1. This research is funded in part through a U.S. Health Resources and Services Administration, State Planning Grant to the Hawaii State Department of Health. Sub-Contract Research Corporation of the University of Hawaii. Research conducted by the University of Hawaii, Social Science Research Institute in collaboration with the Hawaii State Department of Health, Hawaii Institute for Public Affairs: Hawaii Uninsured Project and the Hawaii Health Information Corporation. 1 The State Children’s Health Insurance Program (SCHIP) and Health Insurance Coverage in Hawai ` i Gerard Russo, Ph.D. Sang-Hyop Lee, Ph.D. Lawrence Nitz, Ph.D. Thamana Lekprichakul, Ph.D. Rui Wang, Ph.D. Candidate Jaclyn Lindo, Ph.D. Student University of Hawai`i at Mānoa Kathleen Baker, Ph.D., Hawaii Department of Health HRSA SPG Technical Workshop VIII 30 January 2006

2. Preliminary results. Revised January 2006. Subject to further revision. 2 Economic Issues in SCHIP Further Expansion will Capture Middle Class Children. 200% FPL (current): $46,000 family of four. 250% FPL (proposed): $57,500 family of four. 300% FPL (possible): $69,000 family of four. Few Children Between 200% and 300% FPL are Uninsured. In some cases Public Insurance will replace Private Insurance. Low-End Estimates 5-10% Crowd-Out High-End Estimates 50-70% Crowd-Out We don’t know.

3. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 3 Economic Issues (continued) Crowd-Outs Effects Families Gain Free Children’s Coverage Partially offset by higher taxable wages. Employers Gain from reduced Family Plan Participation. Partially offset by higher taxable wages. Partially offset by reduced productivity or higher wages. Federal Taxpayers Lose (70% FMAP) Partially offset by higher wage and income tax receipts. State Taxpayers Lose (30% of expenditures) Partially offset by higher income tax receipts. Excess Burden of Increased Taxation (0-50%) National Economy (70%) State Economy (30%) Health Plans (neutral or negative effect) Health Care Providers (neutral or negative effect) Net Gain or Loss to Society as a Whole? National or State?

4. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 4 Social Security Amendments: Public Health Insurance USA Medicare: Title XVIII of the Social Security Act 1965 Federal Program Age 65+, Disabled, ESRD Medicaid: Title XIX of the Social Security Act 1965 State/Federal Program Poor, Blind, Disabled, Medically Indigent SCHIP: Title XXI of the Social Security Act 1997 Low-Income Uninsured Children Age 0-18

5. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 5 Hawai ` i Title XXI Program: SCHIP July 2000 SCHIP Hawaii children aged 0 to 18 years 200% of the FPL effective. Hawaii SCHIP is implemented as a Medicaid/QUEST expansion. The Hawaii Medicaid Program is implemented as a Managed Care & Managed Competition Program under the acronym QUEST: 1115 Waiver Demonstration.

6. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 6 SCHIP Federal Medical Assistance Percentage: Hawaii 2000-2005 Enhanced Federal Medical Assistance Percentage (FMAP): Hawaii 2000-2005 Federal Fiscal Year (FFY)Enhanced FMAP: SCHIP 200065.71% 200167.70% 200269.44% 200371.14% 200471.23% 200570.93% Source: Federal Register

7. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 7 Hawai ` i SCHIP Program Eligibility by Age and Federal Poverty Level

8. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 8 2006 US HHS Poverty Guidelines: Hawaii vs. 48 Contiguous States & DC Family SizeHawaii Annual Family Income 48 Contiguous States & DC Annual Family Income 1$11,270$9,800 2$15,180$13,200 3$19,090$16,600 4$23,000$20,000 5$26,910$23,400 6$30,820$26,800 7$34,730$30,200 8$38,640$33,600 Note: For Hawaii family size more than 8 persons add $3,910 for each additional person. For Mainland family size more than 8 persons add $3,400 for each additional person. Source: Federal Register, January 24, 2006, Vol.71, No.15 http://aspe.hhs.gov/poverty/06fedreg.pdf http://aspe.hhs.gov/poverty/06fedreg.pdf

9. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 9 Hawai ` i Population: Children Age 0-18 by Eligibility, 2002-2004 (3-Year Average) Survey Year Medicaid QUEST Eligible SCHIP Eligible 201- 300% FPL 301% + FPL Total Hawaii Children CPS 2003-2005 74,49463,75366,657118,289323,192 HHS 2002-2004 53,71469,90871,693115,082310,396

10. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 10 Comparison of CPS, HHS and SLAITS (age 0-17) Survey Year Medicaid QUEST Income Eligible SCHIP Income Eligible 201- 300% FPL 301% + FPL Total CPS 2002-2004 85,01267,10063,717101,037316,866 HHS 2001-2003 60,94164,57364,928101,367291,810 SLAITS-NSCH 1/2003-7/2004 65,23860,25456,438114,169296,099 SLAITS- CSHCN 2000-2002 60,08073,45962,53099,875295,944 Note: SLAITS and HHS Estimates Based on UHM Imputation for Missing Data

11. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 11 Hawai`i Children Age 0-18, by Income Eligibility Status: Current Population Survey, 2001-2005 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Children 200177,54855,33261,494100,454294,828 200290,90478,82763,33493,887326,952 200384,67169,34962,647123,879340,545 200481,90058,96071,942114,279327,080 200556,91162,95065,382116,708301,951 2001-200578,38765,08464,960109,841318,271 Note: Hawaii low-income children age 0-18 are eligible for free medical assistance under the State’s Medicaid program either through the basic Medicaid or SCHIP financing. In both cases, able-bodied children become QUEST beneficiaries. Eligibility for pregnant women and children follows national standards for the basic Medicaid program—pregnant women and newborns are income eligible up to 185% FPL, children aged 1-5 years are eligible up to 133% FPL, and children age 6-18 up to 100% FPL. The State Children’s Health Insurance Program (SCHIP) is administered as a Medicaid expansion and covers all children up to 200% FPL without regard to family assets. Thus, the Hawaii SCHIP program captures newborns residing in families with incomes 186-200% FPL, children age 1-5, 134-200% FPL and children age 6-18, 101-200% FPL. Throughout, eligibility is determined by the generous Hawaii-specific U.S. Department of Health & Human Services (HHS) Federal Poverty Guidelines. Income data are based on the CPS family unit. Source: University of Hawai`i weighted tabulations. Current Population Survey (CPS), Annual Social and Economic (ASEC) Supplement, 2001- 2005, Hawai`i Sample. CPS 2001-2005: All Children

12. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 12 Hawai`i Children Age 0-18, by Income Eligibility Status: Hawai`i Health Survey, 2000-2004 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Children 200069,41069,09769,51598,758306,781 200177,18969,65562,306102,268311,418 200257,22566,90871,791109,625305,549 200358,71968,36072,716113,437313,231 200445,19874,45570,571122,182312,407 2000-200461,54869,69569,380109,254309,877 Note: Hawaii low-income children age 0-18 are eligible for free medical assistance under the State’s Medicaid program either through the basic Medicaid or SCHIP financing. In both cases, able-bodied children become QUEST beneficiaries. Eligibility for pregnant women and children follows national standards for the basic Medicaid program—pregnant women and newborns are income eligible up to 185% FPL, children aged 1-5 years are eligible up to 133% FPL, and children age 6-18 up to 100% FPL. The State Children’s Health Insurance Program (SCHIP) is administered as a Medicaid expansion and covers all children up to 200% FPL without regard to family assets. Thus, the Hawaii SCHIP program captures newborns residing in families with incomes 186-200% FPL, children age 1-5, 134-200% FPL and children age 6-18, 101-200% FPL. Throughout, eligibility is determined by the generous Hawaii-specific U.S. Department of Health & Human Services (HHS) Federal Poverty Guidelines. Income data are based on the household unit. Source: University of Hawai`i weighted tabulations. Current Population Survey (CPS), Annual Social and Economic (ASEC) Supplement, 2001- 2005, Hawai`i Sample. HHS 2000-2004: All Children

13. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 13 Hawai`i Uninsured Children Age 0-18, by Income Eligibility Status: Current Population Survey, 2001-2005 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Uninsured Children 2001 14,4268,2252,5494,65829,857 2002 14,1757,0325,4134,71131,332 2003 9,6745,5837,6723,06825,996 2004 10,5414,6683,9345,91725,059 2005 6,8552,5713,7253,53416,685 2001-2005 11,1345,6164,6594,37825,786 Note: Hawaii low-income children age 0-18 are eligible for free medical assistance under the State’s Medicaid program either through the basic Medicaid or SCHIP financing. In both cases, able-bodied children become QUEST beneficiaries. Eligibility for pregnant women and children follows national standards for the basic Medicaid program—pregnant women and newborns are income eligible up to 185% FPL, children aged 1-5 years are eligible up to 133% FPL, and children age 6-18 up to 100% FPL. The State Children’s Health Insurance Program (SCHIP) is administered as a Medicaid expansion and covers all children up to 200% FPL without regard to family assets. Thus, the Hawaii SCHIP program captures newborns residing in families with incomes 186-200% FPL, children age 1-5, 134-200% FPL and children age 6-18, 101-200% FPL. Throughout, eligibility is determined by the generous Hawaii-specific U.S. Department of Health & Human Services (HHS) Federal Poverty Guidelines. Income data are based on the family unit as defined in the CPS. Source: University of Hawai`i weighted tabulations. Current Population Survey (CPS), Annual Social and Economic (ASEC) Supplement, 2001- 2005, Hawai`i Sample. CPS 2001-2005: Uninsured Children

14. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 14 HHS 2000-2004: Uninsured Children Hawai`i Uninsured Children Age 0-18, by Income Eligibility Status: Hawai`i Health Survey, 2000-2004 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Children 20004,8944,4223,1221,88314,321 20014,7783,2681,3912,06111,499 20022,7303,9551,9781,1189,781 20032,1744,9311,3771,95810,440 20044,6364,3392,4421,59613,014 2000-20043,8434,1832,0621,72311,811 Source: University of Hawai`i weighted tabulations. Hawai`i Health Survey (HHS), 2000-2004, Hawai`i Sample.

15. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 15 CPS 2001-2005: Percent Uninsured Percent Uninsured Hawai`i Children Age 0-18, by Income Eligibility Status: Current Population Survey, 2001-2005 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Children 200118.60%14.86%4.14%4.64%10.13% 200215.59%8.92%8.55%5.02%9.58% 200311.43%8.05%12.25%2.48%7.63% 200412.87%7.92%5.47%5.18%7.66% 200512.04%4.08%5.70%3.03%5.53% 2001-200514.20%8.63%7.17%3.99%8.10% Source: University of Hawai`i weighted tabulations. Current Population Survey (CPS), Annual Social and Economic (ASEC) Supplement, 2001- 2005, Hawai`i Sample.

16. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 16 HHS 2000-2004: Percent Uninsured Percent Uninsured Hawai`i Children Age 0-18, by Income Eligibility Status: Hawai`i Health Survey, 2000-2004 Survey Year Medicaid QUEST Eligible SCHIP Eligible 201-300% FPL 301%+ FPL Total Children 20007.05%6.40%4.49%1.91%4.67% 20016.19%4.69%2.23%2.02%3.69% 20024.77%5.91%2.76%1.02%3.20% 20033.70%7.21%1.89%1.73%3.33% 200410.26%5.83%3.46%1.31%4.17% 2000-20046.24%6.00%2.97%1.58%3.81% Source: University of Hawai`i weighted tabulations. Hawai`i Health Survey (HHS), 2000-2004, Hawai`i Sample.

17. 30 January 2006Preliminary results. Revised January 2006. Subject to further revision. 17 Mahalo! This research is funded in part by U.S. Department of Health and Human Services Health Resources & Services Administration State Planning Grant Hawaii State Department of Health.