1. Children’s Health Coverage: Moving Forward in Uncertain Times National Association For Children’s Behavioral Health "Doing the Right Thing Right: Children’s Behavioral Health”

2. Children’s Coverage: Moving Forward in Uncertain Times Cindy Mann Georgetown University Health Policy Institute Center for Children and Families Washington, D.C. crm32@georgetown.edu ccf.georgetown.edu

3. Achievements Sharp decline in uninsured rate among low-income children, as the result of Medicaid and SCHIP Coverage has helped children secure the care they need

4. Trends in the Uninsured Rate of Low- Income Children, 1997 - 2005 Source: Georgetown CCF analysis based on data from the National Health Interview Survey, November 2006. Beginning in 2004, the NHIS changed its methodology for counting the uninsured. This results in the data for 2004 and later years not being directly comparable to the data for 1997 – 2003.

5. Coverage Gains Over the Past Decade Have Come Equally from Medicaid & SCHIP Enrollment of Children in Public Coverage (Millions) Source: KCMU & Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, 2007. 21.4 25.2 22.9 28.0 30.9 33.9 33.3 34.4

6. 15.1 to 20% Uninsured (14 states) 0 to 15% Uninsured (24 states + DC) >20% Uninsured (12 states) National Average = 19.3% Note: Low-income is defined as less than 200% of the federal poverty level. *Due to small sample size, all estimates are for CO, CT, DE, MT, NV, NH, NM, ND, VT, WY are imprecise, i.e., they have large standard errors, and should be interpreted as approximations. Source: Health Insurance Coverage in America, 2006 Data Update. Kaiser Commission on Medicaid and the Uninsured, October 2007. The Job’s Not Done… Uninsured Rates Among Low-Income Children by State, 2005-2006 AK HI TX NM*AZ CA NV* WA OR ID MT*ND* SD CO* UT OK KS NE WY* AR LA MSAL GA FL MO IA MN IL IN TN KY SC OH WI MI NC VA PA NY ME DC MD DE* NJ CT* VT* NH* RI MA WV

7. Expanding Coverage

8. A Wave of Support

9. Source: As of January 31, 2008 based on a review by the Center for Children and Families of state initiatives in 2006 and 2007. States Are Moving Forward (2006-2007) Implemented or Recently Adopted Legislation to Improve Children’s Coverage (29 states including DC) FL NC SC GA LATX AL AR KS OKAZ TN MS NV UT CO NM CA WY ID WA OR ND SD NE MT MN IA MO IN MI WI IL ME OH KY HI AK NY PA WV VA CT NJ DE MD RI NH VT DC MA

10. But A Federal Showdown Nonetheless The White House Congress

11. What Were the Issues? Coverage of undocumented children Coverage of parents/adults Coverage of children with income over 200% of FPL –Crowd out –Public versus private

12. Note: Average monthly enrollment for fiscal year 2012; SCHIP & Medicaid would cover 5.8 million children when reductions in other coverage are included; numbers may not sum due to rounding. Source: Congressional Budget Office estimate of changes in SCHIP and Medicaid enrollment of children under the Children’s Health Insurance Program Reauthorization Act of 2007 (October 24, 2007). Children Currently in SCHIP Who Otherwise Would Lose Coverage Children Newly Eligible Through SCHIP Expansions Uninsured Children Already Eligible 3.9 Million Otherwise Uninsured Children “CHIPRA 2” Was Projected to Cover Nearly 4 Million Otherwise Uninsured Children 87% Eligible Under Current Program Rules

13. Characterizations of SCHIP Reauthorization Legislation “This is a bipartisan compromise. It has broad support from Republicans and Democrats. It will help as many as 4 million low- income uninsured children…..It puts the lowest income children first in line….. Here's what it's not: It's not a government takeover of the health system. It does not undermine immigration policy. It's not expanding the program to cover high income kids.” — Senator Charles Grassley (R- Iowa) on the Senate Floor, 9/27/07

14. A Large Majority of Congress Supported The Reauthorization Bill (Vote on first major SCHIP reauthorization bill) Source: Roll No. 906 in the House of Representatives (September 25, 2007) and Record Vote No. 353 in the Senate (September 27, 2007) which sent H.R. 976, the Children's Health Insurance Program Reauthorization Act of 2007, to President Bush who vetoed it on October 3, 2007.

15. Where Are We Now?

16. Projected Growth in Federal SCHIP Expenditures in FY2008 0-6.1% growth (3 states & DC) FL NC SC GA LATX AL AR KS OKAZ TN MS NV UT CO NM CA WY ID WA OR ND SD NE MT MN IA MO IN MI WI IL ME OH KY HI AK NY PA WV VA CT NJ DE MD RI NH VT DC MA Note: This chart shows the projected increase in SCHIP spending in FY08 from actual FY07 spending. In 2008, the projected growth in per capita national health care expenditures is 6.1%. Source: Center for Children and Families analysis of actual FY07 spending data and November 2007 projections of FY08 spending submitted to the Centers for Medicare and Medicaid Services. >100% growth (4 states) 20-100% growth (16 states) 6.1-20% growth (20 states) Negative growth (7 states)

17. Federal Roadblock

18. CMS “August 17 th Directive” Issued August 17 th, 2007 without notice or opportunity to comment In effect, makes it difficult or impossible for states to cover more moderate- income children Major shift in longstanding SCHIP policy Highly controversial and already a source of litigation

19. At Least 23 States Are Affected by the “August 17th” CMS Directive Expansion states already negatively impacted (6 states) FL NC SC GA LATX AL AR KS OKAZ TN MS NV UT CO NM CA WY ID OR ND SD NE MT MN IA MO IN MI WI IL ME OH KY HI AK NY PA WV VA CT NJ DE MD RI NH VT DC MA Source: Center for Children and Families, “Moving Backward: Status Report on the Impact of the August 17 SCHIP Directive To Impose New Limits on States’ Ability to Cover Uninsured Children,” (December 2007) States with approved plans that must comply by August 2008 (14 states including DC) Expansion states with 2008 implementation dates (4 states) WA

20. The Cost of Living Varies Widely Across the United States Note: In 2007, 200% of the federal poverty level for a family of three was $34,340 annually. Source: Center for Children and Families analysis of ACCRA cost of living index for the first quarter of 2007. The cost of goods and services worth $34,340 (200% FPL for a family of three) in the average city, adjusted for the cost of living. 200% FPL for a family of 3

21. The Growing Affordability Gap Between 200% FPL and the Cost of Private Coverage Note: This data represents the cumulative growth in employee premium contributions for employer-sponsored family coverage and the federal poverty level for a family of three, compared to the cumulative growth in the federal poverty level adjusted each year by the federal government. Source: Agency for Healthcare Research and Quality estimates of 1996-2005 Medical Expenditure Panel Survey Insurance Component Tables, generated using MEPSnet/IC (August 21, 2007); and CCF analysis of 1996-2005 Federal Poverty Guidelines.

22. Growth in the Uninsured Driven by Low & Moderate-Income Children 31% have incomes below 200% FPL Source: Urban Institute tabulations of 2006 and 2007 Annual Social and Economic Supplement to the Current Population Survey from J. Holahan & A. Cook, “What Happened to the Insurance Coverage of Children and Adults in 2006?,” Kaiser Commission on Medicaid and the Uninsured (September 2007). Of the 710,000 Newly Uninsured Children in 2006: 21% have incomes at or above 400% FPL 47% have incomes from 200% to 399% FPL

23. And in the States…

24. Most Uninsured Children Are Already Eligible for Medicaid or SCHIP 4.4 Million Eligible for Medicaid 1.7 Million Eligible for SCHIP Source: L.Dubay analysis of March 2005 Current Population Survey using July 2004 state eligibility rules 9 Million Uninsured Children 2.9 Million Ineligible for Medicaid/SCHIP

25. Source: E. McNichol and I. Lav, “22 States Face Total Budget Shortfall of At Least $39 Billion in 2009; 6 Others Expect Budget Problems.” Center on Budget and Policy Priorities, revised March 14, 2008. More Than 25 States Project or Expect Budget Shortfalls FL NC SC GA LATX AL AR KS OKAZ TN MS NV UT CO NM CA WY ID WA OR ND SD NE MT MN IA MO IN MI WI IL ME OH KY HI AK NY PA WV VA CT NJ DE MD RI NH VT DC MA Projected Gap in FY 2009 Expect Gap in FY 2009, Size Unknown Expect Gap in FY 2010

26. Some States Still Moving Forward on Children’s Coverage States that have enacted or are now considering coverage improvements (2008) AlaskaArizona ColoradoIowa KansasMinnesota MontanaNew Jersey New York Utah

27. More Federal Roadblocks

28. Federal Administrative Actions CMS regulations (e.g., TCM, Rehab, School based services, DRA) Audits, deferrals, disapprovals More coming?

29. State State coverage initiatives Meaningful efforts to enroll and retain eligible children Assuring access to care and making EPSDT work for all children Federal Addressing regulations/directive Fiscal/FMAP relief SCHIP reauthorization Broader health reform It’s Time to Move Forward, Not Backward