1. The Future of CHIP and Children’s Health Care Elisabeth Wright Burak Families USA Health Action 2015

2. Unprecedented Progress Covering Children thanks to Medicaid/CHIP Lowest uninsured rate since Census started collecting data in 1987! Source: U.S. Census Bureau, Current Population Survey (CPS), Annual Social and Economic Supplement; American Community Survey (ACS). 2 CPS

3. Source: American Community Survey, 2013.

4. Medicaid and CHIP Enrollment, 2013 Source: Medicaid.gov, available at http://www.medicaid.gov/chip/downloads/fy- 2013-childrens-ever-enrolled-report.pdf 4

5. CHIP Structure and Funding States can use CHIP funds to cover kids in Medicaid (M- CHIP) or create separate CHIP program (S-CHIP)- most use some combination Capped allotments/block grant with enhanced match (65 – 80%) 5 CHIP Reauthorization (2009) - adequate funding for states, incentives to enroll already-eligible children, quality focus.

6. 38 states provide Medicaid or Medicaid-based benefits for CHIP-financed kids Source: “Benefits and Cost Sharing in Separate CHIP Programs,” National Academy for State Health Policy & Center for Children and Families (May 2014) 6

7. ACA - Affordable Care Act (2010) New coverage options for parents through exchanges or Medicaid Keeps children’s coverage stable until 2019 (“Maintenance of Effort” or MOE). Funds CHIP through FY2015 – no new funding after September 30, 2015 without Congressional action Increases each state’s matching rate by 23 percentage starting FY2016 until 2019 Aligns children’s income eligibility in Medicaid (i.e. “stairstep” kids) 7

8. Who are “stairstep” kids? 8

9. Moving “Stairstep” Kids to Medicaid o 28% of S-CHIP kids nationally transfer in 2014 o Ranges from 13% (TN) to 70% (UT) o States continue to receive the CHIP enhanced FMAP 9

10. Medicaid and CHIP Work Together State history and design decisions impact the roles Medicaid and CHIP play (M-CHIP, S-CHIP, combination) In 2013, 66% of CHIP-funded children in separate programs (MACPAC) With 2014 CHIP to Medicaid “stairstep” transitions, we estimate more than half of children funded by CHIP will be in Medicaid, with a minority remaining in separate S-CHIP programs CHIP increasingly a funding source rather than a program 10

11. What Happens to Kids? 11 Public/Medicaid Private: Exchange Marketplaces, ESI, Other “Family Glitch”- Could Become Uninsured

12. CHIP Design Drives What Happens In Each State Without CHIP 12 CHIP-funded children will fall under one of the following scenarios: o Maintain coverage on Medicaid – state receives lower match/less federal funding o Fall into “family glitch”– Lose access to affordable coverage altogether o Estimates range from 500,000-2 Million kids o Move to marketplace coverage with tax credits for families o Opt in to other private coverage options

13. What’s at Stake for Ohio? Preliminary estimates show a loss of up to $146 million in 2016 Estimated FY 2016 loss of CHIP federal funds with current match rate if CHIP funding is not extended Potential boost to State Budget if CHIP funding is extended with 23 percentage point increase in the match rate $47 million$99 million OH FY 2015 FMAP for Medicaid OH FY 2015 Enhanced FMAP for CHIP OH FY 2016 Enhanced FMAP* for CHIP 62.64%73.85%96.85% Source: Preliminary unpublished estimates from draft memo “CHIP Financing Considerations and State-level Funding and Coverage Loss Estimates”, CCF and CBPP, October 2014 *This estimate is calculated by adding the 23 percentage point bump to the 2015 enhanced FMAP for Ohio. Actual percentage in 2016 may vary slightly given that the FMAP is adjusted annually.

14. What’s the Impact on Virginia? Current Matching Rate 23% ACA “Bump” 2016 Match Loss for CHIP- funded Medicaid Coverage (6- 19 yr olds) Up to $24 millionUp to $61 million Loss in CHIP FundsUp to $126 millionUp to $171 million Source: Preliminary unpublished estimates prepared by Georgetown CCF and Center on Budget and Policy Priorities based on March 2015 MACPAC report to Congress. 14 As many as 104,221* VA kids stand to lose CHIP coverage. *Note: Enrollment data reflect all children ever enrolled throughout the year

15. Children’s Coverage in Arizona: What does it mean for the future of CHIP? Michael Perry, PerryUndem Research/Communication Joseph Fu, Arizona’s Children’s Action Alliance

16. Arizona’s Dismantling of CHIP: History of KidsCare and KidsCare II

20. 20

21. Arizona’s Dismantling of CHIP: History of KidsCare and KidsCare II AND all AZ families between 138%-200% ? Employer Uninsured Family Glitch Much higher costs on Marketplace (Georgetown CCF and CAA May 2014 study)

22. LIVING WITHOUT KIDSCARE Insights from Parents of Children Who Lost Their Health Coverage When Arizona Scaled Back Its Children’s Health Insurance Program

23. The Study Georgetown University’s Center for Children and Families sponsored two focus groups and three interviews with Arizona parents who had children enrolled in KidsCare. Fourteen thousand Arizona children lost their health insurance at the end of January 2014 when the state ended its KidsCare program. This study offers a glimpse into what happened to these families. PerryUndem Research and Communication conducted the focus groups and interviews. Joe Fu, Director of Health Policy at Children's Action Alliance, a children’s advocacy organization in Arizona, helped identify and recruit families who had lost coverage. The focus groups were held in Phoenix in October 2014. One group was conducted in Spanish with five Spanish-speaking Latino parents; the other group was held with five English-speaking parents of mixed racial and ethnic backgrounds. The three additional interviews were conducted in November. In all, 13 families participated in this study.

24. Key Findings All parents in this study were highly satisfied with KidsCare. But some parents were frustrated by the frequent changes to KidsCare even before the program ended – some found it difficult to keep their children enrolled over the years. Most parents were unprepared for the end of KidsCare in January 2014. They say they did not receive clear information about why the program was ending or where they should look for new coverage. 1 2 3 “[KidsCare] covered everything. I used to take my daughters to their appoint-ments and I never really had a problem. I was really happy.” Latina, Spanish-Speaking Parent

25. Key Findings Some of these families floundered when KidsCare ended. Some children were transferred directly into the AHCCCS program without any gaps in coverage. The rest applied to AHCCCS later, looked to their employer for coverage, and/or applied for marketplace coverage. Four of the children were uninsured for at least some time period after KidsCare ended. There were disruptions in care for many children when KidsCare ended and some negative effects on children’s health. 4 5 “[My employer’s plan] would be another rent for me and I just can’t afford it.” Mother of Formerly Enrolled Child

26. Key Findings Parents who were able to enroll their children in AHCCCS seem most satisfied. Parents with children who did not qualify for AHCCCS are under financial stress and their children face more difficulties accessing care. All want KidsCare to be reinstated. They feel the program was affordable and offered high quality care for their children. They feel there is no safety net for them anymore. 6 7 8 “KidsCare used to be the option before if [my child] did not qualify for AHCCCS. But now what?” Mother of Formerly Enrolled Child

27. Children’s coverage fluctuations reflect state policy decisions 27

28. What can Arizona’s Experience with Children’s Coverage tell us about the future of CHIP? o CHIP eligibility rollbacks or new restrictions could make more children uninsured o Without ACA maintenance of effort (MOE), states may choose to cut children’s coverage o Children cannot yet rely on marketplace coverage to meet their needs o Without the ACA “stairstep” provision, more children would lose coverage 28

29. Conclusion Uncertainty about CHIP’s future threatens our nation’s progress covering children and ensuring they get the care they need to thrive. 29

30. For more information o CCF website: ccf.georgetown.educcf.georgetown.edu o Twitter @GeorgetownCCF, @ewburak o Say Ahhh! Our child health policy blog: ccf.georgetown.edu/blog/ ccf.georgetown.edu/blog/ o Elisabeth.burak@georgetown.edu Elisabeth.burak@georgetown.edu 30