1. Center for Public Policy Priorities www.cppp.org 1 Texas Medicaid and CHIP Enrollment Update for Children’s Hospital Association of Texas October 24, 2006 Anne Dunkelberg, Associate Director 900 Lydia Street - Austin, Texas 78702 Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org

2. Center for Public Policy Priorities www.cppp.org 2 Texans and Health Insurance US Census Bureau Statistics (March 2006 CPS): Approximately 5.5 million Texans uninsured in 2005 –24.6% of Texans of all ages were uninsured (versus 15.7% U.S.) –26.9% of Texans under age of 65 were uninsured Another three million Texans covered by Medicaid or CHIP (i.e., generally not insured through private coverage) Why are so many Texans uninsured ? Low percentage of employer-sponsored insurance (ESI) –8% below national average for < age 65 (54.5%, vs. 62.8%) –10.4% below national average for < age 18 –Only 12.0% of Texans below poverty have ESI Approximately 83% of Texas Medicaid recipients are below poverty (i.e., most are unlikely to be insured w/o Medicaid)

3. Center for Public Policy Priorities www.cppp.org Texas’ Uninsured by Income, 2005 Income, % of Poverty Uninsured (millions) As % of GroupMax income, Family of 4 All5.524.6% <100%1.5542.2%$20,000 100-200%1.9237.5%$40,000 200-300%1.0426.5%$60,000 300-400%0.44614.8%$80,000 400-500%0.1729.4%$100,000 Above 500%0.3687.1%More than $100K

4. Center for Public Policy Priorities www.cppp.org 4 How Does Immigration Factor In? Immigrants are NOT the primary cause of Texas’ last-place ranking –Census Bureau reported 2.4 million non-citizens (includes both legal residents and undocumented persons); 1.3 million of them are uninsured (54.5% of non-citizens) –BUT! If you removed non-citizens from the equation, Texas would still be tied with New Mexico for the worst uninsured rate at 20.6% uninsured (4.2 million), even if you left the non-citizens in the other state’s counts Without immigrants, New Mexico’s rate would drop to 18.9%

5. Center for Public Policy Priorities www.cppp.org 5 Texas Health Insurance Stats: What They Tell Us About the Need for Outreach? Texas Children who are Uninsured, 2004-05 – U.S. Census All incomes, under age 19 (0-18*; 2-year average 2004-05 Census CPS) 20.4%1.367 million < 200% FPL; under age 19 (0-18; 2-year average 2004-05 Census CPS) 28% of <200%; 13.4% of all kids 919,000 In other words, 2/3 of uninsured Texas children are below 200% of the federal poverty line, despite Medicaid and CHIP. Texas is home to an estimated 230,000 undocumented kids, and another 160,000 legal immigrant (LPR) children under age 18 (Pew Hispanic Center). But, the LPR kids can participate in CHIP. Clearly, undocumented children are just a small part of our uninsured problem At least half of our uninsured kids (~689,000) could enroll in Medicaid or CHIP!

6. Center for Public Policy Priorities www.cppp.org 6 Texas Medicaid: Who it Helps August 2006, HHSC data. Total enrolled 6/1/2006: 2,644,167

7. Center for Public Policy Priorities www.cppp.org 7 Income Caps for Texas Medicaid and CHIP, 2006 $22,078/yr $30,710/yr 185% 133% $16,600 100% $2,256$3,696 13.6%22.3% 74% $7,476 222% $21,708 $33,200 200% Income Limit as Percentage of Federal Poverty Income Annual Income is for a family of 3, except Individual Incomes shown for SSI and Long Term Care

8. Center for Public Policy Priorities www.cppp.org 8 Medicaid in Texas: Who it Helps Medicaid: As of September 2006, 2.6 million Texans were enrolled in Medicaid: 1.75 million were children –about 96,000 of these children, or 5.5%, were receiving disability- related Medicaid (98% of these on SSI) –about 13,100 were pregnant teens (0.8% of the kids; 0.5% of all Medicaid) –125,600 in TANF cash assistance families ( 7.2% of the kids; 4.8% of total caseload) –OTHER 1.5 MILLION predominantly in WORKING POOR FAMILIES About 1.2 million worker-headed families, Other 20% are headed by disabled parents; living on child support from non-custodial parent, or both)

9. Center for Public Policy Priorities www.cppp.org 9 Medicaid in Texas: Who it Helps Medicaid: As of September 2006, 2.6 million Texans were enrolled in Medicaid: 895,000 were adults: –691,000 (79% of the adults) were elderly or disabled. Adults on SSI account for 60% of the aged and disabled recipients –Other adults: 98,600 maternity coverage; 25,500 TANF parents (1.0% of total caseload); –NOTE: there are fewer than 85,000 total poor parents on Texas Medicaid. 59,400 either TMA (Transitional Medicaid Assistance) or parents who are at or below TANF income, but not receiving TANF cash assistance Children’s Health Insurance Program (CHIP): as of September 1, 2003 — 507,259 children as of October 1, 2006 — 300,685 (drop of 206,574, or 41%)

10. Center for Public Policy Priorities www.cppp.org 10 Texas Child Medicaid and CHIP Enrollment (Jan. 2002-October 2006) Source: Enrollment from Texas Health and Human Services Commission; Texas State Demographer's 0-17 Population Estimates 9/03: 2,150,543 10/06: 2,020,710

11. Center for Public Policy Priorities www.cppp.org 11 Texas Child Medicaid Enrollment (February 2001-October 2006) Source: Texas Health and Human Services Commission Simplified Enrollment begins High: 1,838,239

12. Center for Public Policy Priorities www.cppp.org 12 Texas CHIP Enrollment (May 2000-Oct. 2006) Source: All figures from Texas Health and Human Services Commission; Compares most recent month with September 2003 Highest, 5/02: 529,271 9/03: 507,259 10/06: 300,685

13. Center for Public Policy Priorities www.cppp.org 13 CHIP Caseloads: Now and Projected 20062007 September 2003 actual caseload507,259 October 2006 actual caseload300,685 decline, 9/03 to 10/06 (-40.7%)(-206,574) HHSC 2/05 enrollment projection, if 12- month eligibility restored 386,110467,404 SB 1 funded caseload, traditional CHIP (6 month renewal)* 344,750351,132 Additional caseload, perinatal coverage17,42547,498 Total, SB 1 projected CHIP caseload, traditional & perinatal CHIP 362,175398,630 *Rider 57 HHSC (SB 1) requires agency to request more $$ for CHIP from LBB if needed for enrollment and benefits. HHSC Budget Request for 2008-09 would allow enrollment to grow to 339,037 in 2009.

14. Center for Public Policy Priorities www.cppp.org 14 Recent Declines in Texas Children’s Medicaid Enrollment December 2005 October 2006 Decline, December to October State total 1,838,2391,720,025-118,214-6.4% Bexar 139,682134,021-6,478-4.6% Cameron 64,33964,212-1,347-2.1% Dallas 182,954172,030-12,900-7.1% El Paso 98,31991,162-9,054-9.2% Harris 316,896301,042-24,905-7.9% Hays 4,9535,1781553.1% Tarrant 97,90891,296-8,425-8.6% Travis 52,66750,835-3,400-6.5% Webb 36,47333,347-3,727-10.2% Source: Texas Health and Human Services Commission

15. Center for Public Policy Priorities www.cppp.org 15 Children’s Medicaid declines Drop of over 99,000 children statewide from December 2005 to April 2006 caused alarm. As of April, Travis and Hays showing much greater loss since December than statewide loss (-11.4% and -16.8%, vs. -5.4% statewide). However, caseloads improved June to September, and Travis and Hays county child enrollment rebounded by much larger margin than the statewide growth. Then dropped 35,607 from August to September; -28,670 from Sept. to Oct. Net decline since December now -118,214. Travis and Hays counties now doing BETTER than state average (Due to extra State attention to them?). Of concern and unexplained: Webb and El Paso counties drop more than Travis (-10.2, -9.2%)

16. Center for Public Policy Priorities www.cppp.org 16 Adult Medicaid Trends - Statewide Dec-05Sept.-06Dec 05 to Sept. 06 Change Aged and Disabled 687,177710,13122,9543.3% Cash Assistance 31,87625,527-6,349-19.9% Maternity93,61798,6144,9975.3% Other Parents 64,65659,412-5,244-8.1% Total877,326894,58517,2592.0% CAVEAT: Travis and Hays County Medicaid enrollment have DECLINED for adults from December 2005 to September 2006. Points to problems with the IE&E pilot and TIERS

17. Center for Public Policy Priorities www.cppp.org 17 Adult Medicaid Trends – Travis County Dec-05Sept.-06Dec 05 to Sept. 06 Change Aged and Disabled 17,43516,846-589-3.4% Cash Assistance 4,0894,3522636.4% Maternity18281,9671397.6% Other Parents 1,6921,596-96-5.7% Total25,04424,761-283-1.1% From December 2005 to July 2006, Statewide Adult Medicaid enrollment grew by 1%, but Travis County enrollment DECLINED for adults, including aged and disabled and maternity (-6.5% overall) Enrollment since then shows some recovery; Statewide growth 2% since December, but Travis County enrollment dropped -1.1% Points to problems with the IE&E pilot and TIERS.

18. Center for Public Policy Priorities www.cppp.org 18 Adult Medicaid Trends – Hays County Dec-05Sept.-06Dec 05 to Sept. 06 Change Aged and Disabled 1,9561,658-298-15.2% Cash Assistance 34845610831.0% Maternity261273124.6% Other Parents 119106-13-10.9% Total2,6842,493-191-7.1% From Dec. 2005 to Sept. 2006, Statewide Adult Medicaid enrollment grew by 2%, but Hays County enrollment DECLINED for aged and disabled and non- TANF parents (-7.1% overall) Hays County decline as of July was -10.1% (vs. +1.1% statewide), so some improvement over summer. Points to problems with the IE&E pilot and TIERS

19. Center for Public Policy Priorities www.cppp.org 19 Recent Declines in Texas CHIP Enrollment December 2005 September 2006 Decline, December to September State total322,898291,530-31,368-9.7% Bexar 20,91518,443-2,472-11.8% Cameron 7,8147,770-44-0.6% Dallas 33,32530,470-2,855-8.6% El Paso 13,62811,571-2,057-15.1% Harris 65,46556,211-9,254-14.1% Hays 1,4891,342-147-9.9% Tarrant 19,75419,039-715-3.6% Travis 8,5508,8472973.5% Webb 5,2795,153-126-2.4% Source: Texas Health and Human Services Commission

20. Center for Public Policy Priorities www.cppp.org 20 CHIP Declines September ’06 county numbers show slight improvement in SOME counties, while most remain well below December ’05 enrollment. Renewal rates ARE improved: back above 70% for June-Sept.-- compared to 50%-57% from January through May. However, thru September statewide enrollment continues to drop, new enrollment is low. Thus, too early to claim recovery trend for CHIP.

21. Center for Public Policy Priorities www.cppp.org 21 What Texas Spends and how much more it would cost to “Be Average” If State Spending per Texan were equal to the U.S. Average, this budget would increase to $142 Billion Source: LBB Fiscal Size Up 2006-07; NASBO State Expenditure Report 2004 (Jan 2006)

22. Center for Public Policy Priorities www.cppp.org 22 2008-09 Budget Will Be Very Tight State Own-Source Spending and Revenue

23. Center for Public Policy Priorities www.cppp.org 23 HHS Needs in 2008-09 “Above Baseline” Requests Restore 10% Cuts: HHSC $72 million/550 workers; Aging & Disability, $112 million/298 workers; Family & Protective Services, $40 million/Eliminate Prevention services; State Health Services, $236 million/693 workers; Assistive & Rehabilitative Services, $13 million/168 employees HHSC needs $1.8 billion GR ABOVE “base” to maintain caseload growth and inflation/cost increases in Medicaid and CHIP –$1.7 billion for Medicaid (allows for modest caseload growth) –$14.7 million for CHIP; Enrollment assumed to cap at 339,000 in 2009

24. Center for Public Policy Priorities www.cppp.org 24 HHS Needs in 2008-09 (continued) “Above Baseline” Requests Other HHSC: $254 million for community care waiting lists; $237 million to restore Medicaid and CHIP rate cuts from 2003 State Health Services: $116 million for Mental Health and Substance Abuse programs Dept. Aging and Disability: $84 million to MAINTAIN community care: $10.7 million to restore 2003 rate cuts Family and Protective Services: $79.6 million to continue APS/CPS reform; $590 million to replace Rainy Day funds; $51.3 million for caseload growth

25. Center for Public Policy Priorities www.cppp.org 25 Texas Unspent CHIP Funds Lost to Other States FFY 1998 Federal SCHIP Funds Lost - $170 million FFY 1999 Federal SCHIP Funds Lost - $324.5 million FFY 2000 Federal SCHIP Funds Lost - $123.7 million FFY 2001 Federal SCHIP Funds Lost - $85.3 million FFY 2002 Federal SCHIP Funds Lost - $104.6 million FFY 2003 Federal SCHIP Funds Lost - $23.8 million Total lapsed to date (2000-2005): $831.9 million For perspective, TOTAL Texas CHIP spending in FY 2005 was $401.6 million, of which $110 million was state dollars Expected to soon lapse another $26.5 million from the 2004 allocation, based on state estimates as of 8/2006. Source: Center on Budget and Policy Priorities, analysis of CMS data.

26. Center for Public Policy Priorities www.cppp.org 26 History/Context of Texas CHIP and our Federal CHIP Funding Allocation BEFORE 2003 CHIP cuts, Texas was projecting a CHIP federal funding shortfall by late 2006. Had spending held flat at Texas’ fiscal year 2002 high (i.e., no inflation and no enrollment growth) we’d still have had a federal shortfall at least by 2008. Now, state is assuming (in current state budget and in official reports to CMS) that CHIP enrollment will rebound, PLUS a perinatal option is scheduled to begin in January 2007. The latest (unofficial) state projection for federal CHIP shortfall in Texas is 2010. Texas projects 24% growth in CHIP spending from 2006 to 2007; based on this projected (but as yet non-existent) enrollment rebound PLUS new perinatal program Additional Texas CHIP spending planned (pending approval), but not included in current state projections: –SCHIP premium assistance waiver; Galveston regional “3-share” waiver which will include SCHIP

27. Center for Public Policy Priorities www.cppp.org 27 Federal SCHIP Reauthorization, 2007 Other states want Texas’ lapsed funds (Other states have used all their and need more…) Texas’ CHIP allocation (share of the pie) will be targeted to be reduced based on our lower enrollment WILL Congress add money to CHIP to allow for population growth, inflation, or expansion? This is a cautionary example of the problems with block grants

28. Center for Public Policy Priorities www.cppp.org 28 Federal SCHIP Reauthorization, 2007 Priorities: No loss of SCHIP ground in enrollment or benefits (Need $12-$14 b/5 yrs new $$ to sustain) Enough growth to cover all eligible/not enrolled @ current eligibility thresholds Room to cover more uninsured kids NO cuts to Medicaid to offset SCHIP Other issues: Fair treatment of states that did more prior to CHIP

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