Covering the Uninsured
with HIFA Waivers
Terri Coughlin
Sharon Long
John Graves
Annual Meeting of AcademyHealth
Seattle, Washington
June 25, 2006
Funded by the Centers for Medicare and Medicaid Services
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Health Insurance Flexibility and
Accountability (HIFA) Initiative
Goal: reduce number of low-income uninsured
Facilitate coverage expansion by:
• increasing flexibility in Medicaid and SCHIP (e.g.,
capping enrollment, modifying benefits, raising
cost sharing)
• encouraging premium assistance programs
• making unspent SCHIP and DSH allotments
available
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State HIFA Waiver Activity,
Spring 2006
District of
Columbia
Study States
Approved Waivers
Pending Waivers
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Early Look at HIFA Initiative
Examined demonstrations in 10 states
• motivation/goals
• key programmatic features: choice of expansion
population, use of benefit/cost sharing flexibility,
extent of premium assistance
• looked at early effects on uninsurance rates in
AZ and OR
Approach: case studies and CPS analysis
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Motivation and Goals Behind
HIFA Demonstrations
Overall, expanding coverage primary
motivation; not controlling cost
• existing mandate to expand coverage in
several states (ID, IL, ME, NM)
OR important exception
• limiting Medicaid costs major goal
• some planned coverage expansion
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Study States' HIFA Demonstrations,
December 2005
State
Approved Expansion Group
Implementation
Status
Projected Size of Size of Expansion
Expansion
December 2005
Arizona
Childless adults, parents
Yes
48,250
51,911
California
Parents
No
275,000
0
Colorado
Pregnant women
Yes
13,000
260
Idaho
Children
Yes
1,400
333
Illinois
Parents; children
Partially
300,000
114,503
Maine
Childless adults
Partially
11,500
13,634
Michigan
Childless adults
Yes
62,000
63,723
New Jersey
Parents
Yes
12,000
3,087
New Mexico
Uninsured
Partially
40,000
3,005
Oregon
Children, pregnant women, parents,
childless adults
Partially
60,000
43,554
Total
823,150
294,010
Key Features of Study States' HIFA Demonstrations
State
Current Enrollees Benefit
Package/Cost-Sharing Changes
Expansion Enrollees Benefit Package
Premium Assistance Program
Arizona
n/a
Medicaid
new pilot program
California
n/a
SCHIP
feasibility study
Colorado
n/a
SCHIP
none
Idaho
n/a
SCHIP; ESI
new program
Illinois
n/a
Medicaid; ESI
builds on existing program
Maine
n/a
Medicaid; ESI
builds on existing program
Michigan
n/a
reduced Medicaid; ESI
new program
New Jersey
increased cost sharing/benefits
reduced
equivalent HMO; ESI
builds on existing program
New Mexico
n/a
ESI
alternative to premium assistance
program
Oregon
increased cost sharing/benefits
reduced
reduced Medicaid; ESI
builds on existing program
Uninsurance Trends Before
and After HIFA
Looked at uninsurance trends in AZ and
OR, before and after HIFA
Used CPS data from 1997 to 2004
Two-year averages between 1997 to 2004
for the low-income population (less than
200% FPL)
Strictly a trend analysis, not causal
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Percent of Low-Income Uninsured Childless Adults,
Arizona and Comparison States
60%
Comparison
States
Percent Uninsured
50%
40%
Arizona
30%
20%
November
2001
10%
0%
1997/98
1998/99
1999/00
2000/01
Year
Source: Current Population Survey, 1997-2004.
Comparison states are: AL, AR, AK, CO, GA, IN, IA, KY, MD, MT, NE, NH, NM, ND, SC, SD, TX, VT, WV, and WY.
2001/02
2002/03
2003/04
Percent of Low-Income Uninsured Childless Adults,
Oregon and Comparison States
60%
Comparison
States
Percent Uninsured
50%
40%
Oregon
30%
November
2002
20%
10%
0%
1997/98
1998/99
1999/00
2000/01
Year
Source: Current Population Survey, 1997-2004.
Comparison states are: AL, AR, AK, CO, GA, IN, IA, KY, MD, MT, NE, NH, NM, ND, SC, SD, TX, VT, WV, and WY.
2001/02
2002/03
2003/04
Percent of Low-Income Uninsured Parents,
Oregon and Comparison States
60%
50%
Percent Uninsured
40%
Comparison
States
30%
Oregon
November
2002
20%
10%
0%
1997/98
1998/99
1999/00
2000/01
Year
2001/02
Source: Current Population Survey, 1997-2004.
The comparison states are: AL, AR, CO, FL, GA, ID, IN, IA, KS, KY, MD, MS, MT, NV, NH, NM, NC, ND, OK, SD, VT, WV, and WY.
2002/03
2003/04
Summary
HIFA holds considerable appeal
• strong political will among states for expanding coverage
• on the whole, states did not exercise full flexibility provided
under HIFA
Changed Medicaid/SCHIP landscape
• covering higher income parents and childless adults; expanded
premium assistance; mixed benefit packages
• research to understand impacts on beneficiaries and health
care system
300,000 covered under HIFA initiatives as of
December 2005
• below projected 800,000
• cover small share of country’s 34 million low-income uninsured
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