1. CHIPRA Just the Facts, PLEASE Cindy Mann Executive Director Georgetown University Health Policy Institute Center for Children and Families www.ccfgeorgetown.edu National Academy for State Health Policy October 2007

2. Achievements Sharp decline in uninsured rate among low -income children Coverage has let children secure the care they need Cost effective

3. Second Consecutive Year of Rising Number of Uninsured Children Uninsured rate of 11.2% Uninsured rate of 12.1% Source: Kaiser Commission for Medicaid and the Uninsured

4. AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MO KS OH IN NY IL KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA Source: As of September 25, 2007 based on CCF review of state initiatives. TX IL FL AL Implemented or Recently Adopted Legislation to Improve Children’s Coverage (26 states and DC) Considering Significant Proposal to Improve Children’s Coverage (3 states) States are Moving Forward

5. But A Showdown Nonetheless The White House Congress

6. Key Elements Eligibility for children Incentives/options to cover children already eligible but unenrolled Adult coverage Benefits Public/private

7. 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: CBO estimate of changes in SCHIP and Medicaid enrollment of children under the House Amendments to the Senate Amendments to H.R. 976, the Children’s Health Insurance Program Reauthorization Act of 2007 (September 24, 2007). Children Currently in SCHIP Who Could Lose Coverage Children Newly Eligible Through SCHIP Expansions Uninsured Children Already Eligible 3.8 Million Otherwise Uninsured Children CHIPRA Is Projected to Cover Nearly 4 Million Otherwise Uninsured Children 84% Eligible Under Current Program Rules

8. CHIPRA: Children’s Eligibility Income Current flexibility constrained Medicaid match for States covering children over 300% in the future August 17th directive replaced by new rules that take effect in 2010 Immigration statusNo change State employeesNo change AgeNo change

9. CHIPRA Targets Children Currently Eligible but Unenrolled 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 9 Million Uninsured Children

10. How? Performance Bonus Payments Based on: # of children covered (eligible as of 7/07) Medicaid v. SCHIP average per capita cost Must adopt 4 out of 7 designated policies New options Citizenship documentation “Express Lane” Outreach Grants Higher match for translation services

11. Coverage Gains Over the Past Decade Have Come Equally from Medicaid & SCHIP Enrollment of Children in Public Coverage (Millions) Source: CCF, Preliminary data. Based on children ever-enrolled over the course of a year. 21.0 23.5 22.3 25.2 27.2 32.3 30.8 34.0

12. CHIPRA: Other Populations Parents No new waivers Financing moved to separate allotment in 2010 Enhanced match through 2010 “Remap” beginning in 2011 if certain conditions met Childless Adults No new waivers (DRA) Funding moved to separate allotment in 2009 Regular (Medicaid) match in 2009 only for grandfathered individuals Possible Medicaid waiver (for grandfathered individuals) after 2009 Pregnant Women SCHIP option

13. CHIPRA: Benefits & Quality Dental CareRequired Mental Health Not required, but “benchmark” parity Quality Initiatives Development of measures and reporting standards

14. CHIPRA: Public/Private Integration Premium Assistance Option At least 40% Er contribution Voluntary for state/family New Tools State may require ERs to provide info on benefits Child with CHIP/Medicaid must be allowed to enroll in ESI (if offered), regardless of open enrollment periods Other Employer buy-in option Child losing CHIP/Medicaid can enroll in ESI (if offered) regardless of open enrollment periods

15. Where Do We Go From Here?

16. White House Veto WH proposed $4.8b in new federal funds Favors “free competitive marketplace”/private coverage Crowd out concern/income eligibility Objection to offsets

17. Focus on Low-Income Uninsured Children Limits “Crowd Out” Children Who Otherwise Would Have Had Coverage Otherwise Uninsured Children Source: CBO Estimate of Changes in SCHIP and Medicaid in Enrollment of Children under CHIPRA 2007 (September 25,2007. 5.8 Million Children CHIPRA “I think (the Senate Finance Committee) approach is pretty much as efficient as you can possibly get per new dollar spent to get a reduction of roughly 4 million uninsured children.” Peter Orszag, CBO Director (July 19, 2007)

18. States Have Reasons for Moving Forward Growth in Family Insurance Premiums Compared to the Federal Poverty Level Note: This data represents the cumulative growth in employee premium contributions for employer-sponsored family health insurance and the cumulative growth in the federal poverty level for a family of three. 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.

19. 400%+ FPL 200-399% FPL <200% FPL220,000 340,000 150,000 Source: Urban Institute for the Kaiser Commission on Medicaid and the Uninsured Distribution of the Increase in Uninsured Children, by Income, 2005-2006

20. Most Children Covered by SCHIP Have Family Incomes Below 200% FPL At or Below 200% FPL Above 200% FPL 6.7 million children enrolled in SCHIP, 2006 Note: The reporting classification of a child with family income above 200% FPL who Is determined to be eligible at or below 200% FPL due to deductions or disregards (I.e., a net income test) is up to the discretion of the state and constrained by their reporting systems. Source: CCF analysis using enrollment data from C. Peterson & E. Herz, Estimates of SCHIP Child Enrollees Up to 200% of Poverty, Above 200% of Poverty, and of SCHIP Adult Enrollees, Congressional Research Service (March 13, 2007).

21. A Wave of Support

22. Polling: America Wants a Strong Kids Coverage Bill 90%

23. Editorial Boards Nationwide 275+