Children’s Health Coverage: Moving Forward in Uncertain

Times

National Association For Children’s Behavioral Health

"Doing the Right Thing Right: Children’s Behavioral Health”

Children’s Coverage: Moving Forward in Uncertain Times

Cindy MannGeorgetown University Health Policy Institute

Center for Children and FamiliesWashington, D.C.

crm32@georgetown.educcf.georgetown.edu

Achievements

• Sharp decline in uninsured rate among low-income children, as the result of Medicaid and SCHIP

• Coverage has helped children secure the care they need

22.3%

21.5%

20.1% 20.0%

18.0%

15.8% 15.9%

14.9%15.2%

1997 1998 1999 2000 2001 2002 2003 2004 2005

Uninsured rate of children under19

Trends in the Uninsured Rate of Low-Income Children, 1997 - 2005

Source: Georgetown CCF analysis based on data from the National Health Interview Survey, November 2006. Beginning in 2004, the NHIS changed its methodology for counting the uninsured. This results in the data for 2004 and later years not being directly comparable to the data for 1997 – 2003.

Coverage Gains Over the Past Decade Have Come Equally from

Medicaid & SCHIP

20.7 20.9 21.8 23.4 25.5 27.3 27.8 28.3

5.46.16.0

4.6

6.1

0.73.4

2.0

1998 1999 2000 2001 2002 2003 2004 2005

Medicaid SCHIP

Enrollment of Children in Public Coverage (Millions)

Source: KCMU & Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, 2007.

21.4

25.222.9

28.030.9

33.933.334.4

15.1 to 20% Uninsured (14 states)

0 to 15% Uninsured (24 states + DC)

>20% Uninsured (12 states)National Average = 19.3%

Note: Low-income is defined as less than 200% of the federal poverty level.

*Due to small sample size, all estimates are for CO, CT, DE, MT, NV, NH, NM, ND, VT, WY are imprecise, i.e., they have large standard errors, and should be interpreted as approximations.

Source: Health Insurance Coverage in America, 2006 Data Update. Kaiser Commission on Medicaid and the Uninsured, October 2007.

The Job’s Not Done…Uninsured Rates Among Low-Income Children by State,

2005-2006

AK

HI

TX

NM*AZ

CA

NV*

WA

OR ID

MT* ND*

SD

CO*UT

OK

KS

NEWY*

AR

LA

MS AL GA

FL

MO

IA

MN

IL IN

TN

KY

SC

OH

WIMI

NC

VA

PA

NY

ME

DCMD

DE*

NJCT*

VT*

NH*

RI

MA

WV

Expanding Coverage

A Waveof Support

Source: As of January 31, 2008 based on a review by the Center for Children and Families of state initiatives in 2006 and 2007.

States Are Moving Forward (2006-2007)

Implemented or Recently Adopted Legislation to Improve Children’s Coverage (29 states including DC)

FL

NC

SC

GA

LATX

AL

AR

KS

OKAZ TN

MS

NV

UT CO

NM

CA

WY

ID

WA

ORND

SD

NE

MT

MN

IA

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

NY

PA

WV VA

CTNJ

DE

MD

RI

NHVT

DC

MA

But A Federal Showdown

Nonetheless Th

e W

hite

H

ouse

Congress

What Were the Issues?

• Coverage of undocumented children • Coverage of parents/adults• Coverage of children with income over 200%

of FPL – Crowd out– Public versus private

700,000

2,700,000

500,000

New Children's Enrollment in SCHIP & Medicaid

Note: Average monthly enrollment for fiscal year 2012; SCHIP & Medicaid would cover 5.8 million children when reductions in other coverage are included; numbers may not sum due to rounding.

Source: Congressional Budget Office estimate of changes in SCHIP and Medicaid enrollment of children under the Children’s Health Insurance Program Reauthorization Act of 2007 (October 24, 2007).

Children Currently in SCHIP Who Otherwise Would Lose

Coverage

Children Newly Eligible Through SCHIP

Expansions

Uninsured Children Already

Eligible

3.9 Million Otherwise Uninsured Children

“CHIPRA 2” Was Projected to Cover Nearly 4 Million Otherwise Uninsured Children

87% Eligible Under

Current Program

Rules

Characterizations of SCHIP Reauthorization Legislation

“This is a bipartisan compromise. It has broad support from Republicans and Democrats. It will help as many as 4 million low-income uninsured children…..It puts the lowest income children first in line….. Here's what it's not: It's not a government takeover of the health system. It does not undermine immigration policy. It's not expanding the program to cover high income kids.” — Senator Charles Grassley (R-Iowa) on the Senate Floor, 9/27/07

A Large Majority of Congress Supported The Reauthorization Bill

(Vote on first major SCHIP reauthorization bill)

265

159

67

94

29

Support Oppose Present/Not Voting

SenateHouse

332

13

188

Source: Roll No. 906 in the House of Representatives (September 25, 2007) and Record Vote No. 353 in the Senate (September 27, 2007) which sent H.R. 976, the Children's Health Insurance Program Reauthorization Act of 2007, to President Bush who vetoed it on October 3, 2007.

Where Are We Now?

Projected Growth in Federal SCHIP Expenditures in FY2008

0-6.1% growth (3 states & DC)

FL

NC

SC

GA

LATX

AL

AR

KS

OKAZ TN

MS

NV

UT CO

NM

CA

WY

ID

WA

ORND

SD

NE

MT

MN

IA

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

NY

PA

WV VA

CTNJ

DE

MD

RI

NHVT

DC

MA

Note: This chart shows the projected increase in SCHIP spending in FY08 from actual FY07 spending . In 2008, the projected growth in per capita national health care expenditures is 6.1%.Source: Center for Children and Families analysis of actual FY07 spending data and November 2007 projections of FY08 spending submitted to the Centers for Medicare and Medicaid Services.

>100% growth (4 states)

20-100% growth (16 states)

6.1-20% growth (20 states)

Negative growth (7 states)

Federal Roadblock

CMS “August 17th Directive”

• Issued August 17th, 2007 without notice or opportunity to comment

• In effect, makes it difficult or impossible for states to cover more moderate-income children

• Major shift in longstanding SCHIP policy• Highly controversial and already a

source of litigation

At Least 23 States Are Affected by the “August 17th” CMS Directive

Expansion states already negatively impacted (6 states)

FL

NC

SC

GA

LATX

AL

AR

KS

OKAZ TN

MS

NV

UT CO

NM

CA

WY

ID

ORND

SD

NE

MT

MN

IA

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

NY

PA

WV VA

CTNJ

DE

MD

RI

NHVT

DC

MA

Source: Center for Children and Families, “Moving Backward: Status Report on the Impact of the August 17 SCHIP Directive To Impose New Limits on States’ Ability to Cover Uninsured Children,” (December 2007)

States with approved plans that must comply by August 2008 (14 states including DC)

Expansion states with 2008 implementation dates (4 states)

WA

$73,385

$49,862

$37,740

$34,477

$31,078 $31,352$28,552

$0

$10

$20

$30

$40

$50

$60

Houston, TX Des Moines,IA

Columbia,SC

Salt LakeCity, UT

Richmond,VA

Los Angeles,CA

New York(Manhattan),

NY

.

The Cost of Living Varies Widely Across the United States

Note: In 2007, 200% of the federal poverty level for a family of three was $34,340 annually. Source: Center for Children and Families analysis of ACCRA cost of living index for the first quarter of 2007.

The cost of goods and services worth $34,340 (200% FPL for a family of three)

in the average city, adjusted for the cost of living. 200% FPL for

a family of 3

The Growing Affordability Gap Between 200% FPL and the Cost of Private Coverage

103%

0%

24%

0%

20%

40%

60%

80%

100%

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Family Premium 200% FPL (in real dollar terms)

Note: This data represents the cumulative growth in employee premium contributions for employer-sponsored family coverage and the federal poverty level for a family of three, compared to the cumulative growth in the federal poverty level adjusted each year by the federal government.

Source: Agency for Healthcare Research and Quality estimates of 1996-2005 Medical Expenditure Panel Survey Insurance Component Tables, generated using MEPSnet/IC (August 21, 2007); and CCF analysis of 1996-2005 Federal Poverty Guidelines.

Growth in the Uninsured Driven by Low & Moderate-Income Children

31% have incomes below

200% FPLSource: Urban Institute tabulations of 2006 and 2007 Annual Social and Economic Supplement to the Current Population Survey from J. Holahan & A. Cook, “What Happened to the Insurance Coverage of Children and Adults in 2006?,” Kaiser Commission on Medicaid and the Uninsured (September 2007).

Of the 710,000 Newly Uninsured Children in 2006:

21% have incomes at or above 400%

FPL47% have

incomes from 200% to 399%

FPL

And in the States…

Most Uninsured Children Are Already Eligible for Medicaid or SCHIP

4.4 Million Eligible for Medicaid

1.7 Million Eligible for

SCHIP

Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules

9 Million Uninsured Children

2.9 Million Ineligible for

Medicaid/SCHIP

Source: E. McNichol and I. Lav, “22 States Face Total Budget Shortfall of At Least $39 Billion in 2009; 6 Others Expect Budget Problems.” Center on Budget and Policy Priorities, revised March 14, 2008.

More Than 25 States Project or Expect Budget Shortfalls

FL

NC

SC

GALATX

AL

AR

KS

OKAZ TN

MS

NVUT CO

NM

CA

WYID

WA

ORND

SD

NE

MT

MN

IA

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

NY

PA

WV VA

CTNJ

DEMD

RI

NHVT

DC

MA

Projected Gap in FY 2009

Expect Gap in FY 2009, Size Unknown

Expect Gap in FY 2010

Some States Still Moving Forward on Children’s Coverage

States that have enacted or are now considering coverage improvements (2008)

Alaska ArizonaColorado IowaKansas MinnesotaMontana New JerseyNew York Utah

More Federal Roadblocks

Federal Administrative Actions

• CMS regulations (e.g., TCM, Rehab, School based services, DRA)

• Audits, deferrals, disapprovals

• More coming?

State• State coverage initiatives

• Meaningful efforts to enroll and retain eligible children

• Assuring access to care and making EPSDT work for all children

Federal• Addressing regulations/directive

• Fiscal/FMAP relief

• SCHIP reauthorization

• Broader health reform

It’s Time to Move Forward, Not Backward