SCHIP 101: Learning from 10 years of Experience Liz Arjun State Health Policy Analyst Center for Children and Families Georgetown University Health Policy Institute Tennessee First Focus Training June 14, 2007

Overview SCHIP History and Successes Lessons Learned What’s Next?

Key Policy Ingredients of Original SCHIP Legislation Block grant / No entitlement to coverage No mandates / State option with “enhanced matching funds” Funds dedicated to NEW coverage Medicaid treated as the base off of which states would build State flexibility to use Medicaid and/or a separate state program with fewer federal standards

SCHIP Enrollment, (in millions) SCHIP adopted (August 1997) 51 st state implements SCHIP; enrollment efforts are strong; states pursue family coverage waivers (2000) State fiscal crisis and extensive SCHIP cutbacks (2002 – 2004) $1.3 billion in unspent SCHIP funds lost (2004) HIFA initiative allows SCHIP funds to be used for coverage of childless adults (2001) Source: CCF; and enrollment data from Kaiser Commission on Medicaid and the Uninsured.

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

*Poverty status is based on family income and family size using the U.S. Census Bureau poverty thresholds for 2002 Federal Poverty Level (FPL) in 2002 in the 48 contiguous states and the District of Columbia is $15,020 for a family of three. Source: National Health Interview Survey, Percent of Poor and Near-Poor Children with a Usual Place of Care Poor Children*Near-Poor Children*

ESI Coverage Rates Have Declined for Children and Adults Source: Percent with employer-sponsored insurance from E. Gould, “Health Insurance Eroding for Working Families,” Economic Policy Institute (September 2006).

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

Lessons Learned States will use SCHIP to respond to the needs of families Administrative practices and policies make a difference in enrollment and retention States need more tools, incentives and/or requirements to finish the job States need additional funding to cover uninsured children

Children’s Eligibility for Medicaid/SCHIP by Income, May 2007 AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MOKS OH IN NY IL KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM GA Note: The Federal Poverty Line (FPL) for a family of three in 2007 is $17,170. Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission of Medicaid and the Uninsured (2006), as updated by CCF. TX 200% FPL (24 states including DC) FL AL > 200% FPL (18 states) < 200% FPL (9 states) OK

Tennessee Medicaid and SCHIP Income Eligibility Thresholds for Children and Parents Income Threshold as a Percent of the Federal Poverty Line Note: As of June 2007; income thresholds for non-working parents as of July 2006.

Source: Washington State Department of Social and Health Services, 2005, updated January 2005: Administrative order to return to 12-month renewal cycle and establishes continuous eligibility policy 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

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

Medicaid & SCHIP are Reaching an Increasing Share of Eligible Children Source: L. Dubay analysis of 1997,1999,2002 National Survey of America’s Families. SCHIPMedicaid Participation Rate of Eligible Children in Medicaid & SCHIP

Where Does Tennessee Stand? Better Than the U.S. Average, But Worse Than Its Neighbors Uninsured Rate of All Children Uninsured Rate of Low- Income Children Participation in Medicaid/SCHIP Among Low- Income Children U.S. average 11.0%17.9%74.2% Tennessee9.4%15.5%77.6% Alabama5.5%7.7%88.8% Arkansas9.3%11.2%84.4% Kentucky7.8%13.2%80.9% Missouri7.9%13.5%81.4% Source: CCF analysis of CPS 2005 and 2006 March Supplement (i.e., data from 04-05).

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

With 9 Million Uninsured Children, More Needs to Be Done 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) Million Children Under 19 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. Children’s Health Care Coverage, 2005

What Is Next for Children’s Health Insurance? Most Uninsured Children are Eligible Recent Surge of Activity at the State-Level Indicates States are Ready to Move Forward Voters Strongly Support Efforts to Get Children Covered SCHIP Reauthorization is Happening

7 out of 10 Uninsured Children are Eligible But Unenrolled 49% are Medicaid Eligible 19% are SCHIP Eligible Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules

AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MO KS OH IN NY IL KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA Source: As of June 8, 2007 based on CCF review of state initiatives. TX IL FL AL Implemented or Recently Adopted Legislation to Improve Children’s Coverage (18 states and DC) Considering Significant Proposal to Improve Children’s Coverage (11 states) States are Moving Forward

Key State Strategies Enrolling and retaining eligible children Increasing eligibility Integrating with private coverage

Americans Strongly Support Covering Children 84% New York Times, March 2, 2007

Specific Policy Issues Emerging in Reauthorization How much SCHIP funding will be available to states? –Overall Funding –Formula: i.e. historical spending, number of uninsured children, others Who will be covered? –Income range of children who can be covered –Treatment of adults covered with SCHIP funds –Refinancing of pre-SCHIP expansions –Special groups of children (legal immigrants, state employees children)

Specific Policy Issues Emerging in Reauthorization (continued) What kind of coverage or product will be provided? –Pressure on benefit package (HSAs, vouchers) –Efforts to strengthen benchmark standards –Relationship to employer-based coverage (premium assistance) How do we reach eligible, but uninsured children? –Outreach funding and incentives –Helping states with the increased Medicaid costs –Express Lane and other tools –Administrative barriers such as citizenship documentation requirement How do we pay for it?

Timeline for Congressional Action?? Late June After July 4 JulyLate July AugustSept 30 Senate Finance Committee Senate Floor House Energy and Commerce Committee House Floor Conference No new funds available Note: These dates are all tentative