chip reauthorization: new opportunities for moving forward cindy mann center for children and...
TRANSCRIPT
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