schip 101: learning from 10 years of experience liz arjun state health policy analyst center for...
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SCHIP 101:Learning from 10 years of
Experience
Liz Arjun
State Health Policy Analyst
Center for Children and Families
Georgetown University Health Policy Institute
www.ccfgeorgetown.org
Tennessee First Focus TrainingJune 14, 2007
Overview
• SCHIP History and Successes
• Lessons Learned
• What’s Next?
Key Policy Ingredients of Original SCHIP Legislation
• Block grant / No entitlement to coverage• No mandates / State option with
“enhanced matching funds”• Funds dedicated to NEW coverage• Medicaid treated as the base off of which
states would build• State flexibility to use Medicaid and/or a
separate state program with fewer federal standards
SCHIP Enrollment, 1997-2004 (in millions)
0.9
2.7
3.4
3.8 3.9 3.9
1.8
1997 1998 1999 2000 2001 2002 2003 2004
SCHIP adopted(August 1997)
51st state implements SCHIP; enrollment efforts are strong;
states pursue family coverage waivers
(2000)
State fiscal crisis and extensive SCHIP
cutbacks (2002 – 2004)
$1.3 billion in unspent SCHIP
funds lost (2004)
HIFA initiative allows SCHIP funds to be
used for coverage of childless adults
(2001)
Source: CCF; and enrollment data from Kaiser Commission on Medicaid and the Uninsured.
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 low-income children under 19
Trends in the Uninsured Rate of Low-Income Children, 1997- 2005
Source: CCF analysis of National Health Interview Survey.
*Poverty status is based on family income and family size using the U.S. Census Bureau poverty thresholds for 2002 Federal Poverty Level (FPL) in 2002 in the 48 contiguous states and the District of Columbia is $15,020 for a family of three. Source: National Health Interview Survey, 2003.
94.4% 92.8%
61.2%
Public
Private
Uninsured
96.2% 95.5%
67.9%
Percent of Poor and Near-Poor Children with a Usual Place of Care
Poor Children* Near-Poor Children*
ESI Coverage Rates Have Declined for Children and Adults
Source: Percent with employer-sponsored insurance from E. Gould, “Health Insurance Eroding for Working Families,” Economic Policy Institute (September 2006).
65.40%
58.90%60.80%
55.40%
Children under 18 Working Adults
1999-2000 2004-2005
Coverage Gains Over the Past Decade Have Come Equally from
Medicaid & SCHIP
21.0 21.4 21.6 21.9 22.6 25.5 26.3 27.8
3.3 4.65.3
6.26.0
1.90.9
1997 1998 1999 2000 2001 2002 2003 2004
Medicaid SCHIP
Enrollment of Children in Public Coverage (Millions)
Source: CCF, Preliminary data. Based on children ever-enrolled over the course of a year.
21.023.5
22.325.2
27.2
32.330.8
34.0
Lessons Learned
• States will use SCHIP to respond to the needs of families
• Administrative practices and policies make a difference in enrollment and retention
• States need more tools, incentives and/or requirements to finish the job
• States need additional funding to cover uninsured children
Children’s Eligibility for Medicaid/SCHIP by Income, May 2007
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
GA
Note: The Federal Poverty Line (FPL) for a family of three in 2007 is $17,170.Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission of Medicaid and the Uninsured (2006), as updated by CCF.
TX
200% FPL (24 states including DC)
FL
AL
> 200% FPL (18 states)
< 200% FPL (9 states)
OK
70%100%
133%
185%
250% 250% 250%
Infants Children 1-5
Children 6-19
Parents
SCHIP
Medicaid
TennesseeMedicaid and SCHIP Income Eligibility Thresholds
for Children and Parents
Income Threshold as a Percent of the Federal Poverty Line
Note: As of June 2007; income thresholds for non-working parents as of July 2006.
600
605
610
615
620
625
630
635
640
645
650
Th
ou
san
ds
Source: Washington State Department of Social and Health Services, 2005, updated 2006.
January 2005: Administrative order to return to 12-month renewal cycle and establishes continuous eligibility policy
Children's Enrollment in Washington's Public Insurance Programs,April 2002-October 2005
April 2003: State
begins income verification
July 2003:12-month continuous eligibility ends; 6-month renewal cycle replaces 12-month cycle
300
350
400
450
500
550
600
650
700
Oct-9
8
Jan-
99
Apr-9
9
Jul-9
9
Oct-9
9
Jan-
00
Apr-0
0
Jul-0
0
Oct-0
0
Jan-
01
Apr-0
1
Jul-0
1
Oct-0
1
Jan-
02
Apr-0
2
Jul-0
2
Oct-0
2
Jan-
03
Apr-0
3
Jul-0
3
Oct-0
3
Jan-
04
Apr-0
4
Jul-0
4
Oct-0
4
Jan-
05
Th
ou
sa
nd
s
Source: Louisiana Department of Health and Hospitals Monthly Enrollment Reports, 2005
June 2000: Trained
workers in new
philosophy
July 2000: “Ex-Parte” renewalfor childrenlosing cash benefits
June 2001:
Baseline report re:
renewal
July 2001:New renewalprocedures: calls re: renewal formsnot returned, “ex-parte”for LaChip
March 2003:“Reasonable certainty” for
renewal
October 2003:Telephone renewals, rolling renewals
May 2000:“Reasonable
certainty” standard
Enrollment in Louisiana's Medicaid ProgramOctober 1998 - January 2005
Medicaid & SCHIP are Reaching an
Increasing Share of Eligible Children
74% 73%
48%
82%
68%
0%
20%
40%
60%
80%
100%
Source: L. Dubay analysis of 1997,1999,2002 National Survey of America’s Families.
SCHIPMedicaid
1997 1999 2002 1999 2002
Participation Rate of Eligible Children in Medicaid & SCHIP
Where Does Tennessee Stand?Better Than the U.S. Average, But Worse Than Its Neighbors
Uninsured Rate of All Children
Uninsured Rate of Low-
Income Children
Participation in Medicaid/SCHIP
Among Low-Income Children
U.S. average
11.0% 17.9% 74.2%
Tennessee 9.4% 15.5% 77.6%
Alabama 5.5% 7.7% 88.8%
Arkansas 9.3% 11.2% 84.4%
Kentucky 7.8% 13.2% 80.9%
Missouri 7.9% 13.5% 81.4%
Source: CCF analysis of CPS 2005 and 2006 March Supplement (i.e., data from 04-05).
$3.8$4.3
$4.6$5.1
$6.0$6.4
$6.9
$7.6$8.1
$8.8
$9.4
$4.2 $4.2 $4.2 $4.2
$0.1
$0.9
$2.7
$1.9
$5.0$5.0$5.0$5.0$5.0$5.0
$5.0$4.1
$3.2$3.2$3.1
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
SCHIP Spending SCHIP Allotment
(in billions)
Source: 1998-2007 data from Chris Peterson. SCHIP Original Allotments: Funding Formula Issues and Options. Congressional Research Service (October 2006); 2007-2012 spending data from CBO March 2007 SCHIP baseline (February 2007) includes outlays plus additional SCHP spending required to maintain current programs.
SCHIP Spending is Rapidly Outpacing New Funds Being Made Available
With 9 Million Uninsured Children, More Needs to Be Done
Medicaid/ SCHIP25.9%
Uninsured11.6%
Employer-based &
Other 62.5%
Source: CCF analysis of CPS 2006 March Supplement; and Campaign for Children’s Health Care, No Shelter from the Storm: America’s Uninsured Children (September 2006).
77.9 Million Children Under 19
• 88% have at least one employed parent.
• Uninsured children are disproportionately in the South (43%) and West (29%).
• A disproportionate share (38%) of uninsured children are Hispanic.
• 35% of uninsured children live in families with incomes below 100% FPL.
Children’s Health Care Coverage, 2005
What Is Next for Children’s Health Insurance?
• Most Uninsured Children are Eligible
• Recent Surge of Activity at the State-Level Indicates States are Ready to Move Forward
• Voters Strongly Support Efforts to Get Children Covered
• SCHIP Reauthorization is Happening
7 out of 10 Uninsured Children are Eligible But Unenrolled
49% are Medicaid Eligible
19% are SCHIP Eligible
Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CT
NJ
DE
MD
RI
HI
DC
AK
SC
NMOK
GA
Source: As of June 8, 2007 based on CCF review of state initiatives.
TX
IL
FL
AL
Implemented or Recently Adopted Legislation to Improve Children’s Coverage (18 states and DC)
Considering Significant Proposal to Improve Children’s Coverage (11 states)
States are Moving Forward
Key State Strategies
• Enrolling and retaining eligible children
• Increasing eligibility
• Integrating with private coverage
Americans Strongly Support Covering Children
84%84%New York Times, March 2, 2007
Specific Policy Issues Emerging in Reauthorization
• How much SCHIP funding will be available to states?– Overall Funding– Formula: i.e. historical spending, number of uninsured
children, others
• Who will be covered? – Income range of children who can be covered– Treatment of adults covered with SCHIP funds– Refinancing of pre-SCHIP expansions– Special groups of children (legal immigrants, state
employees children)
Specific Policy Issues Emerging in Reauthorization (continued)
• What kind of coverage or product will be provided?– Pressure on benefit package (HSAs, vouchers)– Efforts to strengthen benchmark standards– Relationship to employer-based coverage (premium assistance)
• How do we reach eligible, but uninsured children?– Outreach funding and incentives– Helping states with the increased Medicaid costs– Express Lane and other tools– Administrative barriers such as citizenship documentation
requirement
• How do we pay for it?
Timeline for Congressional Action??
Late June
After July 4
July LateJuly
August Sept30
SenateFinance
CommitteeSenateFloor
House Energy
and CommerceCommittee
House Floor Conference
No new funds available
Note: These dates are all tentative