1. Children’s Health Insurance Coverage and SCHIP Reauthorization Presentation for the University of Florida Medical College Council February 4, 2009 Jill Boylston Herndon, Ph.D. Institute for Child Health Policy Department of Epidemiology and Health Policy Research College of Medicine University of Florida

2. © 2009 Jill Boylston Herndon, all rights reserved. Children’s Insurance Coverage Nationally 2007 Source: Kaiser Family Foundation, statehealthfacts.org. Data Source: U.S. Census Bureau Current Population Survey.

3. © 2009 Jill Boylston Herndon, all rights reserved. Medicaid What is Medicaid? Federal-state health insurance program; established in 1965 as Title XIX of the SSA General guidelines established by the federal government Program requirements and eligibility established by each state Financed jointly by federal and state governments; federal match based on relative per capita income Means-tested – based on Federal Poverty Level; 100% FPL for a family of 4 in 2008 was approximately $21,200 (http://aspe.hhs.gov/poverty/index.shtml)http://aspe.hhs.gov/poverty/index.shtml Who’s Covered? Eligibility varies by state, but there are “mandatory” groups who must be covered including families meeting AFDC requirements, pregnant women and children younger than age 6 with family income at or below 133% FPL, children ages 6-19 in families with income up to 100% FPL, SSI recipients, and low-income Medicare beneficiaries States may establish “medically needy” groups. States may also expand coverage through Section 1115 Medicaid waivers. NOTE: Medicaid does not provide medical assistance for all poor persons (<100% FPL). Only those poor persons who are in one of the designated eligibility groups receive coverage.

4. © 2009 Jill Boylston Herndon, all rights reserved. Medicaid Enrollment and Expenditures By Enrollment Group, FY 2005 58.9 million enrollees 10% aged 14% disabled 26% adults 50% children Expenditures - $304 billion 26% aged 41% disabled 12% adult 17% children 4% unknown Source: Kaiser Family Foundation, http://www.statehealthfacts.orghttp://www.statehealthfacts.org

5. © 2009 Jill Boylston Herndon, all rights reserved. Recent Changes in Medicaid – Deficit Reduction Act of 2005 Citizenship documentation requirements Prior to DRA, 47 states allowed self-declaration Beginning July 1, 2006, documentation to prove citizenship and identity required for applications and renewals States have reported slowed enrollment growth and declines in enrollment; increased administrative costs; processing delays Premiums and cost sharing Prior to DRA, no premiums and very limited copayments Patients who have not paid premiums can be denied services Exemption is maintained for mandatory children and pregnant women Few states to date have imposed new cost sharing Increased flexibility in specifying benefit packages

6. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP: State Children’s Health Insurance Program What is SCHIP? Established under the Balanced Budget Act of 1997 as Title XXI of the SSA Federal-state health insurance program designed to reduce the number of uninsured children General guidelines established by the federal government Program requirements and eligibility established by each state Financed jointly by federal and state governments with federal match based on relative per capita income – higher federal match than for Medicaid Means-tested and not an entitlement program Cost sharing, including premiums, is permitted as long as it does not exceed 5% of family income Who’s Covered? Eligibility varies by state Some states chose to expand their Medicaid program using SCHIP funding; others created a separate program; some used a combination approach Most states cover children in families up to 200% FPL; the lowest is 150% FPL in North Dakota and the highest is 350% FPL in New Jersey

7. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP: Successes & Shortcomings Successes Popular program – received widespread support Reduced uninsurance rates among children and covers about 5 million children at a given point in time and 7 million during one year Improved access to care for children Positive spillover effects on Medicaid Shortcomings/Challenges State flexibility in program design has resulted in fluctuating policies that reflect states’ fiscal health Many Medicaid and SCHIP eligible children remain uninsured Data quality and evaluation of what works and what doesn’t varies across states Limited research on access, quality, and outcomes SCHIP coverage has substituted for private coverage in some cases Source: Kenney G., Yee J. 2007. “SCHIP at a Crossroads: Experiences to Date and Challenges Ahead.” Health Affairs. 26(2):356-369.

8. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP Reauthorization Reauthorization: what is it? The original SCHIP legislation was passed in 1997 and was authorized for 10 years. The program was due to be re-authorized in 2007. In 2007, Congress twice passed legislation to renew SCHIP; both times the legislation was vetoed by President Bush. The debate in 2007 was not about whether to continue the program; rather, it was about the extent to which it should be expanded. Congress extended the program through March 31, 2009, and SCHIP renewal legislation is currently in process.

9. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP Reauthorization Current Status of Legislation Congressional leaders have made reauthorization a priority. Both the House and the Senate have passed legislation that corresponds closely to the 2007 legislation. The House passed its version on January 14 by 289 to 139 votes. The Senate passed its version on January 29 by 66 to 32 votes. Next step: The Senate bill goes to the House. If the House passes the same bill, then it will go to the President. If the House does not pass, then it will go to Conference Committee to work out the differences.

10. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP Reauthorization Key Features of Legislation Extends coverage of the approximately 7 million children currently covered and expands coverage to approximately 4 million children over the next 4 ½ years (through FFY 2013) Provides state options for “Express Lane” eligibility and increases federal funding for outreach to enroll currently eligible but uninsured children Performance bonuses for increasing enrollment of currently eligible but uninsured children Preserves state option to determine income eligibility limit; but federal government’s contribution for children above 300% FPL is reduced to Medicaid matching rate rather than SCHIP rate Provides state option to cover low-income pregnant women, but prohibits new waivers to cover parents and childless adults

11. © 2009 Jill Boylston Herndon, all rights reserved. SCHIP Reauthorization Key Features of Legislation (cont.) Eliminates 5-year waiting period eligibility requirement for documented immigrant children and pregnant women (now state option) Extends Medicaid citizenship documentation requirement to SCHIP, but allows option of documenting citizenship by using existing databases (e.g., Social Security Administration) Provides for development of child-specific quality measures Requires SCHIP plans to include dental coverage and provides state option to offer stand-alone dental coverage to underinsured children (e.g., if ESI doesn’t cover) Increases SCHIP spending (relative to no expansions in coverage) by about $32 billion over 4 ½ years; funded by 62¢ per pack increase in federal cigarette tax

12. © 2009 Jill Boylston Herndon, all rights reserved. Children’s Insurance Coverage in Florida 2007 Source: Herndon J.B., Shenkman E.A. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida. Note: The Census Bureau estimates that 19.5% of children in Florida are uninsured.

13. © 2009 Jill Boylston Herndon, all rights reserved. Overview of Children’s Public Health Insurance Coverage in Florida: Florida KidCare Florida KidCare provides Medicaid (Title XIX) and SCHIP (Title XXI) coverage to the state’s uninsured children through the following four program components: Medicaid for Children - provides coverage for children birth through age 18 meeting the eligibility requirements with Title XIX funding; MediKids - a “Medicaid look alike” program that provides the equivalent of the Medicaid benefit package for children ages 1 through 4 with Title XXI funding; Florida Healthy Kids - provides health coverage for children ages 5-18 with Title XXI funding; and Children’s Medical Services Network (hereafter, CMSN) - provides coverage for children ages 0-18 who have special physical or behavioral health care needs and who are eligible for either Title XIX or Title XXI funding. Children in this program must meet specific clinical eligibility criteria.  KidCare covered 1,401,038 children ages 0-18 in January 2008.

14. © 2009 Jill Boylston Herndon, all rights reserved.

16. Uninsured Children in Florida 62% of uninsured children in Florida were without coverage for more than one year. The following segments of the child population are at disproportionate risk for being uninsured: children ages 12-18, Hispanic children, non-Hispanic black children, children in households below 200% of the FPL, and children whose parents are uninsured. Uninsured children are more likely to have parents who are self-employed, employed part-time, or employed seasonally than insured children. Uninsured children are less likely to have a usual source of care and more likely to use the ER and walk-in clinics as their usual source of care than insured children. 72% of uninsured children in Florida are eligible for KidCare coverage. Source: Herndon J.B., Shenkman E.A. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida.

17. © 2009 Jill Boylston Herndon, all rights reserved. Strategies for Increasing Children’s Health Insurance Coverage Marketing and outreach strategies to identify eligible but uninsured children and facilitate their enrollment Identify barriers to enrollment – e.g., lack of program awareness, barriers in the application process, communication gaps, language and cultural barriers, etc. Campaigns targeted toward the segments that are disproportionately uninsured and most difficult to reach (example: FHKP Act-Out for Health campaign) Streamline enrollment processes and provide application assistance “Express Lane” enrollment – auto-enrollment Improve program retention through outreach and streamlined renewal processes Facilitate family access to coverage For children who do not meet eligibility criteria and do not have access to other sources of coverage – options include: expand public coverage (e.g., broaden eligibility) provide buy-in options to public programs private market solutions – likely in the context of broader health care reform and improving access for the family as a whole

18. © 2009 Jill Boylston Herndon, all rights reserved. References and Resources For information on Medicaid, SCHIP, and Medicare and how these programs are administered, see: www.cms.hhs.gov.www.cms.hhs.gov Center for Children and Families. 2009. Georgetown University Health Policy Institute. “SCHIP Reauthorization in 2009: An Update on the Debate and Side-by-Side of Key Bills Under Consideration.” Available at: http://ccf.georgetown.edu/index/schipreauthorization.http://ccf.georgetown.edu/index/schipreauthorization Florida KidCare. http://www.floridakidcare.org.http://www.floridakidcare.org Florida Healthy Kids Program. http://www.healthykids.org.http://www.healthykids.org Herndon J.B., Vogel B., Bucciarelli R., Shenkman E. 2008. “The Effect of Premium Changes on SCHIP Enrollment Duration.” Health Services Research. 43(2):458-477. Herndon J.B., Vogel B., Bucciarelli R., Shenkman E. 2008. “The Effect of Renewal Policy Changes on SCHIP Disenrollment.” Health Services Research. 43(6):2086-2105. Herndon J.B., Shenkman E. 2008. “The Florida Children’s Health Insurance Study 2007.” Institute for Child Health Policy. University of Florida. Available at: http://www.healthykids.org/evaluation/institute.php?lang=ENG.http://www.healthykids.org/evaluation/institute.php?lang=ENG Kaiser Family Foundation, http://www.statehealthfacts.org.http://www.statehealthfacts.org Kenney G., Yee J. 2007. “SCHIP at a Crossroads: Experiences to Date and Challenges Ahead.” Health Affairs. 26(2):356-369. Nogle J.M., Shenkman E. “The Florida KidCare Evaluation.” Institute for Child Health Policy. University of Florida. http://www.ichp.ufl.edu.http://www.ichp.ufl.edu U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007, U.S. Census Bureau: http://www.census.gov/hhes/www/hlthins/hlthin07.html. http://www.census.gov/hhes/www/hlthins/hlthin07.html