCH OF CHRIST, HELENA, MT

Rev. WRIGHT. Thank you, Senator and Chair. It is an honor to

be here. I am grateful for your leadership of this country in a difficult epoch.

I want to just tell you I have been brought before you today as

an ordained United Church of Christ minister, and I want you to

realize that I recognize the legitimacy of other faiths across this

great Nation, but it is from my own tradition that I speak as an

authority. So I am going to share with you that tradition. I, like

many in the United Church of Christ, am a Congregationalist. We

founded Plymouth Colony and Massachusetts Bay Colony in the

1600s. Fifteen of us were signers of the Declaration of Independence. Congregationalists defended the slaves on the Amistad slave

ship, advocated for more humane living conditions for immigrants

at the turn of the century, labored for civil rights in the 1960s, and

have continued to be advocates for the poor, the dispossessed, and

the disenfranchised in this country. Today, over 35,000 Montana

kids and 8.4 million children across this country have no health

26

care coverage, and this I think constitutes not only an economic crisis but a moral crisis for our Nation. Standing firmly in a deep U.S.

religious and civic tradition, I would urge you, along with thousands of UCC churches and other mainline churches and many

mosques and synagogues across this country, to not only reauthorize CHIP but to expand it.

Jesus Christ, and the Hebrew prophetic tradition represented in

the narrative of Jonah, for instance, had a new vision of humanity

in which all human beings—elders, children, women, men, slaves,

free, Jews, Gentiles—were one in the eyes of God. I think that is

what we recognize when we say that we have one Nation under

God. Standing on the tradition of the Torah, where true worship

of God is marked by justice and mercy, Christ taught God’s reign

would become manifest when we serve the last and the least out

of loving concern. And children at that time, just as they are today,

truly were the last and the least, which is why Christ spends so

much time in the narratives welcoming them, healing them, and

loving them.

I have a young family, and as a minister I minister to many

other young families. I am somewhat acquainted with their needs.

Many children my two young sons go to school with are distracted

because they are living with horrendous coughs and toothaches festering long enough for trips to emergency rooms. A child for whom

the only option when dealing with a toothache or walking pneumonia is the emergency room is a child who lives in constant

threat. According to many child psychologists, such as Dr. Bruce

Perry, for instance, the brain does not develop well under threat,

and the greater the threat, the more severe the handicap of brain

development. Each week my church and countless other churches

in my community give to families to buy food and medicine so that

their futures and the futures of our communities might not be diminished. But what we can afford to give as churches and other religious organizations is just a drop in the bucket, and it does not

keep families from sliding down further and further into the pit of

dysfunction. That is why we need a society that stands for something more than personal gain, where the common concern is something larger than what hard-working synagogues, mosques, or

churches can provide alone.

Fortunately, we do not stand alone in this conviction. It is out

of this faithful concern that Jonathan Winthrop wished that this

new Commonwealth truly would become a Beacon on a Hill and

Light of the Nations. As he prayed to God for deliverance from a

storm off that land which would become Boston: ‘‘Now the only way

to avoid this shipwreck, and to provide for our posterity, is to follow the counsel of Micah, to do justly, to love mercy, to walk humbly with our God. For this end, we must be knit together, in this

work, as one man. We must entertain each other in brotherly affection. We must be willing to abridge ourselves of our superfluities,

for the supply of other’s necessities. We must uphold a familiar

commerce together in all meekness, gentleness, patience, and liberality. We must delight in each other; make other’s conditions our

own; rejoice together, mourn together, labor and suffer together, always having before our eyes our commission and community in the

27

work, as members of the same body. So shall we keep the unity of

the spirit in the bond of peace.’’

And so we must ask: What kind of light in the world as a Nation

are we if our children are without health care?

I see I have reached beyond my 5 minutes here.

The CHAIRMAN. You have a little grace period there.

Rev. WRIGHT. I am almost done.

What kind of future are we providing for our children, the future

of our Nation, when we allow for millions of American children to

be so vulnerable? Truly as a Nation, are we not headed for shipwreck? I think the moral thing to do is not only reauthorize CHIP,

but to act on its expansion, as you stated earlier. In the end, the

greatness of our Nation is measured not by our might but by the

health and well-being of our peoples and the mercy and compassion

of our governance.

Thank you.

The CHAIRMAN. Thank you very much. I appreciate that. Very

nice. [Applause.]

[The prepared statement of Rev. Wright appears in the appendix.]

The CHAIRMAN. Judy, as we work to reauthorize, are there certain sorts of institutions that tend to help work better for outreach

than others? And a lot of people do not read the newspapers. A lot

of people do not even watch the evening news at all. A lot of people,

how do they get their news? Sometimes it is just if they have TV,

it is the soaps or something else, who knows what. As you mentioned earlier, it is just the decisions that people have to—you mentioned like an appointment earlier today, maybe 6 weeks down the

road, that is an eternity in the lives of an awful lot of people.

So is it schools? Is it churches? What is it that tends to work a

little bit better than other institutions to reach people whom maybe

when we reauthorize this we might be aware of as we try to encourage more outreach? Or is there something else? Because you

know a lot more about this.

Ms. STEWART. You know, I think the important thing is to go

where the populations are, and I think we need to make more of

an effort to bring the information to them.

The CHAIRMAN. How do we do that?

Ms. STEWART. I think, you know, school is the logical choice. You

know, they are surrounded by people that they are familiar with.

A lot of times the parents will have relationships if with no one

else other than the school secretary who they are having to call in

to and say your child is sick because they are home with a sore

throat, or the school nurses are certainly a logical point as well,

school counselors.

I think if we work with the schools to get that information out

and accessible to them, that will make them feel comfortable with

sitting down and helping people. I think there goes with it a certain amount of training, because a lot of times people feel very uncomfortable talking to people about: Well, how much do you make,

or do you have insurance?

I think we need to get past that and realize that, you know, it

is such a common problem, we need to do what we can to decrease

28

that stigma to people. And church is, you know, another great opportunity to reach out and get to people.

I had sign-up information at our Little League sign-ups for people who are coming through.

The CHAIRMAN. Sports, yes, that is one area.

Ms. STEWART. So I think communities really need to work with

what works for them, and you need to be able to find out where

are the children, where are the low-income folks—or the middleincome people—who may have access to this, because if one in five

of us is uninsured—one, two, three, four, five; one, two, three, four,

five—you know, there are people everywhere. There are people in

the grocery stores, sitting next to you in church, sitting down the

aisle from you in school. So any place that children congregate—

Head Start, another great opportunity for that.

The CHAIRMAN. That would be one, yes.

Dr. Langohr, on the question of access, you know, particularly

with dental care, it is sometimes hard to find doctors, providers, for

dental care. How do we kind of get from here to there and sort of

connect the dots a little bit? I am just a little bit frustrated on how

kids qualify but just the doctor says no, they are not taking them,

or if the doctor is not there, or whatnot. What do we do about that?

Dr. LANGOHR. Well, I share your frustration. You know, I think

the root of that problem really has to do with reimbursement. Dentists just cannot provide for CHIP or Medicaid because they are not

being reimbursed at the level they should. Also, there are so many

issues to access to care.

The CHAIRMAN. Should we address reimbursement in legislation?

Dr. LANGOHR. I think absolutely that has to happen. Pediatrics

in general is not a very well-reimbursed profession. I am not speaking from the sense of a general pediatrician, but if you compare our

services to services for the elderly, the reimbursement is much

lower. So it is kind of undermining our profession in many ways,

especially for surgeons and sub-specialists and people who do the

hardest work, the developmental folks and mental health folks. So

the infrastructure is poor because reimbursement is poor.

The other issues of access to care have to do with transportation,

poverty, people in transition, people not making appointments. And

if you are dentist and you want to work on a child’s mouth and you

allot an hour for it and they do not show up, you know, eventually

you are not going to take that group of patients who do not show

up. So what do you do? Dental clinics in the community, do you tie

dental clinics with schools? I think there needs to be some rethinking of the infrastructure in terms of providing child care that we

could enhance. What is the role of hospitals? What can we do for

hospitals? How can we help these clinics? What are the services

that are needed? How can we help them in rural States?

Montana is very troubled because we just do not have the infrastructure here for access to care.

The CHAIRMAN. Judy mentioned community health centers. Is

that a role here? Is that part of it?

Dr. LANGOHR. I think absolutely that is a role, and certainly

there are dentists with the community health centers. But there

are just not enough, and those programs have to survive, too, on

low reimbursements.

29

The CHAIRMAN. Maria?

Senator CANTWELL. Dr. Langohr, following up on that, what happens when somebody comes to see you who does not have either

CHIP coverage or Medicaid coverage? What happens?

Dr. LANGOHR. You mean the uninsured?

Senator CANTWELL. Yes.

Dr. LANGOHR. We do not deny access to people at all at our clinic.

They get billed for our services, and over time, if they cannot pay,

that builds up and builds up and builds up, and eventually you

have to make a business decision about coverage for people.

It is not a decision we make very easily at the Children’s Clinic,

and, quite frankly, it is not a decision that we make very well in

terms of business sense, because it is very hard to deny people

care. But there is a limit at which you cannot survive if you continue to do unreimbursed care.

Senator CANTWELL. Did you want to add to that?

Mr. WINDY BOY. Yes, if I can. You know, we are kind of in a

similar situation with the tribes because of what I mentioned about

the Level 12 health care that we offer. There are some times we

have emergencies, not only under dental, but we also have under

emergency health care just in general medicine. And a lot of times

when IHS or our Contract Health Service dollars do not cover that,

then eventually the providers outside the reservation, like the doctor said, the business decision is made there, and a good majority

of people who cannot afford that, get billed for that, and their

names end up in the credit bureau and stuff.

Senator CANTWELL. I am sure one of your points is to make sure

that there are funds within the Indian Health Service to cover access. But back to this question, one thing that I am curious about

is, do you think that we actually have the documentation about

who is getting turned away and what those costs are later in the

system, because, as you are articulating, at some point in time, it

is uneconomical to just keep providing that.

I have found in our State, we find physicians do not really want

to say, ‘‘I am not serving this population anymore.’’ They do not

really want to say that. It is not documented. It is not covered. And

so when you want to come back to try to paint the picture of what

is really happening, it is hard to do that because we do not have

adequate information.

Dr. LANGOHR. I would say that that information is very difficult

to divulge. It is not something a clinic wants to divulge.

Senator CANTWELL. How can we encourage that in some nonattributable way that would help us really categorize the problem?

Because part of our challenge in Washington, DC is to make these

decisions and to allocate resources, by finding out what services are

there and are not there. Sometimes because of this reporting issue,

it can be very, very challenging. And I am sure those patients who

are not seen by your clinic or are not seen by Indian Health Services do show up back in the system at a much higher cost later.

There is so much here that is preventive, but putting our finger on

the solutions is very hard.

Let us just say, for example, if we found out that, 100 percent

of all physicians turn away—I do not know—5 percent, whatever

it is, that might better help us in fashioning a solution. But that

30

information is challenging, so maybe there is a way to get it without having it attributable to specific clinics.

Ms. STEWART. If I may add, one way that I think it is very indicative of the issues is, you look at emergency room visits. We did

a recent study here about dental access, and both the local hospitals were very nice to work with me, and we just worked with

three basic dental diagnoses. And so those people who entered into

the emergency room with those three diagnoses, we looked at the

utilization. And I think that is very telling when, you know, the

majority of the people would access care in practically the most expensive arena for, you know, a toothache, and saying, you know,

well, this is because they could not get to a dentist or, you know,

they are accessing emergency rooms for a sore throat. I think that

is very indicative of access issues.

Senator CANTWELL. The reason I am bringing this up, Mr. Chairman, is, obviously our overall Medicare reimbursement rate in

Washington State is problematic. It is one of the lowest, and we

have seen fewer and fewer physicians practicing in certain areas

because they want a higher reimbursement rate somewhere else.

We asked CBO to do a report, which then came back and said,

there is not really an access problem—partly because the information was not available to document the problem and partly because

people can still go to the emergency room. But, obviously, if they

go to the emergency room, it is a higher cost of care. So in looking

at the CHIP program, I sometimes, particularly as it relates to

dental care in whole regions that do not have access, you almost

think about some sort of voucher or something that could be presentable to a variety of health care providers, because I know the

waiting period at the clinics in our State is just a horrendous

length of time to get access to some of the clinics.

The CHAIRMAN. Senator Cantwell makes an excellent point, and

that is data. You know, so often we are sitting there, and we are

trying to do the right thing. But, boy, I will tell you, our decisions

are based on gut, hunches, intuition, experience, and so forth, all

of which is valuable, but it would help us a lot if we had a little

more data all the way around.

So I encourage the State to try to figure out ways to come up

with data, you know, and, Jonathan, your reservation, and others

perhaps, maybe the legislature. I was very intrigued with your idea

of transferring CHIP over to Medicaid. That is very outside the

box. But it is just data. What is happening? Which kids are accessing, which are not, how many turned away? Senator Cantwell’s

point, because it just helps us so much if we have some data. I encourage all of us to try to—particularly you on the front lines working at this, because you have—you are closer to the data, and it

would help us very, very much.

Rev. WRIGHT. I just think, you know, we talk about data, we talk

about particular aspects of the health care system itself. But I

think we as a Nation really need to be able to rearticulate our

neighborhood vision.

The CHAIRMAN. Clearly.

Rev. WRIGHT. And, you know, serving a church that has Republicans and Democrats both in there, I can tell you from experience

that they are both compassionate people, and they are both quite

31

concerned and willing to give vast amounts of money for serving

other people. But they have a different way of articulating the role

of the State in that. But I think that, you know, as a Nation, if

we talk about a neighborhood concern, we can start to approach

some of our values that we really do hold in common.

I know that you do a lot of work in a bipartisan way. You have

to. But, you know, our own State situation right now is appalling

because we are not getting to the real issue of the human being.

The CHAIRMAN. I think the smaller the community, the more the

community itself can work it out to find solutions. The trouble is

that we are such a big country, and we are talking about Federal

legislation. And so lots of Senators and House Members sitting

back there in Washington, DC want to do the right thing and get

home as much as humanly possible, but still rely more on data, on

evidence, whereas the smaller the community, the more that is in

a certain sense less necessary because people will do the right

thing in most cases.

Rev. WRIGHT. But it is vision that drives it all.

The CHAIRMAN. It is vision.

Rev. WRIGHT. It is your values.

The CHAIRMAN. It is clearly vision, but we also have choices, and

it is dollars, unfortunately, and it is allocation of dollars. And so

we clearly want to persuade people to allocate dollars in a way that

makes sense.

Senator CANTWELL. I would just say, Rev. Wright, that you definitely have a vibrant spirit and a rich soul for someone so young,

and we appreciate your testimony. I think it is moving. I hope that

Senator Baucus can invite you back to persuade and evangelize for

many of our colleagues. But, unfortunately——

The CHAIRMAN. I am not going to touch which side of the aisle

that needs to be on. [Laughter.]

Senator CANTWELL. But, unfortunately, since I have been the victim of the very thing he is talking about—take, for example, veterans’ health care, another thing that your Senators, Senator Tester and Senator Baucus, and my colleague, Senator Murray, and I,

we have all been concerned about. Yet if you go back to the debate,

we had these debates on the Senate floor where the response to our

concern is: ‘‘Well, care is there; care is being provided.’’ And yet

this panel just basically talked about the holes in the current network that you all are trying to close.

So what is helpful for us to win the day in the debate is to show

exactly how people do fall through the cracks and to show that the

population is not getting served. Otherwise, people look at the overall amount of money, or they look at the program, and they say,

‘‘Well, you know, this is covered.’’ I wish you the best of luck with

the Governor of Montana and persuading the legislature to do the

right thing. As I mentioned, Washington State started a program

in 1994 prior to any Federal program. But, you have to have the

commitment on both levels, and oftentimes when people disagree,

the commonality that can get them to agree is common data. And

so, hopefully we can have both your spirit in DC on this important

issue and the data to make the case.

Rev. WRIGHT. The dysfunction, though, is larger than one issue.

The impact of poverty goes far beyond one particular issue. So I

32

think until we as a Nation can grapple with the many different

streams that contribute to poverty and what it is, we are going to

be in trouble.

Senator CANTWELL. I do not know if that is applause or somebody wants to come in. [Laughter.]

But I would say, you know, it is one of the reasons why I decided

to join this Finance Committee, because I think that Senator Baucus shares a vision of where we need to go in eradicating that. By

that I mean an investment in the future. And I think this Finance

Committee has a great ability to make some of the decisions that

will eradicate poverty by saying, let us make college education

more affordable, let us make access to health care a guaranteed

benefit for the children of America, let us make sure that we are

giving families the opportunities to help themselves.

But when you come back to that budget equation, you really do

have to actually count votes, and the challenge that we have is

that, again, some people will use a lack of information documenting

the problem as a way to basically deter progress. And I think the

commitment level for something like the CHIP program is bipartisan, but when you come down to how much money should be

spent, I would like everybody to say let us cover 200 to 250—or

whatever the adjusted rate is. And I might be more willing to make

it an even more aggressive program because we in Washington

State have gone further than other States. But I hope that that

Federal program could be designed to bring States along that have

not been as aggressive.

The CHAIRMAN. That is why the values that you espoused, Reverend, are exactly the goals that we are seeking to achieve. You are

a beacon. You are a guiding light here. We are going to do all we

can to follow that light.

Mr. WINDY BOY. Mr. Chairman, could I enlighten you on what

is going on?

The CHAIRMAN. I would love to be enlightened.

Mr. WINDY BOY. Mr. Chairman, I know I spoke on a tribal level,

but if I can give you hopefully a little bright light from Helena as

well. There are a couple things.

It is unfortunate what has happened in the legislature, and the

citizens of Montana, I am sure they probably have some concerns

about some of this, especially these particular issues. There were

two bills that have been increased, and you probably heard about

them: there is that 200-percent eligibility bill that Representative

Mary Caferro out of Helena sponsored, and then that has been sitting in appropriations since January; and the other one that is

coming from the Senate side, Senator Weinberg had 175 percent

and that is still making its way through. But one of the things that

was interesting on the dental, there was—Representative Bill

Jones has sponsored a couple bills that included dental, so that is

one of the good things to come out of that. But some of the other

things that I think probably need to happen on the State level as

far as some of the eligibility, and that is one of the things I see

as one of the barriers, is determining eligibility. And I think that

if we—and if the forms and the applications were shortened up to

the point where it is more user-friendly, I think that would really

make a difference.

33

The CHAIRMAN. I was going to ask several questions along that

line, but we just do not have the time right now.

Mr. WINDY BOY. And then one more thing, too, you know, as far

as eligibility and other things: I think methamphetamine is going

to be an issue, and the mental health issue I think probably needs

to be addressed at some point.

The CHAIRMAN. Thank you. Thanks for all that you do, Jonathan.

You do a good job.

Let us thank our panel. They have been just great. [Applause.]

Now we are going to get to the third panel, and that is all of you.

We will have a question-and-answer session here.

Since this is a formal hearing, I would like each of you to identify

yourselves. Please give your name and the organization you might

represent and where you are from. We need that for the record.

Also, if you could be very brief. We do not have an awful lot of time

here. We have about 20 minutes. So please get straight to the

point, which then means other people have time to make the points

that they want to make. You all can stay up here if you want, because then you can see people, listen to them, and so forth.

We have a couple of people with prepared remarks, and I urge

them to be very brief as well. Dr. Kevin Rencher is a pediatric dentist from Helena, as well as Clark Sauers, a high school student

who is on the Health Insurance Program. Clark is also from Helena.

STATEMENT OF DR. KEVIN RENCHER, PEDIATRIC DENTIST,

HELENA, MT

Dr. RENCHER. Good afternoon. My name is Dr. Kevin Rencher.

I am a pediatric dentist in Helena, MT. I am in private practice

in Helena. I have been there for 2 years. I also volunteer on

Wednesday afternoons at the local community health center. The

reason I do that is so that kids who cannot afford dental treatment

can see a specialist at the community health center.

As you know, a month ago a 12-year-old boy died in Maryland

from a dental abscess. He had a toothache that spread into the

bone and spread into his brain, and he died.

Two weeks ago, Senator Baucus, I was meeting with some members of your team, and one of them asked me: ‘‘Could this happen

in Montana?’’ My answer was that it absolutely could happen in

Montana. And they said, ‘‘Well, how often do you see it in your

practice?’’ I said, ‘‘Well, I do not know. I will have to go back and

look.’’

Well, it has been 2 weeks exactly since I left your office. In the

last 2 weeks, I have seen 5 children who have had severe, severe

dental decay. When I say ‘‘severe,’’ I mean 20 teeth, at least 20 cavities. They show infections, pain, have been on antibiotics for

weeks. Out of those 5 children that I have seen in the last 2 weeks,

one was from Havre, one was from Box Elder, one was from Great

Falls, one was from Butte, and one was from Dillon. Dillon, MT.

And those patients have been coming to my office. I am in Helena.

Had their parents waited any longer for them to seek care, they

would have become the next dental tragedies. There is a tremendous amount of need in this State, a huge unmet need.

34

There are four statistics that I think it is important that everybody understands. Dental disease is the most common chronic disease in childhood. For every child with unmet medical needs, there

are 3 children with unmet dental needs. More children miss school

for dental disease than for any other reason. And, finally, for every

family with no medical insurance, there are 21⁄2 families without

dental insurance.

For me to come here today, I had to reschedule 40 patients. Out

of those 40 patients, a handful of which have been in pain for several weeks and have been on antibiotics, as my office called these

families to say, ‘‘Listen, we are going to have to reschedule you,’’

I was afraid that they would be frustrated or disappointed that we

had to reschedule them. To my surprise, and to my great happiness, they were grateful that the Senate Finance Committee was

holding this hearing, because these parents understand how important the dental component is to CHIP.

There are three things that we need from the Federal Government. First, CHIP needs to be reauthorized with a much stronger

dental component, and there are three things that we need.

First, we need a Federal guarantee for dental coverage. Too

often, when States have to make cuts, they cut out the dental, and

that is why we see such a problem from the dental component.

There needs to be a Federal guarantee for dental coverage.

Second, we need to allow States to offer dental coverage to those

children via a dental wraparound. There needs to be some sort of

dental wraparound so that children do not lose their dental benefits when their parents receive medical coverage. Oftentimes, that

medical coverage does not cover dental, and those children are

being dropped from CHIP.

And, third, we need to require States to report their dental performance so we can look at the data. Right now the data is extremely lacking when it comes to the dental procedures. We need

to have that data so that in 10 years we can have a much more

educated conversation.

I want to go back to these 5 kids. These 5 kids truly were weeks,

maybe months, from being the next dental tragedies. Havre, Great

Falls, all over the State, they are having to drive to get their dental

treatment completed. We need to do all we can to remove those

barriers, and by reauthorizing CHIP with a much stronger dental

component, we could remove some of those barriers.

Thank you both for your time and your energy on this very, very

important children’s oral health issue.

The CHAIRMAN. Doctor, thank you. That is very compelling. Very

helpful. [Applause.]

[The prepared statement of Dr. Rencher appears in the appendix.]

The CHAIRMAN. I know we do not have time, but I am going to

jump in. Why do States tend to drop dental coverage first? Does

anyone want to take a crack at that for about 30 seconds? They do?

Why? If they do, we have to find out why and do something about

it.

Okay. Yes, next?

35

STATEMENT OF LORI SIMON, MARCH OF DIMES, BILLINGS, MT

Ms. SIMON. Hi, I am Lori Simon with the March of Dimes, and

I would like to thank you, Senator Baucus, for holding this important hearing to discuss CHIP.

The March of Dimes is very concerned with ensuring that pregnant women have access to the full spectrum of maternity care

benefits. This gives infants the best chance for a healthy start and

protects the mother’s health.

Currently, if a State wants to cover pregnant women in CHIP,

they have to get a special waiver or go through a regulatory process that does not allow reimbursement of medically necessary

postpartum care. Do you support giving States the option to cover

pregnant women in CHIP without a waiver? And will you include

a provision to grant States this option in your reauthorization bill?

The CHAIRMAN. Thank you very much. I appreciate that.

Okay, next? Do not forget. Name?

STATEMENT OF CLARK SAUERS, SENIOR, PROJECT FOR

ALTERNATIVE LEARNING, HELENA, MT

Mr. SAUERS. My name is Clark Sauers. I am 17 and a senior at

the Project for Alternative Learning.

The CHAIRMAN. All right. And from Helena.

Mr. SAUERS. From Helena, yes.

The CHAIRMAN. Thank you.

Mr. SAUERS. I am here today to talk about my experiences with

CHIP, and what I have had is—well, let us just start with I am

a very accident-prone person. [Laughter.]

The CHAIRMAN. You are a teenager.

Mr. SAUERS. I am a typical guy, 17, I watched the ‘‘Jackass’’ movies and did not heed the ‘‘Do not attempt this stunt’’ warnings.

Well, a laundry basket and a staircase later, I was in the hospital having surgery on my foot, and CHIP helped me a lot with

that. When I walked out the door, I had to pay $3. And without

CHIP, I do not know how I would have been able to come up with

the money.

And not only that, but I am also here today to say that kids—

I mean, generally, when these bills are talked about, nobody talks

about the kids that CHIP affects. I mean, they are talked about,

but no one talks to them. And that is also the fault of the kids because nobody knows that you can come up here and speak. And one

of the reasons I came today was to show that I am up here, I can

do this, I am talking, just know that your voice can be heard and

that more people should be coming up here and talking about

things that affect them.

Thank you.

The CHAIRMAN. Good. Good for you, Clark. [Applause.]

STATEMENT OF ERAN THOMPSON, MONTANA PEOPLE’S

ACTION, BILLINGS, MT

Mr. THOMPSON. My name is Eran Thompson. I represent Montana People’s Action from right here in Billings. We are here today

to do two really important things. The first one is to make sure

that folks who could not attend, that their voices had an opporVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
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tunity to be heard. The second one is to stress two essential points

that we feel are important for the reauthorization of CHIP.

So starting with our first point, really quickly, we have spent the

last few months organizing our interns to go out door to door, to

stand at tables at food banks, to be at Family Services, wherever

they could, to find CHIP families and to find people who should be

CHIP families.

The CHAIRMAN. Good.

Mr. THOMPSON. And in doing so, we published a storybook that

is available. Our interns have it back there. It is also available on

our website.

The second thing is we talked to some of our friends in Washington, and so Washington Can, a nonprofit organization there, has

sent for you, Senator Cantwell, a letter, a sign-on letter, with several organizations from around the State of Washington to express

their concerns about reauthorizing CHIP.

For Senator Baucus, we have also talked to several Catholic

churches who wish they could be here today, and I have a sign-on

letter for you from several Catholic parishes around the city.

That moves on to our two essential points. You will see the two

flags in front of you on those chocolate chip cookies that were given

to you by Caden and Ethan, members of the Montana People’s Action families.

The first point of those is that $50 billion is great, $60 billion is

better. [Laughter.]

The CHAIRMAN. It is. I agree.

Mr. THOMPSON. And we will have plenty of time to talk about

that some other time.

The second one is a very important and a not often well known

in Montana issue, and we will rise today to ask you to support removal of the 5-year bar for the State Children’s Health Insurance

Program. Under current Federal law, lawfully residing immigrant

children and pregnant mothers are barred from Medicaid and

CHIP for over 5 years. This restriction has increased racial and

ethnic health disparities among children in the U.S., and despite

immigrants’ high rate of employment, almost half of low-income

immigrant children are uninsured, at a rate three times higher

than that of our children from native-born families.

Failing to provide basic preventive health care for immigrant

children jeopardizes their health and creates a need for more expensive subsequent care. Similarly, failing to provide prenatal care

risks the health of newborn U.S. citizens and increases the need for

costly medical interventions after birth.

As a person of color and as a native-born and -raised Montanan,

I cannot understand the deliberate intention to leave these children

behind. Why are their lives less precious than any other child’s?

Can they not be our future leaders, innovators, and productive citizens of our Nation? And does not an investment in their well-being

now make that more likely?

Thank you.

The CHAIRMAN. Thank you, Eran, very much. Thank you. [Applause.]

37

STATEMENT OF RUSS BROWN, ON BEHALF OF STATE REPRESENTATIVE ARLENE BECKER, VICE-CHAIR, MONTANA

HOUSE COMMITTEE ON HEALTH AND HUMAN SERVICES,

BILLINGS, MT

Mr. BROWN. Chairman, Senator, my name is Russ Brown. I have

been asked to read a brief statement into the record on behalf of

State Representative Arlene Becker.

The CHAIRMAN. It will be included.

Mr. BROWN. Thank you.

The CHAIRMAN. You are welcome.

Mr. BROWN [reading]. ‘‘For the record, my name is Arlene Becker, and I reside in Billings, MT. I have been a registered nurse for

over 20 years, and I am currently a State Representative from Billings who is honored to serve in that capacity as Vice Chair of

Montana’s House Health and Human Services Committee.

‘‘I am also proud to note that I serve with a group of caring, committed individuals who sought to emulate Senator Baucus’ lead in

this all so important area of children’s health care with the enactment of CHIP-enabling legislation in Montana.’’

I am going to skip some of this for time.

‘‘For all CHIP’s success, not only is it imperative for CHIP to be

renewed, but expansion of coverage must take place to ensure that

no child is left behind. Reenactment legislation must put kids first.

I strongly encourage you to prioritize those States, including Montana, that do not currently operate at the 200 percent of poverty

level as the primary focus of the first funding allocation.

‘‘I also urge you to eliminate the State university employee exclusion component of CHIP that does not allow children of State university employees to be eligible for this coverage. Children in need

and whose parents fall within the proposed 200-percent level

should not be excluded, regardless of whom their employer is. They

should be as eligible as the children of Federal employees.

‘‘Senators, like yourself, I am passionate and remain committed

to ensuring that all children have access to affordable and adequate health care. The reenactment and expansion of CHIP is a

critical building block in that process.

‘‘Thank you, Senators, for holding this hearing in Montana, and

I can assure you that there is a strong sense of commitment from

our State legislature to work with you in any way possible.

‘‘And, Max’’—or excuse me, Senator Baucus—‘‘many of you noted

the efforts of the Senators before you, Senator Hatch and others.

However, many of us regard you as the godfather, or perhaps the

midwife, of the national CHIP program.’’ [Laughter.]

The CHAIRMAN. We are mixing a lot of metaphors here.

Mr. BROWN. Sorry about that. I am just reading.

‘‘Perhaps the midwife of the national CHIP program, and words

are truly inadequate to express how proud we are of your efforts.

‘‘Thank you.’’

[The prepared statement of Ms. Becker appears in the appendix.]

The CHAIRMAN. Thank you very much. Thanks to Arlene. [Applause.]

I am going to give everybody an offer that they cannot refuse.

Pat?

38

STATEMENT OF PAT CALLBECK-HARPER, ASSOCIATE STATE

DIRECTOR OF AARP, HELENA, MT

Ms. CALLBECK-HARPER. Mr. Chairman, my name is Pat CallbeckHarper. I am associate state director of AARP Montana in Helena,

with 154,000 members. I want to say a word to ask for the inclusion in all of this discussion and the gathering of data of a rather

silent and invisible population that are both advocates of the CHIP

program, could be beneficiaries of the CHIP program, and thanks

to Judy, are also targets of education about the CHIP program.

AARP is the largest supporter of grandparents raising grandchildren in the country. Our Grandparents Information Center on

the Internet says that there are 6,000 Montana grandparents currently in custodial care of their children and raising their grandchildren. They also estimate another 10,000 grandparents are parenting their grandchildren with one of their parents in the home

as well. So they are the household heads parenting their children

and their children’s children.

The newspaper a couple weeks ago talked about a 70-year-old

woman who adopted her 5 great-grandchildren and expected to be

able to raise them on her Social Security income. We in the AARP

know that that is a tragedy in the making, and our grandparents

raising grandchildren support groups are uneven in their knowledge about CHIP, so we have a responsibility at AARP as advocates on CHIP, which we take very seriously. But when they tell

us what their biggest problems are, it is about the cost of medical

care. But, in particular, thanks to our dentist from Helena, dental

care is the most tragic reality for these grandparents in trying to

raise thousands of grandchildren, the average being 3 to 5 grandchildren whom they raise at a time on very, very diminishing incomes.

So whatever we can do in MMA, Max, or Medicare or anything

else to get this universal health care coming, it is going to be a

multigenerational benefit that an expanded CHIP brings to Montana grandparents.

Thank you. [Applause.]

The CHAIRMAN. Thank you, Pat.

Before you go next, I want to ask Dr. Rencher, could you please

tell each of those children that your message was received loud and

clear by this committee?

Dr. RENCHER. Thank you.

The CHAIRMAN. And we very much appreciate their rescheduling

their time to make way for you to come here and explain to us just

how terrible a problem kids have with respect to insufficient dental

care. I just want to thank you. If you could just send that message

back to those kids and the families, that would make a big difference to all of us. Thank you.

STATEMENT OF OLIVIA RIUTTA, REPRESENTATIVE OF WEEL,

HELENA, MT

Ms. RIUTTA. Good afternoon, Chairman Baucus, Senator Cantwell, and members of the panel. I have been in Helena too long.

You can tell.

My name is Olivia Riutta. I am here as a representative of

WEEL. We are a statewide nonprofit organization made up of lowVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
39

income Montana families, and I first just want to say what an

honor it was to drive over with Clark this morning. Such a poised

advocate for youth on the CHIP program.

I want to start out by saying that at WEEL we believe health

care is a human right, and it is a necessary investment in our Montana families, in our communities, and really in our State economy.

You came to Helena in February and challenged the State legislature to push for CHIP expansion in Montana, saying that you

would do the same in Washington, and we are still working on it.

We are not quite there yet, but do not worry, we have not given

up.

And with that, as I was leaving yesterday, the Montana Democratic Women’s Legislative Caucus asked me to read a brief statement because they are busy taking care of business in Helena

today. They cannot be on vacation like the rest of us.

‘‘Senator Baucus and members of the committee, the Montana

Democratic Women’s Legislative Caucus would like to go on the

record as enthusiastically endorsing the proposed renewal and extension of CHIP. Early in the legislative session, we identified expanding coverage of CHIP in Montana as one of its top priorities.

We thank you for your leadership on this innovative health care

program and believe that its continuation in Montana is critical to

the well-being of thousands of Montana’s children who otherwise

would not have access to adequate health care.’’

The letter goes on to specifically address the issue of supporting

further funding for outreach, especially in rural Montana communities, where there are only 8 people per mile. I believe that was

the statistic.

This letter is signed by Senator Carol Williams, which is very exciting, because she is serving as the first majority speaker of the

Montana State Senate ever.

So, with that, I just want to add that we reiterate the feelings

of the caucus that outreach is a serious issue and that there needs

to be an any-door policy in Montana. Wherever children are accessing benefits, accessing programs, going to school, we need to figure

out how we can get them on CHIP and how we can have this information disseminated through means that families are already used

to, that do not carry stigma, and that they are more assured to sign

up for the program on.

Thank you very much.

The CHAIRMAN. Super. Thank you very much. [Applause.]

STATEMENT OF DOLLY ROCKROADS, NORTHERN CHEYENNE

TRIBE, CO-FOUNDER OF THE NATIONAL INDIAN CHILD DEVELOPMENT INSTITUTE

Ms. ROCKROADS. My name is Dolly Rockroads. I am from the

Northern Cheyenne Tribe. I am the co-founder of the National Indian Child Development Institute.

Forty years ago, when John Kennedy was the President, he sent

emissaries to different parts of the country. These emissaries came

back with the concerns and issues of the American people, and one

of the highest priorities was children’s issues, child care, and they

set up the National Child Development Institute.

40

Ten years later, the African American women organized. They

are known as the National Black Child Development Institute.

They have a chapter in every major city in America. The Latino

women have organized. These organizations impact education,

medical issues concerning their children. The Native American

women have never organized. This is what we have done.

Two years ago, when I was at MSU here, through my early childhood classes I was introduced to these organizations. What we are

doing is we are projecting back the customs and the culture to the

young in taking care of their children, and this young man over

here spoke so eloquently. Our child care practices are universal

quality health care practices. And I am going to share just one with

you. The cradle board, for my tribe in its primitive form, it was a

piece of buckskin and a piece of rawhide. Our ancestors swaddled

their newborn to a backboard. You know what a backboard is.

EMTs carry backboards when someone breaks their neck, their

back, they package them. Well, that is what our ancestors did.

Then they became modern. With the introduction of the beads,

they beaded the outside, but the back was still the rawhide. Today

we are even more contemporary. We just take a piece of cardboard

the width and length of the newborn. We tuck it into a corner of

a blanket, and we swaddle our newborn to the backboard.

When you look at the physiology and the anatomy of that little

one, when you are in the womb, you are curled up, your spinal column is wide open. When you are born, you straighten up. Your spinal column comes together and is only starting to fuse together.

That is a universal quality health care practice. They do not

know what causes this. I suspect that has something to do with

that.

I read a book 2 weeks ago on Hilary Clinton. They were at a big

old gathering and such, and she whispered to the old President

Bush, ‘‘Do you know that the majority of our infants do not live to

be a year old?’’ That is what we are up against.

I commend all of you, the leaders, for bringing awareness and

focus to the medical side of America and how we take care of our

children.

Thank you.

The CHAIRMAN. Thank you, Dolly, very much. Thank you. [Applause.]

We have to wrap up after you. You are our wrap-up person.

STATEMENT OF CAROLE LANKFORD, VICE CHAIR OF THE

SALISH-KOOTENAI TRIBE

Ms. LANKFORD. Good afternoon. My name is Carole Lankford. I

am Vice Chair of the Salish-Kootenai Tribe, and I want to thank

you, Chairman Baucus and Senator Cantwell, for coming here, and

all the panel that was here today. It was really nice to have you

come in and hear our stories in Montana.

The Salish-Kootenai has testimony that we have drafted, and we

will forward that to you, because I know there is no time.

Two points I would like to see. I would like to see the enrollment

process a little bit easier, and I like the idea of including pregnant

women. I think that is very important. I see that all the time, InVerDate 11-MAY-2000 16:40 Jul 28, 2008 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6633 43021.000 SFIN1 PsN: SFIN1
41

dian women and women across the State of Montana, you know,

having difficulty having access to care.

So I just want to thank you very much for this opportunity.

The CHAIRMAN. Thank you, Carole, very, very much. [Applause.]

Some of you have prepared remarks, and I would appreciate it

if you could leave it with our clerk over here, with Carla. While I

am mentioning Carla, I would like all of the people who came out

from Washington, DC, who are part of the Finance Committee staff

who helped make all this possible, to be recognized.

First is Carla Martin over here, and Jewel Harper from the

clerk’s office, Lisa Dennis, Erin Shields, and Catherine Dratz. Also

chief counsel for the Finance Committee and Health staff is

Michelle Easton, and, of course, Alice Weiss behind me. Could all

of you please stand? And Carol Hill Johnson from Senator Cantwell’s office. All of you please stand. [Applause.]

Give them a round of applause. They work hard.

I would also like to recognize my staff, which is Melody Haynes—

a lot of you know Melody here in Billings—Jim Corson, Fred Kaiser, Julie Morgan, and Bob Grayson. Could you all please stand,

everybody? Raise your hands if you are already standing. [Applause.]

They do all the work.

This has been just great. I have learned a lot. It was very helpful. And I thank Senator Cantwell. I could speak for her and say

the same. And I thank all of you who took the time to come here.

This is an ongoing process. We have only begun to start now. So

I would urge you to keep talking to us and we will with you.

I am going to do two things. I would like to give you my personal

telephone number as well as my personal private e-mail address.

You really cannot do this in Washington. There are so many people

in the State of Washington. But here is my personal private e-mail

address. It is maxbaucus@earthlink.net. And my private telephone

number is (202) 224–4375.

There are a lot of ideas that this hearing is going to spawn, and

I urge you follow up on it, and we will with you, and just thank

you very, very much for all that you do.

Thank you. The hearing is adjourned.

[Whereupon, at 4:21 p.m., the committee was adjourned.]

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