Progress Enrolling Children in Medicaid and CHIP: New Estimates from the American Community Survey

1. Progress Enrolling Children in Medicaid and CHIP: New Estimates from the American Community Survey G. Kenney, V. Lynch, J. Haley, D. Resnick and M. Huntress (http://www.urban.org/publications/412379.html)

2. Background • Major policy initiatives (i.e. CHIPRA, Connecting Kids to Coverage Challenge) against backdrop of ongoing recession • Prior research found geographic, socioeconomic, and demographic variation in participation • Critical that programs monitor participation patterns and uninsurance among eligibles

3. Data • American Community Survey • Annual survey fielded continuously over a twelve months period. • Approx. 700,000 children sampled • Include health insurance, household and income data. • Allows more precise state and local estimates than previously possible. • Health insurance coverage questions added in 2008.

4. What Information is Included on the ACS? • Based on the long form from the decennial census: • Income, marital status, education, occupation, functional limitation, etc. • Income and household structure information is more limited than on the CPS but appears quite robust • Activity limitations/disability status • In 2008, for the first time, households were asked about insurance coverage status

5. ACS Mail Questionnaire Health Insurance Item Is this person CURRENTLY covered by any of the following health insurance or health coverage plans? Mark “Yes” or “No” for EACH type of coverage in items a-h Insurance through a current or former employer or union (of this person or another family member) Insurance purchased directly from an insurance company (of this person or another family member) Medicare, for people age 65 and over, or people with certain disabilities Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability TRICARE or other military health care VA (including those who have ever enrolled for or used VA health care) Indian Health Service Any other type of health insurance or health coverage plan- specify ___________________________

6. Methods • Concern that the ACS may understate Medicaid and CHIP coverage. • Edit rules were applied that build on those developed by the Census Bureau to account for this. Result was an increase in estimated number of children with Medicaid/CHIP and a reduction in the estimated number of uninsured children—revised ACS uninsured estimate for children very close to NHIS estimate • Simulation model uses state-level eligibility guidelines to determine eligibility of each child based on family-level characteristics, including income.

7. Methods, cont. • Participation rates are defined as the ratio of eligible children enrolled in Medicaid/CHIP to those children plus uninsured children who are eligible for Medicaid/CHIP. • Variation in participation within states can be addressed using public use microdata areas (PUMAs) which are mutually exclusive areas that do not cross state lines and that generally follow the boundaries of county groups, single counties, or census-defined "places”. • All estimates use weights provided by the Census Bureau and standard errors use replicate weights that take into account the complex nature of the sample design.

8. Face Validity: New Medicaid Estimates are Closer to Counts from Administrative Databases Millions Medicaid/CHIP* among children (0-18), 2008 Source: Kenney, G., V. Lynch, A. Cook, and S. Phong. 2010 “Who and Where Are The Children Yet To Enroll In Medicaid And The Children’s Health Insurance Program?”Health Affairs. 29(10): 1920-1929.

9. Face Validity: ACS and CPS Distributions Similar to NHIS After Logical Coverage Editing Source: Urban Institute Tabulations of the 2008 ACS and NHIS; ACS estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage and an over-reporting of non-group coverage on the ACS. Notes: Coverage type shown hierarchically. Medicaid includes Medicaid, CHIP, and other public. ESI includes military. Other includes “don’t know”, “refused”, “not ascertained”

10. Changes Between 2008 and 2009 • 2.5 million additional children were eligible in 2009 due to changes in eligibility rules and changing economic circumstances • The participation rate in Medicaid/ CHIP increased by 2.7%, from 82.1% to 84.8%. • The uninsured rate among children fell from 9.2% to 8.4%. • The number of eligible but uninsured children fell by 340,000 to 4.3 million; the uninsured rate among eligible children fell from 11.7% to 10.2%.

11. Increase in Number of Children (0-18) Eligible for Medicaid/CHIP Between 2008 and 2009 Increase Due to Decline in Income Distribution Increase Due to Eligibility Expansions 1.3 million 1.3 million Total Increase: 2.5 million Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS. Numbers may not sum to total due to rounding.

12. Uninsurance Rate and Number Uninsured Among Children (0-18) Eligible for Medicaid/CHIP, 2008 and 2009 2008 2009 Number Rate 11.7% 4.7 million 10.2% * 4.3 million* Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS. "*" indicates that the change is statistically different from zero at the (.10) level.

13. Changes in Medicaid/CHIP Participation Rates between 2008 and 2009 Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS. "*" indicates that the change is statistically different from zero at the (.10) level. '“^" indicates reference group. '"~" indicates the estimate is significantly different from the reference group at the (.10) level in 2009.

14. Medicaid/CHIP Participation Rates by Region, 2008 and 2009 2008 2009 82.1% Source: Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on data from the 2008 and 2009 American Community Surveys. Note: Estimates reflect an adjustment for the underreporting of Medicaid/CHIP on the ACS. *Indicates that 2009 percentage is statistically different from the 2008 percentage at the .10 level.

15. Increases in Medicaid/ CHIP Participation Rates Among Children (0-18) by State, 2008 to 2009 URBAN INSTITUTE

16. Eligibility of Uninsured Children for Medicaid/CHIP Coverage, 2009 Of the 6.6 million uninsured children in the nation 4.3 million are eligible for Medicaid/CHIP Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.

17. Number of Eligible but Uninsured Children for Selected States, 2009 Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.

18. Simulated Effect of Increases in Participation Rates on the Number of Uninsured Children (0-18) Who Are Eligible for Medicaid/CHIP, 2009 Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey (ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS). Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS. Figure simulates the effects on the number of children who are eligible for Medicaid/CHIP but remain uninsured if states with participation rates below specified thresholds were to attain those thresholds.

19. Related Findings • Research on the factors that influence variation of participation rates across states and within states: • Preliminary findings suggest underlying demographic characteristics of eligibles not the primary determinant of state participation rates. • Participation rates vary substantially within states: In California, for example, the top quartile of PUMAs have participation rates above 89%, while participation is 52% in the area with the lowest participation rate. In Texas, the highest and lowest participation rates by PUMA are 94% and 58% respectively, and in Florida, they are 94% and 38%. • New research on participation rates for adults: • Finds lower participation than for kids, but the number of eligible but uninsured adults appears slightly higher nationally than the number of eligible but uninsured children.

20. Limitations • Despite considerable improvements from unedited ACS estimates, our coverage estimates may still include measurement errors, which could introduce bias into our estimates. • Our Medicaid/CHIP eligibility simulation model also has measurement error. • Small state estimates (such as North Dakota, Vermont, and Wyoming) are less precise because of the relatively smaller sample sizes available for them.

21. Final Thoughts • Key to develop effective strategies that increase public coverage among: adolescents, non-citizen children, Hispanic and Native-American children, etc. • National progress hinges on achieving gains in a relatively small subset of states • To monitor progress and identify needed policy responses and priorities, would ideally use a combination of household survey and administrative data sources

22. Simplification and Coordination in 2014 National Covering Kids and Families NetworkWebinar September 13, 2011Tricia BrooksGeorgetown University Health Policy InstituteCenter for Children and Families

23. Building a Better System Based on Lessons Learned from Covering Kids • Technology-enabled • Coordinated • Consumer-friendly • Simplified

24. Simple, Plain Language • Forms, notices, websites • In all formats (paper, electronic, verbal) • Accessible: • Persons with limited English proficiency (LEP) • Disabled (meet 504 standards) • More guidance expected

25. Consumer Assistance Exchange Medicaid/CHIP Outreach to vulnerable, underserved groups Guidance expected Assistance in person, over the phone, online Applicant may elect for assistance through person of choice • Call center • Robust website • Navigator program • Outreach beyond Navigators (not specified)

26. Simplified Eligibility • All children and adults covered in Medicaid up to 133% FPL • Collapses multiple Medicaid groups into 4 • Excludes eligibility groups not based on income • Replaces disregards/deductions with flat 5 percentage points (138% FPL) • No more asset tests • Same excluded groups as above

27. Simplified Eligibility • Presumptive eligibility • For adults, family planning services now • Hospitals gain prerogative in 2014 • Provisions for express lane eligibility decisions • Assumes ELE does not sunset in 2013 according to CHIPRA (will require legislation)

28. New Income & Household Rules • Consistent standards for all coverage options • Applies also to premium and cost-sharing subsidies in the Exchange • Modified Adjusted Gross Income (MAGI) • It’s a methodology (formula), not a number • Household size = tax filing unit (taxpayer(s) plus tax dependents) • A few exceptions (i.e. custodial parents not claiming child as tax dependent)

29. Children’s Eligibility Eliminates stair-step eligibility based on age States must convert current eligibility to “effective” MAGI standard and maintain level until 2019 Parent cannot enroll in Medicaid unless children have coverage

30. Single, Streamlined Application No wrong door – applicants are determined eligible for all options regardless of point of entry Ability to apply online, over phone, via mail, in-person Verification through electronic sources including new federal data hub Real or near-real time determination

31. The Role of the Exchange • Authorized to make Medicaid decisions • Will transfer enrollment data to agency for Medicaid/CHIP • Must have robust website with electronic application using electronic signature • Regulations stop short of requiring: • “My account” functionality • Third party access (navigators, application assistors)

32. Simplified Application Process • Minimal information • Can’t ask questions not needed for eligibility • Can’t require SSN for non-applicants (Medicaid) • No premium tax credits without SSN • No paper documentation • Can’t require paperwork unless unable to verify through electronic sources • Establishes “reasonable compatibility” concept for differences in reported vs. electronic data

33. Coordination • Single eligibility system/shared eligibility service • Consistent standards for eligibility • Data exchanges between agencies • Medicaid can maintain eligibility if projected annual income is expected to remain below limit • Not quite 12 month continuous eligibility • Seek comment on extending coverage through end of next month to align with Exchange

34. Renewal • Every 12 months • Automatic renewals if data is available • Report changes online, phone, mail, in person • Cannot require signature • Otherwise use pre-populated renewal forms Response online, phone, mail, in person • Electronic signature must be available

35. Challenges/Outstanding Issues • Timeline for developing IT infrastructure • Electronic sources for “current” income • Navigator tug of war • Brokers vs. community organizations • Access to affordable employer-based family coverage • Affordability = < 9.5% household income for individual coverage • CHIP waiting periods

36. Georgetown Health Policy InstituteCenter for Children and Families Tricia Brooks Assistant Professor – Georgetown HPI Senior Fellow – HPI Center for Children and Families pab62@georgetown.edu 202-365-9148 Our Website: http://ccf.georgetown.edu/ Say Ahhh! Our child health policy blog:http://www.theccfblog.org/