1. 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 THE URBAN INSTITUTE

2. 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

3. Study States Approved Waivers Pending Waivers District of Columbia THE URBAN INSTITUTE State HIFA Waiver Activity, Spring 2006

4. THE URBAN INSTITUTE 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

5. THE URBAN INSTITUTE Motivation and Goals Behind HIFA Demonstrations existing mandate to expand coverage in several states (ID, IL, ME, NM) OR important exception limiting Medicaid costs major goal some planned coverage expansion Overall, expanding coverage primary motivation; not controlling cost

6. Study States' HIFA Demonstrations, December 2005

7. Key Features of Study States' HIFA Demonstrations

8. Uninsurance Trends Before and After HIFA THE URBAN INSTITUTE 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

9. Percent of Low-Income Uninsured Childless Adults, Arizona and Comparison States

10. Percent of Low-Income Uninsured Childless Adults, Oregon and Comparison States

11. Percent of Low-Income Uninsured Parents, Oregon and Comparison States

12. 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 below projected 800,000 cover small share of country’s 34 million low-income uninsured 300,000 covered under HIFA initiatives as of December 2005 THE URBAN INSTITUTE