SCHIP 101: Learning from 10 years of Experience

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SCHIP 101Learning from 10 years of Experience

• Liz Arjun
• State Health Policy Analyst
• Center for Children and Families
• Georgetown University Health Policy Institute
• www.ccfgeorgetown.org
• eaa37_at_georgetown.edu
• Tennessee First Focus Training
• June 14, 2007

2
Overview

• SCHIP History and Successes
• Lessons Learned
• Whats Next?

3
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

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SCHIP Enrollment, 1997-2004 (in millions)
State fiscal crisis and extensive SCHIP cutbacks
(2002 2004)
51st state implements SCHIP enrollment efforts
are strong states pursue family coverage
waivers (2000)
1.3 billion in unspent SCHIP funds lost
(2004)
HIFA initiative allows SCHIP funds to be used for
coverage of childless adults (2001)
SCHIP adopted (August 1997)
Source CCF and enrollment data from Kaiser
Commission on Medicaid and the Uninsured.
5
Trends in the Uninsured Rate of Low-Income
Children, 1997- 2005
Source CCF analysis of National Health Interview
Survey.
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Percent of Poor and Near-Poor Children with a
Usual Place of Care
Poor Children
Near-Poor Children
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.
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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).
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Coverage Gains Over the Past Decade Have Come
Equally from Medicaid SCHIP
Enrollment of Children in Public Coverage
(Millions)
34.0
32.3
30.8
27.2
25.2
23.5
22.3
21.0
Source CCF, Preliminary data. Based on
children ever-enrolled over the course of a year.
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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

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Childrens Eligibility for Medicaid/SCHIP by
Income, May 2007
NH
VT
ME
WA
ND
MT
MN
MA
OR
NY
ID
WI
SD
RI
MI
CT
WY
PA
NJ
IA
OH
NE
IN
NV
IL
DE
WV
UT
VA
MD
CO
CA
MO
KS
KY
NC
DC
TN
OK
SC
AR
AZ
NM
GA
AL
MS
TX
LA
AK
FL
HI
gt 200 FPL (18 states)
lt 200 FPL (9 states)
200 FPL (24 states including DC)
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.
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Tennessee Medicaid 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.
12
Children's Enrollment in Washington's Public
Insurance Programs, April 2002-October 2005
January 2005 Administrative order to return to
12-month renewal cycle and establishes continuous
eligibility policy
April 2003 State begins income
verification
July 200312-month continuous eligibility ends
6-month renewal cycle replaces 12-month cycle
Source Washington State Department of Social and
Health Services, 2005, updated 2006.
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Enrollment in Louisiana's Medicaid
Program October 1998 - January 2005
June 2000 Trained workers in new philosophy
June 2001 Baseline report re renewal
July 2001 New renewal procedures calls re
renewal forms not returned, ex-parte for LaChip
July 2000 Ex-Parte renewal for
children losing cash benefits
May 2000 Reasonable certainty standard
October 2003 Telephone renewals, rolling
renewals
March 2003 Reasonable certainty for renewal
Source Louisiana Department of Health and
Hospitals Monthly Enrollment Reports, 2005
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Medicaid SCHIP are Reaching an Increasing Share
of Eligible Children
Participation Rate of Eligible Children in
Medicaid SCHIP
1997 1999 2002
1999 2002
SCHIP
Medicaid
Source L. Dubay analysis of 1997,1999,2002
National Survey of Americas Families.
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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).
16
SCHIP Spending is Rapidly Outpacing New Funds
Being Made Available
(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.
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With 9 Million Uninsured Children, More Needs to
Be Done
Childrens Health Care Coverage, 2005

• 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.

77.9 Million Children Under 19
Source CCF analysis of CPS 2006 March
Supplement and Campaign for Childrens Health
Care, No Shelter from the Storm Americas
Uninsured Children (September 2006).
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What Is Next for Childrens 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

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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
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States are Moving Forward
NH
VT
ME
WA
MT
ND
MN
MA
OR
NY
ID
WI
SD
RI
MI
CT
WY
PA
NJ
IA
OH
NE
IN
NV
DE
IL
WV
VA
UT
MD
CO
CA
MO
KS
KY
NC
DC
TN
SC
OK
AR
NM
AZ
GA
AL
MS
TX
LA
AK
FL
HI
Implemented or Recently Adopted Legislation to
Improve Childrens Coverage (18 states and DC)
Considering Significant Proposal to Improve
Childrens Coverage (11 states)
Source As of June 8, 2007 based on CCF review of
state initiatives.
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Key State Strategies

• Enrolling and retaining eligible children
• Increasing eligibility
• Integrating with private coverage

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Americans Strongly Support Covering Children

• 84
• New York Times, March 2, 2007

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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)

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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?

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Timeline for Congressional Action??
House Energy and Commerce Committee
No new funds available
Senate Finance Committee
Senate Floor
House Floor
Conference
Late June
After July 4
July
Late July
August
Sept 30
Note These dates are all tentative