Recent Pediatric Grand Rounds offers pediatricians relevant advocacy and federal Loan Repayment Program information

Dr. Vivek Balasubramaniam standing in an indoor atrium and wearing a yellow shirt
Vivek Balasubramaniam, MD

Vigorous advocacy is a core tenet of the UW Department of Pediatrics mission. Vivek Balasubramaniam, MD, associate professor, Division of Pulmonology and Sleep Medicine, is an active participant in the department’s advocacy efforts and was instrumental in arranging a recent Pediatric Grand Rounds (PGR) in which Shetal Shah, MD, pediatrician and neonatologist in New York Medical College’s Maria Fareri Children’s Hospital, highlighted several advocacy issues that require pediatricians’ attention.

In his September 29 talk “Update on Federal Advocacy Issues: What Pediatrician Need to Know,” Shah included his examination and explanation of a range of issues important to pediatricians and the children and their families that they care for. They included Medicaid re-enrollment, decline in childhood vaccinations, vaccination reimbursement, and the funding of the Health Resources and Services Administration (HSRA) Loan Repayment Program for health professionals in shortage areas. Below is a review of these topics, as well as further explanation from Balasubramaniam.

Medicaid re-enrollment
More than 41 million children are enrolled in Medicaid and M-CHIP. They account for more than 45 percent of Medicaid recipients. It is likely that most pediatricians have patients dependent on these programs for health care. During the pandemic, the declaration of a Public Health Emergency for COVID-19 was made on January 31, 2020. It was renewed multiple times throughout 2020, 2021, and into 2022. Last renewed on October 13, 2022, for 90 days, that extension ends on January 11, 2023, pending another renewal. The Public Health Emergency declaration allows critical flexibilities hospitals depend on to deliver needed care, and minimize disruptions to an “increasingly fragile” health care delivery system, according to the American Hospital Association.

Because of this declaration due to COVID-19, the federal government changed the annual re-enrollment requirement for Medicaid participants. Rather than being required to re-enroll every year, participants were allowed to forgo that annual re-enrollment requirement for the duration of the COVID-19 public health emergency, now approaching three years. However, it is probable that the Medicaid enrollment protocols will shift back to pre-COVID-19 requirements after the Public Health Emergency attributed to COVID-19 expires.

The date of expiration of the Public Health Emergency is unknown. The U.S. Department of Health and Human Services (HHS) secretary could issue another 90-day extension before the January 11, 2023, deadline. The HHS has promised to give states 60 days notice before the COVID-19 public health emergency is ended.

Shah presented this information with the caveat that many families dependent on Medicaid for health care may not know that they may again be required to re-enroll in Medicaid to maintain benefits after the Public Health Emergency expires. States will have up to 14 months to complete redeterminations and resume normal operations, although many states have indicated they will do this more quickly. During this time, states will begin disenrolling people who no longer qualify or who face administrative barriers, such as responding to mailed requests for information within a set timeframe, even though some may still be eligible. If they don’t re-enroll, they could be dropped from the program. Pediatricians are in the unique position of being able to educate and counsel the families of their young patients about this likely re-instated Medicaid requirement during their clinic visits.

Balasubramaniam, a long-time colleague of Shah among the leadership of the Society for Pediatric Research Advocacy Committee, is very knowledgeable in this area. In an interview, he addressed this issue and a future end to the public health emergency. “Many families have not had to re-enroll in Medicaid for more than two years, and it would be very easy for many to miss their re-enrollment deadline when it is suddenly required again,” Balasubramaniam explained. “We, as their physicians, as advocates for them —paying attention to things that they may not notice — can step up to remind families that the situation is changing, and what they must do to maintain their Medicaid eligibility.”

The Department of Pediatrics is following this issue and will provide future guidance when action is appropriate.

Decline in vaccination administration
Another concern resulting from the COVID-19 Public Health Emergency is the enormous shortfall in childhood vaccinations over the years of the pandemic. Often, it was just too difficult for parents to bring their children to their pediatricians as COVID-19 spread across the country. Further, misinformation and vaccine hesitancy increased enormously during this time, and many young parents adversely influenced by skewed information chose to put off childhood vaccinations. The result, as Shah presented, is that there were 11 million fewer non-flu vaccinations and 1.4 million fewer measles and mumps vaccines administered throughout 2020 and 2021 compared to 2019.

As a consequence of this, Balasubramaniam explained, there has been a re-emergence of some vaccine-preventable disease, such as measles, and he pointed to a recent report showing polio virus was detected in wastewater in New York State.

“One result of our great success in preventing serious diseases through vaccination is that people have no history or experience with them. They don’t have a sister who lost a child to measles or an uncle permanently disabled by polio, and the real and dire effects of these diseases don’t exist as real-life dangers for families,” he said. “They may believe that their choice to vaccinate their children — or not — carries no real consequence for them, but that choice has enormous effect, both individually and for the larger community.”

Balasubramaniam said as advocates for vaccinations, pediatricians can provide the families of their patients with the facts they need to protect their children and encouraged his colleagues to work to remedy the vaccination shortfall.

Vaccination reimbursement
A related area of advocacy regarding vaccinations addressed in Shah’s PGR is the lack of parity between what Medicare and Medicaid reimburse clinicians for vaccinations. A pediatrician who administers a combination vaccination is reimbursed $13.76 regardless of the number of components included. Medicare, conversely, pays an additional amount for each component: in New York State, the example provided in the PGR, a three-component vaccination is reimbursed $42.92 by Medicare and $13.76 by Medicaid. Pediatricians must contact their state and national legislators to urge them to address this enormous disparity.

Shah also examined the expansion of Medicaid to states to extend post-delivery coverage for mothers. It is one area in which Wisconsin pediatricians may wish to exert their influence as advocates — state acceptance of expanded Medicaid. One enormous benefit of the federal American Rescue Plan as it concerns Medicaid is its incentive to states to make mothers Medicaid-eligible for one year post-delivery rather than for only two months. The effect of this expansion of Medicaid has been enormously beneficial to new mothers. While 24 states have adopted it, Wisconsin has not.

“Becoming an active pediatric advocate is not difficult,” Balasubramaniam noted. “Pediatricians are already advocates for their individual patients in their practices every day; advocacy on a larger scale just expands the group.”

Balasubramaniam recalled a message from Mark Del Monte, CEO and executive vice president of the American Academy of Pediatrics, encouraging pediatricians to enter advocacy. Del Monte said that while speaking to a senator or representative may seem daunting, pediatricians already have long experience talking to the most difficult group there is: teen-agers.

“I encourage my colleagues to become active advocates,” Balasubramaniam added. “The need is great, especially now, and success is possible,”

HRSA Loan Repayment Program
Not all effects of the pandemic were damaging. An unusual consequence of the American Rescue Plan — a bill passed by Congress to assist businesses and individuals adversely affected by the pandemic — was the funding of the Health Resources and Services Administration (HSRA) Loan Repayment Program for health professionals in shortage areas. This program allows health professionals with outstanding educational loans who work for at least two years in shortage areas — which includes nearly all pediatric subspecialties —to qualify for three years of loan repayment at $35,000 per year. The program has been funded with $5 million, which would cover 64 awards. Balasubramaniam urged those who may qualify to visit the website and take action.