Breast Health Summit: Update on Health Insurance

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Breast Health SummitUpdate on Health Insurance
Womens Health Access in Texas

• Anne Dunkelberg, Assistant Director
• Center for Public Policy Priorities
  (dunkelberg_at_cppp.org)
• May 4, 2006

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Texas Health Insurance System

• US Census Bureau Statistics (March 2005 CPS)
• Approximately 5.6 million Texans uninsured in
  2004
• 25.1 of Texans of all ages were uninsured
• 27.6 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)
• 9 below national average for lt 65 (54.2, vs.
  63.2)
• 9.3 below national average for lt18
• Only 12.8 of Texans below poverty have ESI
• Approximately 83 of Texas Medicaid recipients
  are below poverty (i.e. are unlikely to be
  insured w/o Medicaid)

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Health Insurance and Women

• Nationally, 19 of women ages 18-64 were
  uninsured in 2004, 80 of them in working
  families.
• In Texas 29 (about 2 million) of women ages
  18-64 were uninsured.
• 40 of Texas women 18-64 live below 200 FPL
  (40,000 pre-tax income for a family of 4).
• 52 of those low-income women are uninsured.
• More adult women today are covered through their
  own ESI than through their spouse, but women
  are less likely than men to get insurance through
  their own job.
• Uninsured women are
• 3.5 times more likely to go without care due to
  cost than insured women.
• twice as likely to have gone without a Pap test
  in the last 2 years than insured women. (Source
  KFF)

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Texas Uninsured by Income
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How Does Immigration Factor In?

• Immigrants are NOT the primary cause of Texas
  last-place ranking
• Census reported 2.47 million non-citizens
  (includes both legal residents and undocumented
  persons) 1.43 of them uninsured (57.8 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 20.8
  uninsured, (even if you left the non-citizens in
  the other states counts)
• Without immigrants, New Mexicos rate would drop
  to 19, and Californias to 14

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Texas Medicaid Who it Helps
December 2005, HHSC data.
Total enrolled 12/1/2005 2,707,681
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Medicaid in Texas Who it Helps

• Medicaid
• As of December 2005, 2.7 million Texans were
  enrolled in Medicaid
• 1.8 million were children
• about 89,700 of these children, or 5, were
  receiving disability-related Medicaid (98 of
  these on SSI)
• about 12,500 were pregnant teens (0.7 of the
  kids 0.5 of all Medicaid)
• 141,700 in TANF cash assistance families (5.2 of
  total caseload)
• OTHER 1.6 MILLION predominantly in WORKING POOR
  FAMILIES
• (about 1.3 million worker-headed families,
• Other 20 are headed by disabled parents or
  living on child support from non-custodial
  parent)
• 898,500 were adults
• 691,000 (77 of the adults) were elderly or
  disabled. Adults on SSI account for 60 of the
  aged and disabled recipients
• Other adults 91,500 maternity coverage 31,000
  TANF parents (1.1 of total caseload)
• NOTE there are fewer than 95,000 poor parents on
  Texas Medicaid- see pie chart. 63,000 either TMA
  (Transitional Medicaid Assistance) or parents who
  are at or below TANF income, but not receiving
  TANF cash assistance
• Childrens Health Insurance Program (CHIP)
• as of September 1, 2003 507,259 children
• as of April 1, 2006 292,681 (drop of 214,578,
  or 42)

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Income Caps for Texas Medicaid and CHIP, 2006
21,708
33,200
30,710/yr
30,710/yr
22,078/yr
222
200
16,600
7,476
185
185
2,256
3,696
133
100
74
13.6
22.3
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
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Why Very Few Poor Parents are Enrolled in Texas
Medicaid

• Texas Medicaid income cap for poor parents has
  not been increased by our Legislature for 20
  years.
• Working poor parents in Texas can get Medicaid
  now ONLY if they earn less than the
  legislatively-imposed income cap of 188 per
  month for a family of 3 (308 if one parent is
  working).
• This fixed dollar amount cap does not increase
  from year to year with inflation. In 2006 this
  income cap denies Medicaid to parents with
  incomes above 13.6 of the federal poverty
  income.
• Forces poor parents with high medical needs to
  choose between work and health care 15 hours of
  work per week at minimum wage (5.15 per hour)
  makes them too well off to get Medicaid.
• Texas can increase the Medicaid income limit for
  parents to any level it chooses, without any
  special federal approval. The only limiting
  factor is our willingness to put up our states
  share (about 40) of the costs.
• Today, fewer than 95,000 poor Texas parents get
  Medicaid, though
• there are about 836,000 poor parents in the state
  
• 61 of adult Texans 18-64 below poverty are
  uninsured
• 1.8 million Texas children have Medicaid coverage

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Medicaid Covers the Uninsurable

• Medicaid covers huge numbers of medically
  uninsurable Americans - (so average cost per
  client is higher than private market)
• Most Americans with mental retardation
• Most Americans with serious mental illness that
  began before or in early adulthood
• Most Americans in nursing homes ( 70 in Texas)
• Many Americans with disabilities acquired before
  adulthood, or in early adulthood
• Largest source of federal spending on HIV/AIDS
  (49 in 2005)
• Medicaid provides prenatal and maternity care for
  nearly half the children born in Texas and U.S
• However, Medicaid pays many providers well below
  private-market rates - (so cost per client is
  less than it would be in private market)
• Texas Physician reimbursement rates not increased
  in a decade

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Who is Left Out of Medicaid?

• Medicaid is not available to all poor or
  low-income Texans
• Must have limited income and assets in most cases
• Must qualify categorically (e.g. be pregnant and
  earning 185 FPL or less)
• VERY FEW working poor adults qualify for Texas
  Medicaid
• Categories not covered
• Non-disabled, childless adults
• 25 year-old single construction worker cannot get
  coverage, even if laid off
• Undocumented immigrants, except in an emergency
  (and must meet all income and categorical
  requirements)
• The undocumented 25 year-old single construction
  worker construction worker cannot get covered
• Legal immigrants, though Texas has option
• Lawful permanent resident of U.S. who entered U.S
  in 1998 cannot get coverage, even if severely
  disabled

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New CHIP Perinatal Coverage Planned

• Last-minute addition to the budget bill
  authorized this (Rider 70 HHSC).
• HHSC plans start-up 9/2006.
• The benefit and eligibility belong to the
  perinate, not the mother.
• Will provide prenatal care and delivery to U.S
  citizen women 186-200 FPL (not quite low enough
  to qualify for Medicaid).
• ALSO will pick up mothers 0-200 FPL who do not
  qualify for Medicaid maternity coverage because
  they are either a legal immigrant or an
  undocumented resident.
• This means that many of the covered perinates
  would already have been eligible for Medicaid at
  birth, i.e. all those with incomes below 185
  FPL.
• over 39,000 will be infants who would have been
  enrolled in Medicaid at birth under current
  rules, and
• about 8,300 are perinates whose prenatal care
  would not have been covered without this option
  (but would have qualified for CHIP after birth).

Center for Public Policy Priorities www.cppp.o
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Womens Health and Family Planning Medicaid
Waiver

• SB 747 by Senator John Carona
• Texas Medicaid will provide basic medical
  check-ups and birth control services to adult
  Texas women (ages 18 and older) up to 185 of the
  poverty line (thats 2,559 per month pre-tax
  income for a family of 3 in 2005).
• Currently in Texas, working mothers must live at
  or below 23 of the FPL to qualify for Medicaid
  (22 of poverty is less than 308 per month for a
  family of 3) and childless women cant qualify at
  all so the waiver could help many thousands of
  women who cant get full Medicaid benefits.
• Texas has the highest of uninsured women aged
  18 to 64 (29.3) in the nation (the U.S. average
  is 18.6)
• About 40 of all Texas women live below 200 of
  poverty, and 52 of them are uninsured.
• HHSC still negotiating details with CMS,
  tentative September 2006 start-up.

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Background Medicaid BCCPTA

• New Medicaid eligibility option enacted by
  Congress in 2000
• Linked to CDC public health program (NBCCEDP)
• Medicaid coverage for
• Women,
• Screened under the program (state options here)
• In need of treatment
• Under age 65
• Uninsured/underinsured
• Full Medicaid coverage until cancer treatment
  ends
• Enhanced federal match
• Medicaid income eligibility limits do not apply
  immigration eligibility restrictions do apply
• States have IMPORTANT OPTIONS which affect the
  number of women who get help-- variation is
  substantial

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The Awful Acronyms

• Federal law that created the Medicaid coverage
  option is the Breast and Cervical Cancer
  Prevention and Treatment Act (BCCPTA) this is
  how federal Medicaid authorities (CMS) refer to
  the Medicaid coverage.
• Just for todays presentation, I will refer to
  BCC Medicaid.
• Eligibility for BCC Medicaid is LINKED to the
  CDCs National Breast and Cervical Cancer Early
  Detection Program (NBCCEDP) this is how FEDS
  refer to this cancer screening program.
• In TEXAS, the NBCCEDP screening program is
  administered by the Texas Department of State
  Health Services (DSHS), and THEY refer to their
  screening program as Breast and Cervical Cancer
  Control Services (BCCCS). So you may see
  NBCCEDP and BCCCS used interchangeably in
  Texas.

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BCC Medicaid Links 2 Programs that are Quite
Different

• NBCCEDP public health, surveillance, outreach
• Target population non-screened women,
  regardless of insurance status age 40-64
  (breast), 18-64 (cervical)
• 15 of eligible population screened
• Provides clinical breast examinations,
  mammograms, pelvic examinations, and Pap tests
  through 42 Texas contractors
• Income eligibility limit of 200-250 FPL no cost
  to client
• Block grant funding limited
• BCC Medicaid coverage
• Target population uninsured women under 65
• Treatment oriented
• Not income limited
• Entitlement

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Screened Under the Program?

• The federal law says a woman must be screened
  under the NBCCEDP program to be eligible for the
  BCCPTA Medicaid coverage.
• BUT states actually have LOTS of flexibility to
  DEFINE screened under the program.
• There are 3 options for defining screened under
  the program.
• The impact of the different choices can be quite
  significant
• Texas chose 1, and Georgia 3,
• as a result Texas served 1,200 women over roughly
  the same period that Georgia served 4,200
• Even though our population at 22.3 million is
  over 2.5 times theirs at 8.7 million.

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Screened Under the Program Defined

• Three options
• 1. NBCCEDP (Title XV) funds paid for all or part
  of screening service (26 states, e.g. CO, IN. MT,
  PA, TX)
• 2. The individuals screening may not have been
  paid directly by NBCCEDP, but the provider is one
  who receives Title XV funds (13 states, e.g. IL,
  MD, NY)
• 3. Screening rendered by any other
  provider/entity designated by the state (11
  states, e.g. CA, GA, TN)

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Option 1 is Narrowest Consequences

• Excludes women screened elsewhere
• Uninsured women in Option 1 states (including
  Texas) who
• pay out of pocket or
• get charity care for screening, or
• Get diagnosed in the ER
• Become ineligible for BCC Medicaid if the
  provider listed above was not one of the 42
  NBCCEDP contractors.
• American Cancer Society toll-free help lines have
  identified numerous Texas women in this situation.

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Option 3

• Georgia uses Option 3
• recognizes any licensed provider
• Patients screened/diagnosed by any appropriately
  licensed provider are referred to an NBCCEDP
  contractor.
• Those meeting 200 FPL income eligibility
  standard are referred to Medicaid for BCC
  Medicaid.
• As a result, Georgia served 4,200 women over
  roughly the same period that Texas served just
  1,200.
• Even though our population, at 22.3 million, is
  over 2.5 times theirs (at 8.7 million).

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Next Steps for Advocates, Providers Increase
Public Awareness!

• The Womens health waiver, plus any increase in
  BCCC program funding, will provide many more
  women access to screening.
• So, it will be more important than ever for ALL
  providers, advocates, and CBOs to understand how
  the current option 1 pathway to BCC Medicaid
  works in Texas TO ENSURE THAT NOT A SINGLE
  ELIGIBLE UNINSURED WOMAN IS DENIED COVERAGE!
• This may require all of us partnering with the
  state to help educate all health care providers
  on the correct way to make sure a woman gets BCC
  Medicaid coverage.

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CMS QA on Medicaid BCCPTA

• http//new.cms.hhs.gov/MedicaidEligibility/
• downloads/breastandcervical4.pdf

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Next Steps for Advocates, Providers Opportunity
for Change

• Texas law (Senator Jane Nelsons SB 532, which
  became law in 2001) does not require Texas to use
  Option 1.
• Recent awareness of the problems with Option 1
  could result in the policy being changed to
  Option 3 without any action by the Legislature.
• If not changed at the agency level, watch for
  possible legislative action in January 2007.
• Messages of support to Governor, First Lady, and
  Senator Nelson may be helpful.

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Opportunities RIGHT NOW!

• Support state funding for Texas BCCC program to
  double the number of women screened.
• Support Option 3 to allow more uninsured women
  to access treatment for breast and cervical
  cancer through Medicaid.
• Support a Texas Tax system that will make it
  possible to find money for better womens health
  care programs!
• Get involved with outreach
• Letting immigrant mothers know about the new
  prenatal care program
• Helping women get breast and cervical cancer
  screening and treatment, and Family Planning/GYN
  care

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THINK BIG for the FUTURE

• Support Expansion of Full Medicaid benefits for
  Working Poor Parents
• Learn about, think about, talk about how Texas
  and the U.S. can work toward Health Security for
  everyone!

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