Covering Children: Medicaid and SCHIP Progress and Challenges

1. Getting to the Finish Line: Covering Children Eligible for Medicaid and SCHIP

2. Getting to the Finish Line: Covering Children Eligible for Medicaid and SCHIP Cindy Mann Georgetown University Health Policy Institute Center for Children and Families crm32@georgetown.edu ccf.georgetown.edu Alliance for Health Reform February 26, 2007

3. Getting to the Finish Line: The Experience Since SCHIP • Substantial progress has been achieved. • Experience shows that enrollment and retention efforts can work in Medicaid and SCHIP. • But fiscal considerations sometimes stall or reverse progress. • Coverage goal needs to be explicit and policies and funding streams need to be aligned with this broadly held goal.

4. Accomplishments

5. Trends in the Uninsured Rate of Low-Income Children, 1997 - 2005 Source: Georgetown CCF analysis based on data from the National Health Interview Survey, November 2006. Beginning in 2004, the NHIS changed its methodology for counting the uninsured. This results in the data for 2004 and later years not being directly comparable to the data for 1997 – 2003.

6. Coverage Disparities Continue but Narrow “(C)ontinued growth in public coverage has been a major factor in improving rates of health coverage for children. These changes have been particularly dramatic for minority children.” AHRQ, (September 2006)

7. More Children are Eligible: Medicaid/SCHIP Income Eligibility Levels, 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) Note: The Federal Poverty Line (FPL) for a family of three in 2006 was $16,600. Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission of Medicaid and the Uninsured, 2007.

8. Participation Among Eligible Children Has Increased in Medicaid & SCHIP Note: These participation rates consider children who are eligible based on income and assets, but does not consider non-financial eligibility criteria such as immigration status. Source: L. Dubay analysis of National Survey of America’s Families.

9. Enrollment in Louisiana's Medicaid Program October 1998 - January 2005 June 2000: Trained workers in new philosophy June 2001: Baseline report re: renewal July 2001: New renewal procedures: calls re: renewal forms not returned, “ex-parte” for LaChip May 2000: “Reasonable certainty” standard July 2000: “Ex-Parte” renewal for children losing cash benefits October 2003: Telephone renewals, rolling renewals March 2003: “Reasonable certainty” for renewal Source: Louisiana Department of Health and Hospitals Monthly Enrollment Reports, 2005

10. Where Are We Now?

11. Most Uninsured Children Are Eligible for Public Coverage (2004) SCHIP Eligible Medicaid Eligible Medicaid Eligible SCHIP Eligible Not Eligible Not Eligible 9.0 Million Uninsured Children 6.5 Million Low-income Uninsured Children Source: L. Dubay analysis of March 2005 Current Population Survey using July 2004 eligibility rules.

12. What’s Behind These Numbers? Over the past ten years: • Medicaid and SCHIP have done a much better job reaching, enrolling, and retaining eligible children. But: • The number of children has grown. • States have significantly expanded their programs--more children are eligible. • Employer-based coverage has declined (for children and adults) -- more eligible children need public coverage. • Coverage progress has been uneven.

13. More Children are Eligible: Percent of Children Eligible for Medicaid or SCHIP (1997-2002) Note: These percentages are based on a state’s financial eligibility rules only. Source: L. Dubay analysis of National Survey of America’s Families.

14. More Children Need Public Coverage:ESI Coverage Rates for Children and Parents (1998-2005) Source: CCF analysis of National Health Interview Survey.

15. Participation Varies Widely Across States (2004) Note: These participation rates consider those enrolled in Medicaid/SCHIP as a percent of those who are who meet financial eligibility requirements, not including adjustments for immigration status. Source: L. Dubay analysis of 2005 CPS using July 2004 eligibility rules.

16. Continuing the Progress

17. Characteristics of Uninsured Children Eligible for Medicaid/SCHIP (2004) • Vast majority (93%) have incomes below 200% FPL. • Most (70%) parents are employed. • Many in small firms or self-employed. • Many children cycle on and off public coverage; when told their children are likely to be eligible parents are eager to enroll. • Significant regional variations. Source: Holahan, Cook, & Dubay, Characteristics of the Uninsured: Who Is Eligible for Coverage and Who Needs Help Affording Coverage?, Kaiser Commission on Medicaid and the Uninsured (February 2007). The data in the first three bullets are based on estimates of the eligible but uninsured that adjust for the CPS Medicaid undercount, but do not adjust for immigration status. Summer & Mann, Instability of Public Health Insurance Coverage for Children and Their Families: Causes, Consequences, and Remedies, Commonwealth Fund (June 2006). Kenney, Haley, & Tebay, Familiarity with Medicaid and SCHIP Programs Grows and Interest in Enrolling Children Is High, Urban Institute (July 2003).

18. Steps States Have Taken to Simplify Enrollment & Renewal in Medicaid/SCHIP Source: Cohen Ross & Cox, Resuming the Path to Health Coverage for Children and Parents, Kaiser Commission on Medicaid and the Uninsured (January 2007).

19. Other Measures • 16 states adopted “continuous eligibility” in Medicaid and 25 states in SCHIP. • 9 states use “presumptive eligibility” for children in Medicaid and 6 states in SCHIP. • Community-based application/retention assistance Simplified documentation • Relying on information on hand and appropriately coordinating with other programs? • Fully automated eligibility systems? • Effective outreach? Source: Cohen Ross & Cox, Resuming the Path to Health Coverage for Children and Parents, Kaiser Commission on Medicaid and the Uninsured (January 2007).

20. Children's Enrollment in Washington's Public Insurance Programs, April 2002-October 2005 April 2003: State begins income verification July 2003:12-month continuous eligibility ends; 6-month renewal cycle replaces 12-month cycle 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, updated 2006.

21. Federal Opportunities • Assure adequate funding for SCHIP and Medicaid. • SCHIP freeze in Georgia • Could provide additional support for coverage costs that states incur when enrollment efforts are successful or require simplified procedures. • Some new tools could help. • Eliminate federally-imposed barriers.

22. Getting to the Finish Line By bringing participation rates up to the levels already achieved in some states (e.g., 90% - 92%), the number of uninsured children could be cut by about half (4.1 - 4.6 million).