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

1. Key Issues In SCHIP Reauthorization Cindy Mann Center for Children and Families Georgetown University Health Policy Institute www.ccfgeorgetown.org crm32@georgetown.edu Health Journalism 2007

2. Children’s Eligibility for Medicaid/SCHIP by Income, July 2006 IL NH VT ME WA MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA OH NE IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI > 200% FPL (15 states) < 200% FPL (10 states) 200% FPL (26 states including DC) Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission of Medicaid and the Uninsured, 2007.

4. Trends in the Uninsured Rate of Low-Income Children, 1997- 2005 Source: CCF analysis of National Health Interview Survey.

5. Coverage Gains Over the Past Decade Have Come Equally from Medicaid & SCHIP Enrollment of Children in Public Coverage (Millions) 34.0 32.3 30.8 27.2 25.2 23.5 22.3 21.0 Source: CCF, Preliminary data. Based on children ever-enrolled over the course of a year.

6. SCHIP Reauthorization: What’s Ahead

7. Children’s Health Care Coverage, 2005 • 88% have at least one employed parent. • Uninsured children are disproportionately in the South (43%) and West (29%). • A disproportionate share (38%) of uninsured children are Hispanic. • 35% of uninsured children live in families with incomes below 100% FPL. 77.9 million children under 19 Source: CCF analysis of CPS 2006 March Supplement; and Campaign for Children’s Health Care, No Shelter from the Storm: America’s Uninsured Children (September 2006).

8. The Political Environment in Washington: Much Has Changed OUT IN Rep. Joe Barton (R-TX) Rep. John Dingell (D-MI)

9. …But Much Remains the Same Before Elections After Elections Federal Budget Deficit (in billions) Federal Budget Deficit (in billions) Note: Deficit shown is “on-budget” which excludes social security and other dedicated taxes. Source: Congressional Budget Office, The Budget and Economic Outlook: An Update (August 2006)

10. Political Environment Outside of Washington • State fiscal situations stronger • Health care again a major issue • Children’s coverage played a role in many state gubernatorial elections • An increasing number of states moving forward with major coverage expansions for children (e.g., HI, IL, MA, PA, WA) • Even more are considering proposals (e.g., CA, CO, CT, MN, NY, OH, OR, WI)

11. What Are the Key Issues in SCHIP Reauthorization?

12. Key Issues: Financing • Size of the national allotments • Dividing the allotments among states • “Offsets”

13. SCHIP Spending is Rapidly Outpacing New Funds Being Made Available (in billions) Source: 1998-2007 data from Chris Peterson. SCHIP Original Allotments: Funding Formula Issues and Options. Congressional Research Service (October 2006); 2007-2012 spending data from CBO March 2007 SCHIP baseline (February 2007) includes outlays plus additional SCHP spending required to maintain current programs.

14. SCHIP Enrollment Projections, 2007-2016 Millions of People Assumes federal SCHIP allotments remain at $5 billion after FY 2007 Source: The Kaiser Commission on Medicaid and the Uninsured. Additional Detail of the FY 2007 Budget from Office of the Actuary at CMS.

15. Voters Strongly Support Investing More Money in SCHIP Which statement best describes your thoughts on what Congress should do about SCHIP? Increase SCHIP funding so that it can cover even more uninsured children 82% Support investing more money in SCHIP Don’t know/ refuse Increase SCHIP funding so that it can continue to cover the current number of children Fund SCHIP at current levels even though some children will lose coverage Source: Poll conducted by Lake Research Partners for CCF (November 2006).

16. Dividing the Dollars Targeting the dollars to children? Formula fight among states?

17. Children’s Coverage vs. Special Interests? • “Paygo” rules require offsets • Cuts in other spending • New revenues/closing down current “loopholes”

18. Key Issues: Financing (con’t) • Reducing costs by limiting who can be covered with SCHIP funds • Children over 200% of FPL ($40,000/year for a family of four) • Adults (mostly parents)

19. SCHIP Enrollment by Category (2006) Parents of Children in Medicaid/SCHIP Children and Pregnant Women Adults without Children 7.4 Million SCHIP Enrollees Note: Ever-enrolled over the course of a year. Source: CBO March 2007 Baseline: State Children’s Health Insurance Program (February 23, 2007).

20. (Some of the) States with SCHIP Populations Targeted for Cuts (March 2007) IL NH VT ME WA MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA OH NE IN NV DE IL WV UT VA MD CO MO CA KS KY NC DC TN OK SC AR NM AZ AL GA MS TX LA AK FL HI Children >200% FPL (17 states) Adults (14states) Note: “Adults” include waiver-based coverage for pregnant women, parents of children in Medicaid/SCHIP, and adults without children. In February 2007, Pennsylvania received CMS approval to expand SCHIP eligibility to 300% FPL. Additional states could be affected depending on how the limits are defined. Source: CCF, States Affected by Proposals to Reduce SCHIP Coverage Options (February 7, 2007).

21. What Will Twice the Poverty Level Buy? Purchasing power of 200% FPL by select metropolitan areas adjusted for the cost of living. 200% FPL Note: In 2006, 200% FPL for a family of three was $33,200 annually. Source: CCF analysis using 2006 ACCRA data.

22. Meet the Chappell Family Beverly and her husband both work and raise their two children, Nathan and Rebecca, in NH. The family’s yearly income varies between $40,000 and $50,000. • Years ago, they had insurance through work but also much debt. • Children covered by SCHIP in NH; $50-$90/monthly premiums. Parents are uninsured because of costs. • Nathan’s asthma now well managed; no more ER visits. • Nathan would lose his coverage if NH no longer covered families with incomes above 200% of the poverty level.

23. Median Medicaid/SCHIP Income Eligibility Threshold, July 2006 Poverty Line for a Family of 3 $16,600 (2006) Note: Eligibility levels for parents are based on the income threshold applied to a working parent in a family of 3 Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2007.

24. Meet Sawsan Hamad Mother of 4, working and going to school in Arizona • Total family income, $22,400 • Access only to very limited health insurance through her job/school • Ms. Hamad and her childrenhave SCHIP; $35/month in premiums • Last summer, Ms. Hamad was diagnosed with cancer; with SCHIP-funded coverage she is getting needed treatment.

25. Other Key Issues • Lifting restrictions on immigrant coverage • Subsidizing employer based coverage • New DRA rules requiring families to document citizenship • Incentives and supports for moving forward

26. 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.

27. What’s Ahead? • Strong track record • Many states eager to move forward • Strong public and bipartisan support • But don’t assume smooth sailing