Cindy Mann Georgetown University Health Policy Institute Center for Children and Families Washington, D.C. crm32@georgetown.edu ccf.georgetown.edu April.

Cindy MannGeorgetown University Health Policy Institute

Center for Children and FamiliesWashington, D.C.

crm32@georgetown.educcf.georgetown.edu

April 2009

Health Reform: Children and Medicaid

MEDICAID’S ROLE FOR CHILDREN

Medicaid/CHIP’s Role for Children and Pregnant Women

Source: KCMU, KFF, and Urban Institute estimates; Birth data: NGA, MCH Update.

41%

51%

27%

Percent with Medicaid Coverage:

All Children

Low-Income Children

Births (Pregnant Women)

Source: Johns Hopkins University Bloomberg School of Public Health analysis of the National Health Interview Survey for the Center for Children and Families (March 1, 2008).

Trends in the Coverage Rate of Low-Income Children, 1997- 2006

Coverage Gains Have Come Equally from Medicaid & CHIP

Enrollment of Children in Public Coverage (Millions)

Source: KCMU & Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, 2007.

21.4

25.222.9

28.030.9

33.933.334.4

Source: Kaiser Commission on Medicaid and the Uninsured analysis of CBO March 2006 baseline and CMS Statistical Enrollment Data System, 2006; and CMS FY 2005 SCHIP Enrollment Report (July 12, 2006).

Children’s Enrollment in Medicaid and CHIP, 2005

Regular Medicaid SCHIP

28 million

6 million

1.7 million are in SCHIP-financed

Medicaid expansions

4.4 million are in separate SCHIP

programs

Medicaid Benefits

• Physician services• Laboratory and x-ray services• Inpatient hospital services• Outpatient hospital services• Early and periodic screening,

diagnostic, and treatment (EPSDT) services for individuals under 21

• Family planning • Rural and federally-qualified health

center (FQHC) services• Nurse midwife services• Nursing facility (NF) services for

individuals 21 or over

• Prescription drugs• Clinic services• Dental services, dentures• Physical therapy and rehab services• Prosthetic devices, eyeglasses• Primary care case management• Intermediate care facilities for the mentally

retarded (ICF/MR) services• Inpatient psychiatric care for individuals under

21 • Home health care services• Personal care services• Hospice services

“Mandatory” Items and Services “Optional” Items and Services

Source: Kaiser Commission on Medicaid and the Uninsured.

But For Children

• All recommended screenings (check-ups)

• All mandatory and optional treatment services: “All necessary health care, diagnosis services, treatment, and other measures…to correct or ameliorate defects, and physical and mental illnesses and conditions…”

Source: Federal Medicaid Law, Title XIX.

Low-Income Children are More Likely than Higher-Income Children to be in

Poor Health

92.8%

6.1%1.1%

9.0%1.7%

8.3%

89.4%

16.0%

3.9%

80.1%

25.0%

66.7%

Excellent Good Fair/Poor

400+% FPL 200-399% FPL 100-199% FPL 0-99% FPL

Source: 2003 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health, www.nschdata.org (accessed 3/31/09).

Health Status, 2003

The Effects of Poor Health?

• A child’s health is predictive of his/her health in adulthood

• Poor child health can limit educational attainment

• Poor health reduces annual earnings by 15 to 20%, either through reduced work hours or hourly wages

Source: C. Perry& L. Blumberg, “Making Work Pay II: Comprehensive Health Insurance for Low-Working Families,“ The Urban Institute (July 2008); and Robert Wood Johnson Foundation, “Overcoming Obstacles to Health” (February 2008).

MEDICAID AND HEALTH REFORM

Medicaid is a Major Purchaser of Health Care

16% 17%

40%

8%13%

Total PersonalHealth Care

Hospital Care ProfessionalServices

Nursing HomeCare

PrescriptionDrugs

Source: M. Hartman, et al., “National Health Spending in 2007: Slower Drug Spending Contributes to Lowest Rate of Overall Growth Since 1998,” Health Affairs 28(1): 246-261, January/February 2009. Note: Medicaid spending includes both the federal, the state, and the local portion of Medicaid, but does not include spending in SCHIP.

Total National

Spending(billions)

$1,878 $697 $702 $190 $228

Medicaid as a share of national personal health care spending, 2007:

Minimum Medicaid Eligibility Levels

133%133%

100%

42%

74%

0%0%

100%

200%

PregnantWomen

Pre-SchoolChildrenSchool-

Age

Children Parents

Elderly andIndividuals

with

DisabilitiesChildless

Adults

Note: Parent eligibility level reflects the level in the median state. The federal poverty level was $9,800 for a single person and $16,600 for a family of three in 2006. Source: Cohen Ross and Cox, 2007 and KCMU, Medicaid Resource Book, 2002.

Income eligibility levels as a percent of the Federal Poverty Level:

Decoding the Federal Poverty Line

For a family of 3, annually

For a family of 3, monthly

100% FPL $18,310 $1,526

150% FPL $27,465 $2,289

200% FPL $36,620 $3,052

Source: Federal Register, Vol. 74, No. 14, January 23, 2009.

42%

28%

15%

15%

The Majority of Uninsured Children are Low-Income

Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

Children = 8.9 million

Under 100%

100-199%

200-299%

300% +

70% below 200% FPL

Income Levels of Uninsured, 2007

Strengthening Medicaid

• Improving participation rates among eligible people

• Provider access/payment rates

• Financing

600,000

605,000

610,000

615,000

620,000

625,000

630,000

635,000

640,000

645,000

650,000

Apr-02Jun-02Aug-02Oct-02Dec-02Feb-03Apr-03Jun-03Aug-03Oct-03Dec-03Feb-04Apr-04Jun-04Aug-04Oct-04Dec-04Feb-05Apr-05

Source: Washington State Department of Social and Health Services, 2005.

January 2005: Administrative

order to return to 12-month

renewal cycle and establishes

continuous eligibility policy

Children's Enrollment in Washington's Public Insurance ProgramsApril 2002-April 2005

April 2003: State begins income verification

July 2003: 12-month continuous eligibility ends; 6-month renewal cycle replaces

12-month cycle

Medicaid Coverage Improves Children’s Access to Care

Source: Kaiser Commission on Medicaid and the Uninsured analysis of National Center for Health Statistics, CDC. 2007. Summary of Health Statistics for U.S. Children: NHIS, 2007. Note: Questions about dental care were analyzed for children age 2-17. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. An asterisk (*) means in the past 12 months.

1%4%

2% 3%

13%

28%

4%3% 3%2%

12%

6%3%

18%17%

32%

24%

13%

No Usual Souceof Care

PostponedSeeking CareDue to Cost*

Needed Care butDid Not Get itDue to Cost*

Last MD Contact>2 Years Ago

Unmet DentalNeed Due to

Cost*

Last Dental Visit>2 Years Ago

Employer/Other Private Medicaid/Other Public Uninsured

Source: S.Dorn, et al.,”Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses,“ Kaiser Commission on Medicaid and the Uninsured, April 2008. Note: a 1% increase in unemployment also equals a 3-4% decline in state revenues.

1%

Increase in National Unemployment Rate

=1.0

Increase in Medicaid & Other Public Enrollment

(million)

1.1

Increase in Uninsured(million)

Medicaid Reduces the Impact of Unemployment on Uninsurance

by Nearly One Half

“Dual” Eligibles$107.5 billion

41%

Total Medicaid Expenditures = $262.9 billion

Children$48.5 billion

18%

Adults$28.6 billion

11%

Other Aged and Disabled

$78.2 billion30%

“Dual” Eligibles Accounted for More Than 40% of Medicaid Spending in 2005

Source: J. Holahan, D. Miller, & D. Rousseau, “Rethinking Medicaid’s Financing Role for Medicare Enrollees,” Kaiser Commission on Medicaid and the Uninsured (February 2009). Note: Spending on prescription drugs for dual eligibles, which became a Medicare responsibility in 2006, is excluded in order to approximate the share of post-2005 Medicaid spending that is attributable to duals. However, because this amount also excludes “clawback” payments states began paying the federal government in 2006, this estimate is probably conservative.

Integrating Medicaid

• Coordinate/align enrollment with subsidies/tax credits for families above Medicaid eligibility

• Ensure Medicaid is at the table for– Quality initiatives– HIT– “Purchasing for value” initiatives

KEEPING WHAT WORKS AND FIXING WHAT NEEDS TO BE

FIXED

Meet Emily Demko

• Toddler with Down Syndrome

• Needs extensive care, including speech and physical therapy

New Fee Schedule in Utah’s CHIP Program – Modeled after Private

InsuranceFor families with incomes > 150% of FPL:• $500 - $1500 deductible• 50% for mental health service inpatient or outpatient care• 20% coinsurance for: inpatient or outpatient care; surgeon and

anesthesiologist services; ambulance; lab and x-ray services over $350 any dental care other than cleaning, x-ray, fluoride & sealants; home health; hospice; medical supplies

• 25% coinsurance for brand name drugs on approved list• $100 co-pay for ER visits (including emergencies)• $30 co-pay for urgent care center visit or specialist• $20 co-pay for physician; (other than specialist; no co-pay for well-child

care); vision and hearing screenings; physical therapy • $10 co-pay for generic drugs

Maximum Annual Out-of-pocket Expense Is Nearly 60% of Monthly

Gross Income

$1,373

$2,289

$0

$500

$1,000

$1,500

$2,000

$2,500

5% Cap Monthly Income

Taking Care of Children in Health Reform

• All children should be covered

• Medicaid plays a unique role for children

• Strengthen and integrate Medicaid while maintaining its key elements