Cindy Mann Georgetown University Health Policy Institute Center for Children and Families

1. Health Reform: Children and Medicaid Cindy Mann Georgetown University Health Policy Institute Center for Children and Families Washington, D.C. crm32@georgetown.edu ccf.georgetown.edu April 2009

2. MEDICAID’S ROLE FOR CHILDREN

3. Medicaid/CHIP’s Role for Children and Pregnant Women Percent with Medicaid Coverage: All Children Low-Income Children Births (Pregnant Women) Source: KCMU, KFF, and Urban Institute estimates; Birth data: NGA, MCH Update.

4. Trends in the Coverage Rate of Low-Income Children, 1997- 2006 Source: Johns Hopkins University Bloomberg School of Public Health analysis of the National Health Interview Survey for the Center for Children and Families (March 1, 2008).

5. Coverage Gains Have Come Equally from Medicaid & CHIP Enrollment of Children in Public Coverage (Millions) 34.4 33.9 33.3 30.9 28.0 25.2 22.9 21.4 Source: KCMU & Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, 2007.

6. Children’s Enrollment in Medicaid and CHIP, 2005 28 million 1.7 million are in SCHIP-financed Medicaid expansions 6 million 4.4 million are in separate SCHIP programs Source: Kaiser Commission on Medicaid and the Uninsured analysis of CBO March 2006 baseline and CMS Statistical Enrollment Data System, 2006; and CMS FY 2005 SCHIP Enrollment Report (July 12, 2006).

7. Medicaid Benefits “Mandatory” Items and Services “Optional” Items and Services • Physician services • Laboratory and x-ray services • Inpatient hospital services • Outpatient hospital services • Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 • Family planning • Rural and federally-qualified health center (FQHC) services • Nurse midwife services • Nursing facility (NF) services for individuals 21 or over • Prescription drugs • Clinic services • Dental services, dentures • Physical therapy and rehab services • Prosthetic devices, eyeglasses • Primary care case management • Intermediate care facilities for the mentally retarded (ICF/MR) services • Inpatient psychiatric care for individuals under 21 • Home health care services • Personal care services • Hospice services Source: Kaiser Commission on Medicaid and the Uninsured.

8. But For Children • All recommended screenings (check-ups) • All mandatory and optional treatment services: “All necessary health care, diagnosis services, treatment, and other measures…to correct or ameliorate defects, and physical and mental illnesses and conditions…” Source: Federal Medicaid Law, Title XIX.

9. Low-Income Children are More Likely than Higher-Income Children to be in Poor Health Health Status, 2003 Source: 2003 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health, www.nschdata.org (accessed 3/31/09).

10. The Effects of Poor Health? A child’s health is predictive of his/her health in adulthood Poor child health can limit educational attainment Poor health reduces annual earnings by 15 to 20%, either through reduced work hours or hourly wages Source: C. Perry& L. Blumberg, “Making Work Pay II: Comprehensive Health Insurance for Low-Working Families,“ The Urban Institute (July 2008); and Robert Wood Johnson Foundation, “Overcoming Obstacles to Health” (February 2008).

11. MEDICAID AND HEALTH REFORM

12. Medicaid is a Major Purchaser of Health Care Medicaid as a share of national personal health care spending, 2007: Total National Spending (billions) $1,878 $697 $702 $190 $228 Source: M. Hartman, et al., “National Health Spending in 2007: Slower Drug Spending Contributes to Lowest Rate of Overall Growth Since 1998,” Health Affairs 28(1): 246-261, January/February 2009. Note: Medicaid spending includes both the federal, the state, and the local portion of Medicaid, but does not include spending in SCHIP.

13. Minimum Medicaid Eligibility Levels Income eligibility levels as a percent of the Federal Poverty Level: Note: Parent eligibility level reflects the level in the median state. The federal poverty level was $9,800 for a single person and $16,600 for a family of three in 2006. Source: Cohen Ross and Cox, 2007 and KCMU, Medicaid Resource Book, 2002.

14. Decoding the Federal Poverty Line Source: Federal Register, Vol. 74, No. 14, January 23, 2009.

15. The Majority of Uninsured Children are Low-Income Income Levels of Uninsured, 2007 300% + 200-299% 100-199% 70% below 200% FPL Under 100% Children = 8.9 million Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

16. Strengthening Medicaid Improving participation rates among eligible people Provider access/payment rates Financing

17. Children's Enrollment in Washington's Public Insurance Programs April 2002-April 2005 July 2003: 12-month continuous eligibility ends; 6-month renewal cycle replaces 12-month cycle April 2003: State begins income verification January 2005: Administrative order to return to 12-month renewal cycle and establishes continuous eligibility policy Source: Washington State Department of Social and Health Services, 2005.

18. Medicaid Coverage Improves Children’s Access to Care Source: Kaiser Commission on Medicaid and the Uninsured analysis of National Center for Health Statistics, CDC. 2007. Summary of Health Statistics for U.S. Children: NHIS, 2007. Note: Questions about dental care were analyzed for children age 2-17. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. An asterisk (*) means in the past 12 months.

19. Medicaid Reduces the Impact of Unemployment on Uninsurance by Nearly One Half 1.1 1.0 = 1% Increase in National Unemployment Rate Increase in Medicaid & Other Public Enrollment (million) Increase in Uninsured (million) 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.

20. “Dual” Eligibles Accounted for More Than 40% of Medicaid Spending in 2005 Total Medicaid Expenditures = $262.9 billion Other Aged and Disabled $78.2 billion 30% “Dual” Eligibles $107.5 billion 41% Adults $28.6 billion 11% Children $48.5 billion 18% Source: J. Holahan, D. Miller, & D. Rousseau, “Rethinking Medicaid’s Financing Role for Medicare Enrollees,” Kaiser Commission on Medicaid and the Uninsured (February 2009). Note: Spending on prescription drugs for dual eligibles, which became a Medicare responsibility in 2006, is excluded in order to approximate the share of post-2005 Medicaid spending that is attributable to duals. However, because this amount also excludes “clawback” payments states began paying the federal government in 2006, this estimate is probably conservative.

21. Integrating Medicaid • Coordinate/align enrollment with subsidies/tax credits for families above Medicaid eligibility • Ensure Medicaid is at the table for • Quality initiatives • HIT • “Purchasing for value” initiatives

22. KEEPING WHAT WORKS AND FIXING WHAT NEEDS TO BE FIXED

23. Meet Emily Demko • Toddler with Down Syndrome • Needs extensive care, including speech and physical therapy

24. New Fee Schedule in Utah’s CHIP Program – Modeled after Private Insurance For families with incomes > 150% of FPL: $500 - $1500 deductible 50% for mental health service inpatient or outpatient care 20% coinsurance for: inpatient or outpatient care; surgeon and anesthesiologist services; ambulance; lab and x-ray services over $350 any dental care other than cleaning, x-ray, fluoride & sealants; home health; hospice; medical supplies 25% coinsurance for brand name drugs on approved list $100 co-pay for ER visits (including emergencies) $30 co-pay for urgent care center visit or specialist $20 co-pay for physician; (other than specialist; no co-pay for well-child care); vision and hearing screenings; physical therapy $10 co-pay for generic drugs

25. Maximum Annual Out-of-pocket Expense Is Nearly 60% of Monthly Gross Income

26. Taking Care of Children in Health Reform • All children should be covered • Medicaid plays a unique role for children • Strengthen and integrate Medicaid while maintaining its key elements