CHIP Reauthorization: New Opportunities for Moving Forward

Cindy MannCenter for Children and Families

Georgetown University Health Policy Institute

http://ccf.georgetown.edu

Commonwealth Fund Leadership Forum on

Early Childhood Development

February 6, 2009

11%

29%

4%

55%

Public Programs’ Coverage Role Today (Non-elderly, 2007)

20%

11%

6%63%

Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

Children = 78.6 million

Individual Coverage

Employer-Sponsored Insurance

Medicaid/ Other Public

Uninsured

Adults = 182.8 million

42%

28%

15%

15%

Income Levels of Uninsured, 2007

35%

29%

25%

11%

Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

Children = 8.9 million Adults = 36.1 million

Under 100%

100-199%

200-299%

300% +

70% below 200% FPL 84% below

200% FPL

Source: S.Dorn, et al.,”Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses,“ Kaiser Commission on Medicaid and the Uninsured, April 2008. Note: a 1% increase in unemployment also equals a 3-4% decline in state revenues.

Impact of Unemployment Growth on Medicaid and SCHIP

1%

Increase in National Unemployment Rate

=1.0

Increase in Medicaid &

SCHIP Enrollment

(million)

&

1.1

Increase in Uninsured

(million)

$3.4

$2.0

$1.4 State

Federal

Increase in Medicaid & SCHIP Spending

(billion)

CHIPRA: Key Features

• New funding levels and formula• New incentives to enroll Medicaid children• Eligibility changes• Benefit changes• Significant new emphasis on quality, access

Allotments Over Time

Source: Congressional Budget Office, “CBO’s Preliminary Estimate of the Effects on Direct Spending and Revenues of the Children’s Health Insurance Program Reauthorization Act of 2009” (January 13, 2009; Congressional Budget Office, “Fact Sheet for CBO’s March 2008 Baseline: State Children’s Health Insurance Program” (March 12, 2008); and Center for Children and Families analysis of historic allotments as reported in the Federal Register.

New Formula Addresses “Mismatch” Under Old Formula

Source: C. Peterson, “What Happens to SCHIP After March 31, 2009?,” Congressional Research Service (December 19, 2008)

CHIPRA: Key Features

• New funding levels and formula• New incentives to enroll Medicaid children• Eligibility changes• Benefit changes• Significant new emphasis on quality, access

Enrollment of Children in Public Coverage (Millions)

Source: Center for Children and Families analysis of preliminary data. Based on children ever-enrolled over the course of a year.

21.023.5

22.325.2

27.2

32.330.8

34.0

Coverage Gains Over the Past Decade Have Come Equally from

Medicaid & SCHIP

Children Currently Eligible but Unenrolled

4.4 Million are Eligible for Medicaid

1.7 Million are Eligible for SCHIP

Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules

9 Million Uninsured Children

Reaching the Eligible but Unenrolled Children

< 1%

Procedural closings in Louisiana:

Source: LaCHIP/Medicaid Eligibility Division, La. Department of Health & Hospitals, September 2008

Performance Bonuses

Approximate Effective Medicaid Match Rate for Additional Enrollment

Current Match RateCaseload Between 100-110% of Target

Caseload Above 110% of Target

50% 57.5% 81.25%

60% 66% 85%

70% 74.5% 88.75%

80% 83% 92.5%

CHIPRA: Key Features

• New funding levels and formula• New incentives to enroll Medicaid children• Eligibility changes• Benefit changes• Significant new emphasis on quality, access

The Affordability Gap is Widening

Source: Center for Children and Families analysis of Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2008; and the Federal Poverty Level for a family of three, 1999-2008, available: http://aspe.hhs.gov/poverty/figures-fed-reg.shtml.

Source: D. Cohen Ross, A. Horn, & C. Marks, “Health Coverage for Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles,” Kaiser Commission on Medicaid and the Uninsured (January 2008);updated by the Center for Children and Families. Note: States with asterisks (*) have enacted, but not yet implemented to the levels shown.

FL

NC*

SC

GALA*TX

AL

AR

KS*

OK*AZ TN

MS

NVUT

NM

CA

WYID

WA*

ORND

SD

NE

MT*

MO

IN*

MI

WI

IL

ME

OH*

KY

HI

AK

PA

WV* VA

CTNJ

DEMD

RI

NHVT

DC

MA

CO*

IA*

NYMN

Medicaid and SCHIP Eligibility Levels for Children, January 2009

> 250% FPL (21 states)

200% FPL (16 states)

201%-250% FPL (9 states)

< 200% FPL (5 states)

The “Welcome Mat” Effect

STATETotal New Enrollment

Previously Eligible

Illinois 244,700 165,600 (68%)Data from November 2005 - June 2008

Massachusetts 51,000 32,750 (64%)Data from June 2006 - June 2008

Pennsylvania 19,000 11,000 (59%)Data from February 2007 - June 2008

Wisconsin 49,108 40,881 (83%)Data from February 2008 - May 2008

Source: Center for Children and Families, "Putting Out the Welcome Mat: Implications of Coverage Expansions for Already-Eligible Children” (September 9, 2008).

Source: CBO, January 16,2009. Note: Average monthly enrollment for fiscal year 2013.

Uninsured Children Already Eligible

4.1 Million Otherwise Uninsured Children

CHIPRA Would Cover 4 Million Otherwise Uninsured Children

Children Newly Eligible Through CHIP Expansions

Children Slated to Lose Coverage at Current

Funding Levels

83% Eligible Under

Current Program

Rules

CHIPRA: Key Features

• New funding levels and formula• New incentives to enroll Medicaid children• Eligibility changes• Benefit changes• Significant new emphasis on quality, access

Benefits

• Mental health parity• Dental coverage required• Supplemental dental coverage permitted• Clarification of “DRA” EPSDT provision

CHIPRA: Key Features

• New funding levels and formula• New incentives to enroll Medicaid children• Eligibility changes• Benefit changes• Significant new emphasis on quality,

access

Quality Initiative

• Not limited to public program coverage• Development of child health measures

addressing quality and stability; monitoring and reports to Congress.

• New reporting from State Medicaid and CHIP programs

• HHS to publish best practices; new demonstration grants; funding for data system upgrades

What’s Next?

FL

NC

SC

GALATX

AL

AR

KS

OKAZ TN

MS

NVUT

NM

CA

WYID

WA

ORND

SD

NE

MT

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

PA

WV VA

CTNJ

DEMD

RI

NHVT

DC

MA

CO

IA

NYMN

State Budget Woes Worsening

Source: E. McNichol and I. Lav, “State Budget Troubles Worsen,” Center on Budget and Policy Priorities (January 29, 2009). Note: includes states with shortfalls in FY 2009 or projected shortfalls for FY 2010.

States with Shortfalls (47 states, including DC)

Source: As of September 17, 2008 based on a review by the Center for Children and Families of state initiatives in 2007 and 2008.

State Action on Children’s Health Coverage2007-2008

Implemented 2007 Legislation to Improve Children’s Coverage (15 states)

FL

NC

SC

GALATX

AL

AR

KS

OKAZ TN

MS

NVUT

NM

CA

WYID

WA

ORND

SD

NE

MT

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

PA

WV VA

CTNJDE

MD

RI

NHVT

DC

MA

Enacted New Legislation/Took Administrative Action to Improve Children’s Coverage (10 states)

CO

IA

NYMN

Take Aways

• FMAP increase could change the landscape• Significantly increased allotments; shortfalls

should be averted.

Take Aways

• Incentive effect of new allotment formula• Incentive effect of performance bonus

payments• New opportunity for federal match for

covering legal immigrant children/pregnant women

Source: National Immigration Law Center, “Guide to Immigrant Eligibility for Federal Programs” (December 2007); updated by the Center for Children and Families.

FL

NC

SC

GALATX

AL

AR

KS

OKAZ TN

MS

NVUT

NM

CA

WYID

WA

ORND

SD

NE

MT

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

PA

WV VA

CTNJ

DEMD

RI

NHVT

DC

MA

CO

IA

NYMN

State Covering Legal Immigrant Children

States Covering Legal Immigrant Children Not Eligible for Federal Funds (23 states, including DC)

Take Aways

• New data and reporting on enrollment and quality

• Quality measures and demos