CHIP Reauthorization: New Opportunities for Moving Forward Cindy Mann Center for Children and Families Georgetown University Health Policy Institute Commonwealth Fund Leadership Forum on Early Childhood Development February 6, 2009

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

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

Source: S.Dorn, et al.,”Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses,“ Kaiser Commission on Medicaid and the Uninsured, April Note: a 1% increase in unemployment also equals a 3-4% decline in state revenues. Impact of Unemployment Growth on Medicaid and SCHIP 1% Increase in National Unemployment Rate = 1.0 Increase in Medicaid & SCHIP Enrollment (million) & 1.1 Increase in Uninsured (million) $3.4 $2.0 $1.4State Federal Increase in Medicaid & SCHIP Spending (billion)

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

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.

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

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

Enrollment of Children in Public Coverage (Millions) Source: Center for Children and Families analysis of preliminary data. Based on children ever-enrolled over the course of a year Coverage Gains Over the Past Decade Have Come Equally from Medicaid & SCHIP

Children Currently Eligible but Unenrolled 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 9 Million Uninsured Children

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

Performance Bonuses Approximate Effective Medicaid Match Rate for Additional Enrollment Current Match Rate Caseload Between % of Target Caseload Above 110% of Target 50%57.5%81.25% 60%66%85% 70%74.5%88.75% 80%83%92.5%

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

The Affordability Gap is Widening Source: Center for Children and Families analysis of Kaiser/HRET Survey of Employer-Sponsored Health Benefits, ; and the Federal Poverty Level for a family of three, , available:

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

The “Welcome Mat” Effect STATE Total New Enrollment Previously Eligible Illinois244,700165,600 (68%) Data from November June 2008 Massachusetts51,00032,750 (64%) Data from June June 2008 Pennsylvania19,00011,000 (59%) Data from February June 2008 Wisconsin49,10840,881 (83%) Data from February May 2008 Source: Center for Children and Families, "Putting Out the Welcome Mat: Implications of Coverage Expansions for Already-Eligible Children” (September 9, 2008).

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

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

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

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

Quality Initiative 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

What’s Next?

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

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

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

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

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

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