CHIPRAJust the Facts, PLEASE

Cindy MannExecutive Director

Georgetown University Health Policy InstituteCenter for Children and Families

www.ccfgeorgetown.edu

National Academy for State Health PolicyOctober 2007

Achievements

• Sharp decline in uninsured rate among low -income children

• Coverage has let children secure the care they need

• Cost effective

Second Consecutive Year of Rising Number of Uninsured Children

300,000

710,000

2005 2006

Uninsured rate

of 11.2%

Uninsured rate

of 12.1%

Source: Kaiser Commission for Medicaid and the Uninsured

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TNNC

NH

MA

VT

PA

VAWV

CT

NJ

DE

MD

RI

HI

DC

AK

SC

NMOK

GA

Source: As of September 25, 2007 based on CCF review of state initiatives.

TX

IL

FL

AL

Implemented or Recently Adopted Legislation to Improve Children’s Coverage (26 states and DC)

Considering Significant Proposal to Improve Children’s Coverage (3 states)

States are Moving Forward

But A Showdown Nonetheless Th

e W

hite

H

ouse

Congress

Key Elements

• Eligibility for children

• Incentives/options to cover children already eligible but unenrolled

• Adult coverage

• Benefits

• Public/private

700,000

2,500,000

600,000

New Children's Enrollment in SCHIP & Medicaid

Note: Average monthly enrollment for fiscal year 2012; SCHIP & Medicaid would cover 5.8 million children when reductions in other coverage are included; numbers may not sum due to rounding.

Source: CBO estimate of changes in SCHIP and Medicaid enrollment of children under the House Amendments to the Senate Amendments to H.R. 976, the Children’s Health Insurance Program Reauthorization Act of 2007 (September 24, 2007).

Children Currently in SCHIP Who Could Lose Coverage

Children Newly Eligible Through SCHIP

Expansions

Uninsured Children Already

Eligible

3.8 Million Otherwise Uninsured Children

CHIPRA Is Projected to Cover Nearly 4 Million Otherwise Uninsured Children

84% Eligible Under

Current Program

Rules

CHIPRA: Children’s Eligibility

Income

Current flexibility constrained• Medicaid match for States covering children over 300% in the future• August 17th directive replaced by new rules that take effect in 2010

Immigration status No change

State employees No change

Age No change

CHIPRA Targets 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

How?

Performance Bonus Payments

Based on:• # of children covered (eligible as of 7/07)• Medicaid v. SCHIP• average per capita cost

Must adopt 4 out of 7 designated policies

New optionsCitizenship documentation

“Express Lane”

OutreachGrants

Higher match for translation services

Coverage Gains Over the Past Decade Have Come Equally from

Medicaid & SCHIP

21.0 21.4 21.6 21.9 22.6 25.5 26.3 27.8

4.65.3

6.2

3.3

6.0

1.90.9

1997 1998 1999 2000 2001 2002 2003 2004

Medicaid SCHIP

Enrollment of Children in Public Coverage (Millions)

Source: CCF, 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

CHIPRA: Other Populations

Parents

No new waivers

Financing moved to separate allotment in 2010

Enhanced match through 2010

“Remap” beginning in 2011 if certain conditions met

Childless Adults

No new waivers (DRA)

Funding moved to separate allotment in 2009

Regular (Medicaid) match in 2009 only for grandfathered individuals

Possible Medicaid waiver (for grandfathered individuals) after 2009

Pregnant Women

SCHIP option

CHIPRA: Benefits & Quality

Dental Care Required

Mental HealthNot required, but “benchmark” parity

Quality InitiativesDevelopment of measures and reporting standards

CHIPRA: Public/Private Integration

Premium Assistance Option

At least 40% Er contribution

Voluntary for state/family

New Tools

State may require ERs to provide info on benefits

Child with CHIP/Medicaid must be allowed to enroll in ESI (if offered), regardless of open enrollment periods

OtherEmployer buy-in option

Child losing CHIP/Medicaid can enroll in ESI (if offered) regardless of open enrollment periods

Where Do We Go From Here?

White House Veto

• WH proposed $4.8b in new federal funds

• Favors “free competitive marketplace”/private coverage

• Crowd out concern/income eligibility

• Objection to offsets

Focus on Low-Income Uninsured Children Limits “Crowd Out”

Children Who Otherwise

Would Have Had Coverage

Otherwise Uninsured Children

Source: CBO Estimate of Changes in SCHIP and Medicaid in Enrollment of Children under CHIPRA 2007 (September 25,2007.

2

3.8

Medicaid/SCHIP Enrollment

5.8 Million Children

CHIPRA“I think (the Senate Finance

Committee) approach is pretty much as efficient as you can possibly get per new dollar spent to get a reduction of roughly 4 million uninsured children.”  

Peter Orszag,

CBO Director

(July 19, 2007)

States Have Reasons for Moving Forward Growth in Family Insurance Premiums Compared

to the Federal Poverty Level

102.7%

24.0%

0%

20%

40%

60%

80%

100%

120%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Family Premium Federal Poverty LevelNote: This data represents the cumulative growth in employee premium contributions for employer-sponsored family health insurance and the cumulative growth in the federal poverty level for a family of three.

Source: Agency for Healthcare Research and Quality estimates of 1996-2005 Medical Expenditure Panel Survey Insurance Component Tables, generated using MEPSnet/IC (August 21, 2007); and CCF analysis of 1996-2005 Federal Poverty Guidelines.

400%+ FPL

200-399% FPL

<200% FPL220,000

340,000

150,000

Source: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured

Distribution of the Increase in Uninsured Children, by Income, 2005-2006

Most Children Covered by SCHIP Have Family Incomes Below 200% FPL

8.7%91.3%At or Below 200% FPL

Above 200% FPL

6.7 million children enrolled in SCHIP, 2006

Note: The reporting classification of a child with family income above 200% FPL who Is determined to be eligible at or below 200% FPL due to deductions or disregards (I.e., a net income test) is up to the discretion of the state and constrained by their reporting systems.

Source: CCF analysis using enrollment data from C. Peterson & E. Herz, Estimates of SCHIP Child Enrollees Up to 200% of Poverty, Above 200% of Poverty, and of SCHIP Adult Enrollees, Congressional Research Service (March 13, 2007).

A Waveof Support

Polling: America Wants aStrong Kids Coverage Bill

90%

Editorial Boards Nationwide

275+