Learning From Doing
Gene Lewit
The David and Lucile Packard Foundation
CHSR, Chicago, IL, June 27, 2009




Enacted 1997
Federal block grant program authorized for
10 years
Support for state programs to cover
uninsured children in families with incomes
too high to qualify for Medicaid
Flexibility to the states in program design
Uninsurance Rate of Children in the U.S. Has
Declined Because of Medicaid and SCHIP
16
14
12
10
8
6
4
2
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008






ASPE SCHIP Evaluation
CMS SCHIP Evaluation
Assessing the New Federalism @ UI
Many state specific evaluations
Child Health Insurance Research Initiative
(CHIRI)
Many others
The Child Health Insurance
Research Initiative (CHIRI™)
 9 studies of public child health insurance
programs and health care delivery systems,
funded by AHRQ, The David and Lucile Packard
Foundation, and HRSA.
 Emphasis on vulnerable children, e.g., minority
children and children with special health care
needs.
 Role of policymakers: provide input into research
and products, disseminate products, implement
findings.




Access and Quality in SCHIP and Medicaid
Enrollment and Disenrollment
Provider Participation
Special Populations
◦ Adolescents
◦ CSHCN
◦ Minority Children


SCHIP and Medicaid Design Choices
CHIRI website: www.ahrq.gov/CHIRI





Most SCHIP enrollees were from families with a full-time worker and incomes
equal to or below 150 percent of the Federal Poverty Level (FPL).
Minorities and children with special health care needs (CSHCN) comprised a
significant proportion of SCHIP enrollees.
SCHIP improved health care access and quality for low-income children and
these gains were generally shared by minority children and CSHCN.
Most SCHIP enrollees (over three quarters) retained public insurance
coverage after leaving SCHIP, but others became uninsured and few obtained
private insurance coverage.
SCHIP retention was increased by a simplified renewal policy that
automatically reenrolled children in SCHIP unless their families submitted
reenrollment forms indicating a change affecting their eligibility.



“CHIPRA” refers to the Children’s Health
Insurance Program Reauthorization Act of
2009
Extends CHIP Authorization to 2013 with
increased funding but does much more
The law, summary and other information is
available at: www.ccf.georgetown.edu.
4.1 Million Otherwise Uninsured Children
83%
Eligible
Under
Current
Program
Rules
Source: CBO, January 16,2009. Note: Average monthly enrollment for fiscal year 2013.
Newly
Eligible
Uninsured
Children
(700,000)
Already
Eligible
Uninsured
Children
(3,400,00)






New funding levels and formula
New options and funding to boost
participation
Eligibility changes
Benefit changes
Outreach initiative
New quality, access measures






New funding levels and formula
New options and funding to boost
participation
Eligibility changes
Benefit changes
Outreach initiative
New quality, access measures
9 Million Uninsured Children
4.4 Million are
Eligible for
Medicaid
1.7 Million
are Eligible
for SCHIP
Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules


Must have significant enrollment growth
Must have implemented 5 out of 8 policies:
◦
◦
◦
◦
◦
◦
◦
◦
No asset test
No in person interview
Joint application/process
12-month continuous eligibility
Administrative renewals
Presumptive eligibility
Express Lane
Premium assistance
Approximate Effective Medicaid Match
Rate for Additional Enrollment
Current Match Rate
Caseload Between
100-110% of Target
Caseload Above
110% of Target
62.14%
67.8%
85.8%


Citizenship documentation (now required in
CHIP)
Express Lane






New funding levels and formula
New options and funding to boost
participation
Eligibility changes
Benefit changes
Outreach initiative
New quality, access measures



August 17th directive is rescinded
States can set their income eligibility levels
◦ CHIP match for coverage of children up to 300%
of FPL (net)
◦ Medicaid match for higher income children
(exceptions for states already above 300%)
Federal matching funding for immigrant children
and pregnant women legally resident for less than
5 years
Medicaid and SCHIP Authorized Eligibility
Levels for Children, January 2009
WA*
MT*
VT
ND
OR
MN
ID
WY
NV
UT
AZ
CO*
IL
OK*
TX
IN*
MO
PA
OH*
KY
WV*
TN
AR
MS
AL
VA
NJ
DE
MD
NC*
DC
RI
CT
SC
GA
LA*
FL
HI
< 200% FPL
(4 states)
MA
NY
IA*
KS*
NM
AK
ME
MI
NE
CA
WI
SD
NH
200% FPL
(16 states)
201%-250% FPL
(9 states)
> 250% FPL
(21 states)
Source: D. Cohen Ross, A. Horn, & C. Marks, “Health Coverage for Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles,”
Kaiser Commission on Medicaid and the Uninsured (January 2008);updated by the Center for Children and Families.
Note: States with asterisks (*) have enacted, but not yet implemented to the levels shown.
State Covering Legal Immigrant Children
with State Funds
WA
MT
VT
ND
OR
MN
ID
WY
NV
UT
AZ
MA
NY
IA
CO
IL
KS
OK
NM
TX
PA
OH
IN
MO
KY
WV
AR
AL
VA
NC
TN
MS
AK
ME
MI
NE
CA
WI
SD
NH
NJ
DE
MD
RI
CT
DC
SC
GA
LA
FL
HI
States Covering Legal Immigrant Children Not
Eligible for Federal Funds (17 states, including DC)
Source: National Immigration Law Center, “Guide to Immigrant Eligibility for Federal Programs” (July 2007); updated by the Center for Children
and Families. Note: Alaska, Colorado, Florida, New Mexico, Ohio, and Wyoming provide coverage to some legal immigrants. Ohio provides
coverage to persons legally residing in the U.S. on August 22, 1996, and persons under an order of supervision. The state does not provide
coverage to most qualified immigrants who entered after August 22, 1996, even after completing the federal 5-year bar.
STATE
Total New
Enrollment
Previously
Eligible
Illinois
244,700
165,600 (68%)
Data from November 2005 - June 2008
Massachusetts
51,000
32,750
(64%)
11,000
(59%)
40,881
(83%)
Data from June 2006 - June 2008
Pennsylvania
19,000
Data from February 2007 - June 2008
Wisconsin
49,108
Data from February 2008 - May 2008
Source: Center for Children and Families, "Putting Out the Welcome Mat: Implications of Coverage Expansions for Already-Eligible
Children” (September 9, 2008).






New funding levels and formula
New options and funding to boost
participation
Eligibility changes
Benefit changes
Outreach initiative
New quality, access measures
Focus Turns to the States Moving Forward: 2008
WA
MT
VT
ND
OR
MN
ID
WY
NV
UT
AZ
MA
NY
IA
CO
IL
KS
OK
NM
TX
IN
MO
PA
OH
KY
WV
AR
AL
VA
NC
TN
MS
AK
ME
MI
NE
CA
WI
SD
NH
NJ
DE
MD
RI
CT
DC
SC
GA
LA
FL
HI
Enacted New Legislation/Took
Administrative Action to Improve Child and
Family Coverage (11 states)
Implemented 2007 Legislation to Improve
Child and Family Coverage (15 states)
Source: As of January 1, 2009 based on a review by the Center for Children and Families of state initiatives in 2007 and 2008.