washington state’s initiative: cover all children by 2010 robin arnold-williams, secretary...

Washington State’s Initiative:

Cover all children by 2010

Robin Arnold-Williams, SecretaryDepartment of Social and Health Services, Washington

State

AcademyHealth Annual Research Meetings 2006

June 24-27, 2006

Seattle, Washington

Robin Robin Arnold-Arnold-

Williams,Williams,Secretary, Secretary,

DSHS, DSHS, Washington Washington

StateState

AcademyAcademyHealthHealth

ResearchResearchConferenceConference

Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 22

The Evergreen State storyThe Evergreen State story Part I: A national leaderPart I: A national leader

Basic Health planBasic Health plan Pregnant women, children’s coveragePregnant women, children’s coverage 1994 expansion of ceiling to 200% FPL1994 expansion of ceiling to 200% FPL Established Healthy OptionsEstablished Healthy Options SCHIP lets state raise eligibility to 250%SCHIP lets state raise eligibility to 250%

Part II: Cutbacks and transitionsPart II: Cutbacks and transitions Children’s Health Program (CHP)Children’s Health Program (CHP) Unsuccessful CHP transition to Basic HealthUnsuccessful CHP transition to Basic Health Budget shortfalls impact MedicaidBudget shortfalls impact Medicaid

Part III: New approachesPart III: New approaches Governor pledges coverage by 2010 for all childrenGovernor pledges coverage by 2010 for all children CHP restored; Eligibility hurdles removedCHP restored; Eligibility hurdles removed Enrollment increases in forecastEnrollment increases in forecast Employer-Sponsored Insurance Employer-Sponsored Insurance




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 33

PART ONEPART ONE

In the 1990s, Washington In the 1990s, Washington State emerged as a State emerged as a national leader among national leader among states expanding states expanding public-financed health public-financed health insuranceinsurance for children for children




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 44

Beginnings…Beginnings…

In 1988, Washington created its Basic Health Plan In 1988, Washington created its Basic Health Plan (BHP) – a managed care pilot for the working poor.(BHP) – a managed care pilot for the working poor.

In 1989, Washington expanded coverage for pregnant In 1989, Washington expanded coverage for pregnant women and infants to 185% FPL.women and infants to 185% FPL.

In 1990, Children’s Health Program (CHP) for In 1990, Children’s Health Program (CHP) for coverage of coverage of allall children up to 100% FPL. children up to 100% FPL.

In 1991, coverage for citizen children converted to In 1991, coverage for citizen children converted to Medicaid, while CHP remained for non-citizen Medicaid, while CHP remained for non-citizen children. (Same coverage for both groups.)children. (Same coverage for both groups.)

In 1993, Washington adopted a “managed In 1993, Washington adopted a “managed competition” health-care reform plan aimed at competition” health-care reform plan aimed at universal coverage.universal coverage.

As part of 1993 health reform, BHP became a As part of 1993 health reform, BHP became a permanent statewide program with funding to cover permanent statewide program with funding to cover 250,000 persons.250,000 persons.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 55

An era of expansionAn era of expansion

Under 1993 health-care reform, all Washington residents Under 1993 health-care reform, all Washington residents were were to receive a Uniform Benefit Package (UBP) were were to receive a Uniform Benefit Package (UBP) through certified health plans by 1997.through certified health plans by 1997.

Medicaid coverage for children expanded to 200% FPL in Medicaid coverage for children expanded to 200% FPL in July 1994. (Washington was one of only four states July 1994. (Washington was one of only four states covering children at that income level.)covering children at that income level.)

Medicaid coverage for families, pregnant women and Medicaid coverage for families, pregnant women and children steered to managed care (Healthy Options children steered to managed care (Healthy Options program), using same health plans as commercial payers.program), using same health plans as commercial payers.

Washington’s early move to 200% for children limited Washington’s early move to 200% for children limited state’s ability to take advantage of State Children’s Health state’s ability to take advantage of State Children’s Health Insurance Program (SCHIP).Insurance Program (SCHIP).

In 2000, Washington implemented SCHIP to cover In 2000, Washington implemented SCHIP to cover children up to 250% FPL – currently sixth highest ceiling children up to 250% FPL – currently sixth highest ceiling in country.in country.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 66

PART TWOPART TWO

Beginning in 1995 Beginning in 1995 Washington’s public health Washington’s public health programs underwent programs underwent changes that reflected a changes that reflected a dramatically different dramatically different policymaking environment.policymaking environment.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 77

National leadershipNational leadership By the mid-1990s, Washington State was By the mid-1990s, Washington State was

regarded as a leader in efforts to expand public regarded as a leader in efforts to expand public health insurance coveragehealth insurance coverage

Then, setbacks:Then, setbacks:– In 1995, state’s health-care reform law was drastically In 1995, state’s health-care reform law was drastically

reduced by the Legislature, this time focusing just on reduced by the Legislature, this time focusing just on BHP and Medicaid for low-income uninsured residents.BHP and Medicaid for low-income uninsured residents.

– Welfare reform at the national level threatened current Welfare reform at the national level threatened current coverage of immigrant families and children.coverage of immigrant families and children.

But also, some further successes:But also, some further successes:– Washington remained among states with highest Washington remained among states with highest

Medicaid and SCHIP eligibility coverage.Medicaid and SCHIP eligibility coverage.– SCHIP funding used to provide prenatal care and SCHIP funding used to provide prenatal care and

related health care for non-citizen pregnant women, and related health care for non-citizen pregnant women, and to help finance coverage for Medicaid children in to help finance coverage for Medicaid children in families above 150% of FPL.families above 150% of FPL.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 88

Budget squeezesBudget squeezes

In 2001, the state’s revenue picture darkenedIn 2001, the state’s revenue picture darkened

DSHS developed a “Medicaid Reform Waiver” in 2002 that DSHS developed a “Medicaid Reform Waiver” in 2002 that included flexible benefit design, cost-sharing, premiums for included flexible benefit design, cost-sharing, premiums for higher-income families and enrollment caps.higher-income families and enrollment caps.

The state adopted income verification and signature The state adopted income verification and signature requirements, eliminated 12-month continuous eligibility for requirements, eliminated 12-month continuous eligibility for children, set six-month reviews of family income.children, set six-month reviews of family income.

The bulk of the waiver was never approved, but the proposal The bulk of the waiver was never approved, but the proposal to implement premiums on higher-income Medicaid families to implement premiums on higher-income Medicaid families and SCHIP children was OKd by CMS in late 2003.and SCHIP children was OKd by CMS in late 2003.

Outgoing Governor Locke defers Medicaid premiums until Outgoing Governor Locke defers Medicaid premiums until January 2005. January 2005.

In July 2004, SCHIP implemented a $5 monthly premium In July 2004, SCHIP implemented a $5 monthly premium increase per child (to $15 total per child, capped at three increase per child (to $15 total per child, capped at three children per family)children per family)




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 99

Medicaid premiumsMedicaid premiums

Family incomeFamily income Estimated Estimated enrollmentenrollment

Monthly premium Monthly premium under waiverunder waiver

0 to 150% FPL0 to 150% FPL No premiumsNo premiums

151-200% FPL151-200% FPL 80,00080,000 $10/month (*)$10/month (*)

201-250% FPL201-250% FPL 10,00010,000 $15/month (**)$15/month (**)

NOTES:NOTES:

(*) All premiums would have been subject to a three-child cap – a (*) All premiums would have been subject to a three-child cap – a maximum any individual family would have to paymaximum any individual family would have to pay

(**) SCHIP families were already paying $10/month(**) SCHIP families were already paying $10/month

FY2005 revenue estimated at $30 million for Medicaid, $1 million for SCHIP




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1010

Children’s coverageChildren’s coverage

Children’s Health ProgramChildren’s Health Program In 2002, Legislature ends Children’s Health In 2002, Legislature ends Children’s Health

Program Program Legislature appropriates $20 million for additional Legislature appropriates $20 million for additional

Basic Health slots for families and children Basic Health slots for families and children displaced from CHP and state-only family displaced from CHP and state-only family medical program. medical program.

More than 25,000 children lose fee-for-service More than 25,000 children lose fee-for-service Medicaid look-alike coverage. Medicaid look-alike coverage.

State outreach successfully transitions 12,400 State outreach successfully transitions 12,400 children into Basic Health. children into Basic Health.

By January 2005, enrollment falls to 5,700 – By January 2005, enrollment falls to 5,700 – most of them covered through community grant most of them covered through community grant programs.programs.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1111

PART THREEPART THREE

Governor Chris Governor Chris Gregoire commits Gregoire commits Washington State to Washington State to cover all children by cover all children by 20102010




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1212

A new era in eligibilityA new era in eligibility

Incoming Governor Gregoire indefinitely Incoming Governor Gregoire indefinitely postpones Medicaid children’s premiums in postpones Medicaid children’s premiums in January 2005.January 2005.

2006 Legislature later passes Governor’s 2006 Legislature later passes Governor’s request to abandon Medicaid children’s request to abandon Medicaid children’s premiums altogether.premiums altogether.

In March 2005, state re-institutes 12-month In March 2005, state re-institutes 12-month continuous eligibility for children.continuous eligibility for children.

Legislators re-establishes Children’s Health Legislators re-establishes Children’s Health Program (CHP) with funding for 4,300 children’s Program (CHP) with funding for 4,300 children’s slots beginning January 2006.slots beginning January 2006.

2006 supplemental budget provides additional 2006 supplemental budget provides additional funding to cover 14,000 children by October funding to cover 14,000 children by October 2006.2006.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1313

Restoring CHPRestoring CHPRenewed program began Jan. 1, 2006, but with higher than expected rates of denial

862

2,330

3,6144,285

4,839

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000Jan

-06

Mar-

06

May-0

6

Ju

l-06

Sep

-06

No

v-0

6

Jan

-07

Mar-

07

May-0

7

Actuals

Target

Higher Than Expected Denial Rate. • 39% of reviewed applications have been denied. • 48% of denials were because family had income above 100% of poverty level. • 34% of denials were for failure to complete application. • 18% of denials were because child above age 18 or was eligible for Medicaid.

Target

Actual




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1414

Status of children’s coverageStatus of children’s coverage Medicaid and SCHIP provide health insurance Medicaid and SCHIP provide health insurance

coverage for 1/3 of all children in the state.coverage for 1/3 of all children in the state. 50% of all children in households with incomes 50% of all children in households with incomes

under 250% of Federal Poverty Level (FPL).under 250% of Federal Poverty Level (FPL). 60% (two in three) of children in families 60% (two in three) of children in families

under 250% FPL are in public insurance under 250% FPL are in public insurance programs.programs.

Medicaid children’s caseload not increased at the rate Medicaid children’s caseload not increased at the rate assumed in earlier forecasts. assumed in earlier forecasts.

Medicaid Children’s coverage – state saw Medicaid Children’s coverage – state saw higher-than-expected exits from coverage higher-than-expected exits from coverage after tougher eligibility-review rules after tougher eligibility-review rules implemented.implemented.

Medicaid family coverage - lower entry rates Medicaid family coverage - lower entry rates and higher exit rates.and higher exit rates.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1515

Status of children’s coverageStatus of children’s coverage

Children’s program growth rates are expected to Children’s program growth rates are expected to remain above population growth rates during remain above population growth rates during FY2007-09.FY2007-09.

Federal Medicaid citizenship verification Federal Medicaid citizenship verification requirements will probably have repercussions requirements will probably have repercussions for children’s Medicaid caseload.for children’s Medicaid caseload.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1616

Status of children’s coverageStatus of children’s coverage

Comparison of Forecasts Children Covered through State-Financed Health Programs

450,000

470,000

490,000

510,000

530,000

550,000

570,000

590,000

610,000

630,000

3835

3

3844

3

3853

4

3862

6

3871

8

3880

8

3889

9

3899

1

3908

3

3917

3

3926

4

3935

6

3944

8

3953

9

3963

0

3972

2

3981

4

3990

4

Actuals

Jun06 forecast

Comparison of forecasts: Children covered through state-financed health programs

Governor’s eligibility policy implemented

Difference between baseline and June forecast = 78,238




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1717

Employer-Sponsored InsuranceEmployer-Sponsored Insurance

Part of Governor’s strategy is to partner with Part of Governor’s strategy is to partner with employers in order to offer coverage to all children.employers in order to offer coverage to all children.

Funded by 2006 Legislature.Funded by 2006 Legislature. Employer-Sponsored Insurance (ESI) pilot program Employer-Sponsored Insurance (ESI) pilot program

pays family’s portion of premiums for employer pays family’s portion of premiums for employer coverage of Medicaid dependents when arrangement coverage of Medicaid dependents when arrangement is cost-effective for the state.is cost-effective for the state.

Enrollment reached 1,283 clients in May 2006.Enrollment reached 1,283 clients in May 2006. Preliminary estimates show 37% reduction in monthly Preliminary estimates show 37% reduction in monthly

client costs.client costs. In utilization, that is a savings of $64 per client per In utilization, that is a savings of $64 per client per

month. month. Governor and Health Care Authority also are working Governor and Health Care Authority also are working

on health insurance options for small business.on health insurance options for small business.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1818

ESI on track to hit targetESI on track to hit target

Increase in ESI Coverage for Low-Income Families

0

1,000

2,000

3,000

4,000

5,000

6,000

Mo

nth

De

c-0

4

Ap

r-0

5

Au

g-0

5

De

c-0

5

Ap

r-0

6

Au

g-0

6

De

c-0

6

Ap

r-0

7

Au

g-0

7

De

c-0

7

Ap

r-0

8

Au

g-0

8

De

c-0

8

Ap

r-0

9

Actuals

Target




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 1919

Lessons learnedLessons learned

Integrated programs: Integrated programs: Washington had the advantage of Washington had the advantage of integrating children’s health programs regardless of funding integrating children’s health programs regardless of funding source. This allows a seamless transition with the same benefit source. This allows a seamless transition with the same benefit design as children move up in income levels. design as children move up in income levels.

Children’s outreach:Children’s outreach: In the 99-01 biennium, we received In the 99-01 biennium, we received $10 million from CMS for outreach. Growth in the CN-children’s $10 million from CMS for outreach. Growth in the CN-children’s caseload continued at a steady pace, above the growth in state caseload continued at a steady pace, above the growth in state population.population.

Implementation of SCHIP:Implementation of SCHIP: SCHIP got off to a late start SCHIP got off to a late start in 2000 because we were already covering children up to 200% in 2000 because we were already covering children up to 200% FPL under Medicaid. The program has remained small since there FPL under Medicaid. The program has remained small since there are fewer uninsured children at those income levels.are fewer uninsured children at those income levels.

CHP transition:CHP transition: The Legislature’s plan to move CHP The Legislature’s plan to move CHP (immigrant children) to the Basic Health Plan was ultimately (immigrant children) to the Basic Health Plan was ultimately unsuccessful. The families had no experience with managed care, unsuccessful. The families had no experience with managed care, they were switched to a subsidized-premium system, and they they were switched to a subsidized-premium system, and they eventually dropped out of coverage. eventually dropped out of coverage.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2020

Lessons learned, continuedLessons learned, continued

CHP revival:CHP revival: By the time the CHP program was By the time the CHP program was re-implemented, the demographics had changed. We re-implemented, the demographics had changed. We expected large numbers of unserved clients and developed expected large numbers of unserved clients and developed processes to deal with the crunch. So far, we have had processes to deal with the crunch. So far, we have had trouble meeting our targeted enrollments. trouble meeting our targeted enrollments.

FPL standards:FPL standards: One of the things that has changed is One of the things that has changed is the Federal Poverty Level (FPL) indicators. Today, many the Federal Poverty Level (FPL) indicators. Today, many families on minimum wage still exceed the 100% FPL families on minimum wage still exceed the 100% FPL standard.standard.

Income verification:Income verification: An experiment in 2003 ended An experiment in 2003 ended automatic annual eligibility for children, replacing it with automatic annual eligibility for children, replacing it with tighter income verification procedures and more frequent tighter income verification procedures and more frequent reviews. Research showed the decline in caseload was reviews. Research showed the decline in caseload was due to healthy eligible families dropping off the rolls. due to healthy eligible families dropping off the rolls.

Immigrant health:Immigrant health: Historically, CHP children cost us Historically, CHP children cost us about 20% less than Medicaid children. Pregnant about 20% less than Medicaid children. Pregnant immigrant women are among the healthiest members of immigrant women are among the healthiest members of the pregnant population. the pregnant population.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2121

APPENDIXAPPENDIX

Program characteristics of Program characteristics of children’s coverage in children’s coverage in Washington State.Washington State.

Programs based on Medicaid Programs based on Medicaid benefit design.benefit design.




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2222

Children’s program characteristicsChildren’s program characteristics

Medicaid ProgramMedicaid Program Coverage:Coverage: Citizen children up to age 19 in households Citizen children up to age 19 in households

up to 200% FPL ($33,200 for family of 3)up to 200% FPL ($33,200 for family of 3) Benefit design:Benefit design: Full-scope medical, dental, vision, Full-scope medical, dental, vision,

hearing behavioral health and EPSDT coverage. Long-hearing behavioral health and EPSDT coverage. Long-term care services for disabled children through State term care services for disabled children through State Plan and waiver services.Plan and waiver services.

Cost sharing:Cost sharing: None None Delivery system:Delivery system: Managed care “Healthy Options” Managed care “Healthy Options”

program, except for Foster Care and SSI and related program, except for Foster Care and SSI and related disabled children.disabled children.

Financing:Financing: Title XIX – 50% FMAP Title XIX – 50% FMAP Number of children:Number of children: 542,165 (Feb06) 542,165 (Feb06)




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2323


State Children’s Health Insurance ProgramState Children’s Health Insurance Program Coverage:Coverage: Citizen children up to age 19 in households Citizen children up to age 19 in households

between 200% and 250% FPL ($41,500 for family of 3)between 200% and 250% FPL ($41,500 for family of 3) Benefit design:Benefit design: Full-scope medical, dental, vision, Full-scope medical, dental, vision,

hearing, behavioral health, and EPSDT coverage.hearing, behavioral health, and EPSDT coverage. Cost sharing:Cost sharing: $15 per-month per-child premium, with $15 per-month per-child premium, with

three-child maximum three-child maximum Delivery system:Delivery system: Managed care “Healthy Options” Managed care “Healthy Options”

programprogram Financing:Financing: Title XXI – 65% FMAP Title XXI – 65% FMAP Number of children:Number of children: 11,825 (February 06) 11,825 (February 06)




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2424


Children’s Health ProgramChildren’s Health Program Coverage:Coverage: Non-citizen children up to age 18 in Non-citizen children up to age 18 in

households up to 100% FPL ($16,600 for a family households up to 100% FPL ($16,600 for a family of three)of three)

Benefit design:Benefit design: Full-scope medical, dental, vision, Full-scope medical, dental, vision, hearing, and EPSDT coverage. hearing, and EPSDT coverage.

Cost sharing:Cost sharing: None None Delivery system:Delivery system: Fee-for-service system (will be Fee-for-service system (will be

reviewed after one-year)reviewed after one-year) Financing:Financing: State-only program. State-only program. Number of children:Number of children: 4,839 (May 2006) 4,839 (May 2006)




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Seattle, Seattle,

June 24-27, June 24-27, 2006 2006 2525


Basic Health ProgramBasic Health Program Coverage:Coverage: Children up to age 22 in families up to 200% Children up to age 22 in families up to 200%

FPL ($33,200 for family of three)FPL ($33,200 for family of three) Benefit design:Benefit design: Inpatient and outpatient hospital, Inpatient and outpatient hospital,

physician services, laboratory and x-ray services, physician services, laboratory and x-ray services, chiropractic and physical therapy, chemical dependency chiropractic and physical therapy, chemical dependency and mental heath services. and mental heath services.

Cost sharing:Cost sharing: $15 co-payments for office visits; multi-tier $15 co-payments for office visits; multi-tier drug co-payments; and, 20% hospital, laboratory and x-drug co-payments; and, 20% hospital, laboratory and x-ray coinsurance with $150 deductible. $17 to $56 per-ray coinsurance with $150 deductible. $17 to $56 per-month premium depending on family income and health month premium depending on family income and health plan. plan.

Delivery system:Delivery system: Managed care (same plans as Managed care (same plans as Medicaid Healthy Options program).Medicaid Healthy Options program).

Financing:Financing: State-only programState-only program Number of children:Number of children: 13,705 -- does not include Medicaid 13,705 -- does not include Medicaid

BHP+ children BHP+ children (*)(*)( * )( * ) Parents enrolled in BHP are able to have their Medicaid eligible children receive full- Parents enrolled in BHP are able to have their Medicaid eligible children receive full-scope Medicaid coverage with no cost-sharing and be enrolled in the same health plan. scope Medicaid coverage with no cost-sharing and be enrolled in the same health plan. This is called BHP+ coverage.This is called BHP+ coverage.

washington state’s initiative: cover all children by 2010 robin arnold-williams, secretary...

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