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9/8/2014
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The Future of Children’s Coverage: CHIP and Medicaid
Joe TouschnerSeptember 17, 2014
3:30 pm
Overview
o Our Children’s Coverage Success Story
o How the ACA Impacted the Children’s Coverage Landscape
o How Does CHIP Stack Up as the ACA Is Implemented?
o Looking Ahead
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Unprecedented Progress Covering Children Thanks to Medicaid/CHIP
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Source: “Table 124. No health insurance coverage among persons under age 65, by selected characteristics: United States, selected years 1984-2011” NHIS Trend Tables. Available at http://www.cdc.gov/nchs/data/hus/2012/124.pdf; Early Release of Selected Estimates Based on Data From the 2012 National Health Interview Survey. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201306.pdf
Unprecedented Progress Covering Children Thanks to Medicaid/CHIP
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
11.0%
12.0%
13.0%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
ACS
Lowest uninsured rate since Census started
collecting data in 1987!
Source: U.S. Census Bureau, Current Population Survey (CPS), Annual Social and Economic Supplement; American Community Survey (ACS) 4
CPS
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Even as more children have slipped into poverty, coverage rates have improved.
Source: American Community Survey, 2008 ‐ 2012 5
9.3%8.6% 8.0% 7.50% 7.20%
18.2%
20.0%21.6%
22.50% 22.60%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2008 2009 2010 2011 2012
Children's Uninsured Rate Children's Poverty Rate
10.9
7.6
8.3
8.8
5.312.4
4.1
5.9
6.6
10.113.2 5.7
7.3
16.6
10.1
8.0
7.9
9.3
8.5
5.8
6.46.9
5.8
6.0
11.1
7.0
8.4
4.0
4.7
3.3
4.6
5.3
5.5
3.5
13.9
3.9 5.6
3.85.1
3.5
3.8
4.5
4.02.8
1.7
1.4
8.8
4.0
3.9
5.4
Uninsured rate lower than national rate(31 states, including DC)
Uninsured rate higher than national rate(15 states)
5.1
No statistically significant difference from the national average (5 states)
Rate of Uninsured Children By State
Source: “Children’s Health Coverage on the Eve of the Affordable Care Act,” Georgetown Center for Children and Families
(November 2013).
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Children are much less likely to be uninsured than adults.
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8.0%
21.4%
7.5%
21.0%
7.2%
20.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Children Adults
2010 2011 2012
Source: American Community Survey, 2010 ‐ 2012
Today’s Children’s Coverage Landscape
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How Children Were Covered, 2012
Source: Georgetown University Center for Children and Families analysis of estimates from the US Census Bureau’s 2012 American Community Survey. Note: Coverage sources are not mutually exclusive. Children may have more than one source of coverage. Medicare excluded.
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Of 72.6 million children
Medicaid & CHIP, 37.4%
Employer, 51.4%
Individual Market, 7.1%
Uninsured , 7.1%
Medicaid & CHIP Employer IndividualMarket
Uninsured
EWB6
How Low-Income Children Were Covered, 2012
Source: Georgetown University Center for Children and Families analysis of estimates from the US Census Bureau’s 2012 American Community Survey. Note: Coverage sources are not mutually exclusive. Children may have more than one source of coverage. “Low-income” defined as under 200% of the Federal Poverty Level (FPL). Medicare excluded.
Of 32.8 million low-income children
Medicaid & CHIP, 67.3%
Employer, 21.7%
Individual Market, 4.5%
Uninsured , 10.0%
Medicaid & CHIP Employer IndividualMarket
Uninsured
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EWB7
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Medicaid and CHIP Enrollment, 2012
Source: Medicaid.gov: http://medicaid.gov/Federal-Policy-Guidance/Downloads/FY-2012-Childrens-Enrollment-04_09_13.pdf 11
CHIP, 8,148,397
Medicaid, 36,305,242
EWB8
Children’s Health Insurance Program (CHIP) Basics
• State-federal partnership
• Well-funded block grant – capped allotments
• States can use CHIP funds to cover kids in Medicaid or create separate CHIP program - most use some combination
• Enhanced federal match (65% - 81%)
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State CHIP Choices
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Medicaid Expansion Separate CHIP CombinationProgram
138% of FPL
State’s Maximum Eligibility Threshold for Children
Med
icaid
Med
icaid
CHIP
CHIP
M’caid
Medicaid and CHIP: Managed Care
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Managed Care Penetration, US
Medicaid for children, 2011
86.5%
Separate CHIP,2013
80.2%(state range: 2.5‐100%)
Source: Medicaid and CHIP Payment and Access Commission, Report to the Congress on Medicaid and CHIP, March 2014 and June 2014
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Medicaid and CHIP: Benefits for Children
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Children’s Benefits
Medicaid Children receive medically necessary services through the Early and Periodic Screening, Diagnosis, and Treatment benefit standard (EPSDT)
CHIP States select benefits by choosing a benchmark plan or Secretary‐approved coverage‐Dental benefits required
• Dental benefits required since CHIP Reauthorization (2009)
• All states had offered some benefits pre-CHIPRA, though some used $ cap or excluded orthodontics
• No rules yet to define benefit, but medically necessary orthodontics must be covered
• States may select benchmark plan or design their own benefit
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[D]ental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions
CHIP Dental Benefits
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• Option for states to offer supplemental dental benefits through CHIP to children with private medical coverage
• Iowa has adopted this option
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Supplemental Dental in CHIP
Where Does CHIP Stand in the Context of the ACA?
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Public Children’s Coverage in the U.S., 2014
*Median income threshold**Federal minimum under Medicaid
19SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, Updated by KCMU (forthcoming).
Affordable Care Act (2010)
• Keeps children’s coverage stable until 2019, assuming federal funding is in place (“Maintenance of Effort” or MOE).
• Funds CHIP through September 2015• Increases each state’s CHIP matching rate
by 23 percentage points, starting in October 2015
• New coverage options for parents through exchanges or Medicaid
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Medicaid and CHIP: Too integrated to be separated!
• State history and design decisions impact the roles Medicaid and CHIP play (Medicaid expansion, Separate CHIP, Combination)
• CHIP often a funding source rather than a program
• In 2013, 66% of CHIP-funded children in separate programs (MACPAC)
• Due to recent federal and state policy changes, we estimate less than half of CHIP kids will remain in separate programs for 2014
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What changes are on the horizon for CHIP?
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CHIP Timeline
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1997
CHIP Enacted
1997
CHIP Enacted
2007
CHIP Reauthorization
Vetoed; Temporary Funding Extended
2007
CHIP Reauthorization
Vetoed; Temporary Funding Extended
2009
CHIPRA Enacted: Funding
through 2013, Dental Benefits Required
2009
CHIPRA Enacted: Funding
through 2013, Dental Benefits Required
2010
ACA Enacted: Establishes
MOE, Extends CHIP Funding through 2015
2010
ACA Enacted: Establishes
MOE, Extends CHIP Funding through 2015
2015
CHIP Funding Expires
2015
CHIP Funding Expires
2016
Federal Match
Increases 23 Percentage
Points
2016
Federal Match
Increases 23 Percentage
Points
What Happens to CHIP Kids if Funding Runs Out?
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Enrolled children will fall under one of three scenarios: o Continuing coverage in Medicaid – state
receives lower match/less federal fundingo Move to marketplace coverage with
premium and cost sharing subsidies for families
o Fall into “family glitch”– Lose access to subsidized coverage altogether
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Visualizing What Happens to CHIP Kids if Funding Runs Out
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Public/Medicaid: EPSDT Private: Essential Health Benefits
Uninsured
What Happens to CHIP Kids if Funding Runs Out?
o CCF analysis with Center on Budget and Policy Priorities:o Roughly 4 million children remain in Medicaid,
states lose enhanced CHIP match
o Roughly 4 million kids would lose CHIPo Some eligible for Marketplace subsidies
o Many could become uninsured
o Over a year, 900,000 children in Texas alone would forgo CHIP coverage
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Key Questions for the Future of CHIP
o Why do we need CHIP if we have the exchanges?
o Why don’t we cover children with their parents in the exchange?
o Or at a minimum why don’t we let parents choose?
o Is kids coverage better in CHIP or the exchange?
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CHIP Affordability
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o For most kids in most scenarios, CHIP is significantly more affordable than marketplace plans
o CCF analysis of Arizona plans found that families paid more in QHPs than CHIP in 17 out of 18 scenarios
o 20 states limit cost-sharing in CHIP below required 5% of income cap
Sources: “Benefits and Cost Sharing in Separate CHIP Programs,” National Academy for State Health Policy & Center for Children and Families (May 2014).T. Brooks, M. Heberlein, & J. Fu, “Dismantling CHIP in Arizona: How Losing KidsCare Impacts a Child’s Health Care Costs,” Center for Children and Families (May 2014)
EWB9
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CHIP Affordability
29Source: “Comparison of Benefits and Cost Sharing in Children’s Health Insurance Programs to Qualified Health Plans,” Wakely Consulting Group (July 2014)
How Do CHIP Benefits Compare?
• States designed CHIP benefits with children’s needs in mind
• Most states use Medicaid benefits as a starting place for CHIP
• Most programs provide dental without significant limitations, vision/corrective lenses, mental health parity
30Source: “Benefits and Cost Sharing in Separate CHIP Programs,” National Academy for State Health Policy & Center for Children and Families (May 2014)
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Dental Benefits in Marketplaces• Unclear how well Marketplaces are meeting
children’s oral health needs• Benefits often defined by state’s CHIP benefit
or federal employees’ plan• Can children access the benefit?
• Fewer than 1 in 6 child enrollees took up stand-alone dental plans in FFMs and California
• State range: 2.6% - 36%• 1 in 3 medical plans in FFMs offer embedded
dental benefits• State range: 0% - 100%
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Sources: “Update: Take-up of Pediatric Dental Benefits in Health Insurance Marketplaces Still Limited,” American Dental Association (May 2014); Children’s Dental Health Project, Teeth Matter Blog (March 2014)
CHIP Coverage vs. Marketplaces for Kids
Evidence suggests: CHIP is more affordable
for families (in many cases, much more so)
Pediatric Essential Health Benefits (EHBs) have gaps
Dental plan choice challenges families
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Keeping Our Commitment to Kids
Keeping CHIP andMedicaid strong and stable will be vital to continued success covering kids in the coming years
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Simpson Family of Benton, AR
CHIP Resources• Dismantling CHIP in Arizona: How Losing
KidsCare Impacts a Child’s Health Care Costs (CCF, May 2014)
• Benefits and Cost Sharing in Separate CHIP Programs (CCF and NASHP, May 2014)
• Comparison of Benefits and Cost Sharing in Children’s Health Insurance Programs to Qualified Health Plans (Wakely Consulting Group, July 2014)
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For More Information
o Joe Touschner, Georgetown University Center for Children and Familieso [email protected]
o CCF website: ccf.georgetown.edu
o Twitter @GeorgetownCCF
o Say Ahhh! Our child health policy blog: ccf.georgetown.edu/blog/
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http://nadpconverge.org/evaluations
