CHIP Reauthorization: New Opportunities for Moving Forward

1. CHIP Reauthorization: New Opportunities for Moving Forward • Cindy Mann • Center for Children and Families • Georgetown University Health Policy Institute • http://ccf.georgetown.edu • Commonwealth Fund Leadership Forum on • Early Childhood Development • February 6, 2009

2. Public Programs’ Coverage Role Today(Non-elderly, 2007) Children = 78.6 million Adults = 182.8 million Employer-Sponsored Insurance Uninsured Medicaid/ Other Public Individual Coverage Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

3. Income Levels of Uninsured, 2007 Children = 8.9 million Adults = 36.1 million 300% + 200-299% 100-199% 70% below 200% FPL 84% below 200% FPL Under 100% Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

4. Impact of Unemployment Growth on Medicaid and SCHIP $3.4 1.1 $1.4 State 1.0 = & 1% $2.0 Federal Increase in National Unemployment Rate Increase in Medicaid & SCHIP Enrollment (million) Increase in Uninsured (million) Increase in Medicaid & SCHIP Spending (billion) 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.

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

6. 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.

7. New Formula Addresses “Mismatch” Under Old Formula Source: C. Peterson, “What Happens to SCHIP After March 31, 2009?,” Congressional Research Service (December 19, 2008)

8. CHIPRA: Key Features • New funding levels and formula • New incentives to enroll Medicaid children • Eligibility changes • Benefit changes • Significant new emphasis on quality, access

9. 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 23.5 25.2 22.3 21.0 Source: Center for Children and Families analysis of preliminary data. Based on children ever-enrolled over the course of a year.

10. Children Currently Eligible but Unenrolled 9 Million Uninsured Children 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

11. Reaching the Eligible but Unenrolled Children Procedural closings in Louisiana: < 1% Source: LaCHIP/Medicaid Eligibility Division, La. Department of Health & Hospitals, September 2008

12. Performance Bonuses

13. CHIPRA: Key Features • New funding levels and formula • New incentives to enroll Medicaid children • Eligibility changes • Benefit changes • Significant new emphasis on quality, access

14. 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.

15. Medicaid and SCHIP Eligibility Levels for Children, January 2009 WA* NH VT MT* ME ND OR MN MA ID WI SD NY WY MI RI CT IA* PA NV NE NJ OH* IL UT IN* DE CO* CA WV* KS* VA MD MO KY NC* DC TN AZ OK* NM AR SC MS AL GA TX LA* AK FL HI < 200% FPL (5 states) 200% FPL (16 states) 201%-250% FPL (9 states) > 250% FPL (21 states) 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.

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

17. CHIPRA Would Cover 4 Million Otherwise Uninsured Children 4.1 Million Otherwise Uninsured Children Children Newly Eligible Through CHIP Expansions 83% Eligible Under Current Program Rules Uninsured Children Already Eligible Children Slated to Lose Coverage at Current Funding Levels Source: CBO, January 16,2009.Note: Average monthly enrollment for fiscal year 2013.

18. CHIPRA: Key Features • New funding levels and formula • New incentives to enroll Medicaid children • Eligibility changes • Benefit changes • Significant new emphasis on quality, access

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

20. CHIPRA: Key Features • New funding levels and formula • New incentives to enroll Medicaid children • Eligibility changes • Benefit changes • Significant new emphasis on quality, access

21. QualityInitiative • 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

22. What’s Next?

23. State Budget Woes Worsening WA NH VT MT ME ND OR MN MA ID WI SD NY WY MI RI CT IA PA NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC MS AL GA TX LA AK FL HI States with Shortfalls (47 states, including DC) 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.

24. State Action on Children’s Health Coverage 2007-2008 WA NH VT MT ME ND OR MN ID WI MA SD NY WY MI RI IA PA CT NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC MS AL GA TX LA AK HI FL Enacted New Legislation/Took Administrative Action to Improve Children’s Coverage (10 states) Implemented 2007 Legislation to Improve Children’s Coverage (15 states) Source: As of September 17, 2008 based on a review by the Center for Children and Families of state initiatives in 2007 and 2008.

25. Take Aways • FMAP increase could change the landscape • Significantly increased allotments; shortfalls should be averted.

26. 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

27. State Covering Legal Immigrant Children WA NH VT MT ME ND OR MN MA ID WI SD NY WY MI RI CT IA PA NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC MS AL GA TX LA AK FL HI States Covering Legal Immigrant Children Not Eligible for Federal Funds (23 states, including DC) Source: National Immigration Law Center, “Guide to Immigrant Eligibility for Federal Programs” (December 2007); updated by the Center for Children and Families.

28. Take Aways • New data and reporting on enrollment and quality • Quality measures and demos