Cindy Mann Georgetown University Health Policy Institute Center for Children and Families Washington, D.C. [email protected] ccf.georgetown.edu April 2009 Health Reform: Children and Medicaid
Dec 14, 2015
Cindy MannGeorgetown University Health Policy Institute
Center for Children and FamiliesWashington, D.C.
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