Transcript Slide 1

1
The Nuts and Bolts of the
Texas CHIP Coalition/
Insure Texas Kids Campaign
Agenda for the 80th Texas Legislature
Building on the Success of Texas Medicaid and CHIP
House Committee on Human Services
Austin, Texas
March 1, 2007
Anne Dunkelberg, Associate Director
([email protected])
900 Lydia Street - Austin, Texas 78702
Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org
Center for Public Policy Priorities
www.cppp.org
2
Uninsured Texas Children:
We CAN Cut the Number in Half by Enrolling
Kids Who are Eligible Right Now
•Texas is home to nearly 1.4 million uninsured children.
• 2/3 of these uninsured Texas children are below 200% of the federal
poverty line, despite Medicaid and CHIP.
•More than HALF our uninsured Texas Kids Could be enrolled in
Medicaid or CHIP today! (Adjusting for ~230,000 undocumented kids; another
160,000 legal immigrant (LPR) children can participate in CHIP (Pew Hispanic Center)).
Texas Children who are Uninsured, 2004-05 – U.S. Census
All incomes, under age 19 (0-18*; 2-year
average 2004-05 Census CPS)
20.4%
1.367 million
< 200% FPL; under age 19 (0-18; 2-year
average 2004-05 Census CPS)
28% of <200%;
13.4% of all
kids
919,000
Center for Public Policy Priorities
www.cppp.org
3
CHIP and Medicaid: Helping Texas Kids
As of February 2007:
• 1.77 million Texas children (under age 19) were enrolled in Medicaid
•
•
•
•
about 100,700 of these children get Medicaid because of a serious disability
About 122,000 in TANF cash assistance families (7% of the kids)
About 12,700 pregnant teens (less than 1% of the children)
Other 1.53 MILLION predominantly in WORKING poor families
• 325,479 Texas children were enrolled in CHIP.
“CHIP stands on the broad shoulders of Medicaid”
That’s 2.09 million Texas children –
nearly one-third of all our kids.
Center for Public Policy Priorities
www.cppp.org
4
Income Caps for Texas Medicaid and CHIP, 2006
250%
200%
$21,708
$30,710/yr $30,710/yr
$22,078/yr
150%
100%
$16,600
$33,200
222%
200%
Long
Term
Care
CHIP
$7,476
185% 185%
133%
50%
100%
$2,256
$3,696
13.6% 22.3%
74%
0%
Pregnant Newborns Age 1-6 Age 6-18 TANF Working SSI (aged
Women
parent of Parent of
or
2, no
2
disabled)
income
Mandatory
Optional
Income Limit as Percentage of Federal Poverty Income
Annual Income is for a family of 3,
except Individual Incomes shown for SSI and Long Term Care
Center for Public Policy Priorities
www.cppp.org
Texas Kids’ Uninsured Rate Drops,
Thanks to CHIP and Medicaid
BEFORE CHIP and streamlined Children’s Medicaid
In 1997, When Congress created the CHIP Block Grant, U.S. Census
estimated that:
• 24%-25% of Texas children were uninsured (about 1.4 million children),
– and over three quarters (76%) of these were in families at or below 200% FPL.
•
There were about 5.95 million Texas children (under age 19).
SINCE CHIP and Streamlined Children’s Medicaid:
• 20.4% of Texas children under age 19 (1.37 million) are uninsured
– just over two-thirds (68%) are in families below 200% FPL.
•
There are about 6.6 million Texas children (under age 19).
Texas CHIP and streamlined children’s Medicaid have provided
health coverage for about 1 million more Texas children.
Uninsured Texas children below 200% FPL have dropped from 35%
to 29% (kids potentially served by children's Medicaid and CHIP) .
Center for Public Policy Priorities
www.cppp.org
5
6
The Insure Texas Kids Campaign and the Texas
CHIP Coalition urge the following plan of action
for the 80th Texas Legislature:
• Implement 12 months continuous eligibility for CHIP and
Children’s Medicaid
• Eliminate bureaucratic roadblocks to encourage personal
responsibility and help low income families achieve selfsufficiency:
– Fix problems with the Integrated Eligibility System to prevent eligible
kids from losing CHIP and Medicaid coverage
– Eliminate the CHIP asset test
– Eliminate the CHIP 90 day delay of coverage for uninsured children
– Deduct childcare and child support expenses when calculating income
for CHIP
• Provide adequate reimbursement for Medicaid and CHIP
providers
• Invest in outreach and education to ensure that all eligible
children get the care that they need
Center for Public Policy Priorities
www.cppp.org
7
Texas Child Medicaid Enrollment
(February 2001-February 2007)
Simplified Enrollment
begins
High:
1,838,239
1,900,000
now:
1,769,244
1,600,000
1,300,000
b
7Fe
-0
6
6
O
ct
n0
6
Ju
b0
-0
5
Fe
5
O
ct
n0
5
Ju
b0
-0
5
Fe
4
O
ct
n0
4
Ju
b0
-0
3
Fe
3
O
ct
n0
3
Ju
b0
-0
2
Fe
2
O
ct
n0
2
Ju
b0
-0
1
Fe
1
O
ct
n0
Ju
Fe
b0
1
1,000,000
Source: Texas Health and Human Services Commission
Center for Public Policy Priorities
www.cppp.org
8
Texas CHIP Enrollment
(May 2000-February 2007)
Highest, 5/02:
529,271
600,000
9/03:
507,259
2/07:
325,479
400,000
200,000
Se
M
ay
-0
0
p0
Ja 0
nM 01
ay
-0
Se 1
p0
Ja 1
nM 02
ay
-0
Se 2
p0
Ja 2
nM 03
ay
-0
Se 3
p0
Ja 3
nM 04
ay
-0
Se 4
p0
Ja 4
nM 05
ay
-0
Se 5
p0
Ja 5
nM 06
ay
-0
Se 6
p0
Ja 6
n07
0
Source: All figures from Texas Health and Human Services Commission;
Compares most recent month with September 2003
Center for Public Policy Priorities
www.cppp.org
9
Texas Child Medicaid and CHIP Enrollment
6.5
Enrollment (millions)
5.5
Estimated child population growth
of almost 70,000 per year
2.5
4.5
Sept. ’03:
2,150,543
3.5
2.0
2.5
Combined CHIP/Child
Medicaid Enrollment
Feb. ’07:
2,094,723
pr
0
A
n
Ja
Ju 2
l0
O 2
ct
Ja 02
n
0
A 3
pr
0
Ju 3
l0
O 3
ct
Ja 03
n
0
A 4
pr
0
Ju 4
l0
O 4
ct
0
Ja 4
n
0
A 5
pr
0
Ju 5
l0
O 5
ct
0
Ja 5
n
0
A 6
pr
0
Ju 6
l0
O 6
ct
Ja 06
n
07
0.5
02
1.5
1.5
Child population (millions)
3.0
Sources: Enrollment from Texas Health and Human Services Commission;
Texas State Demographer's 0-17 Population Estimates
Center for Public Policy Priorities
www.cppp.org
10
Implement 12 months continuous eligibility
for CHIP and Children’s Medicaid
• Federal Medicaid law allows states to offer periods of guaranteed eligibility
up to 12 months. Re-certification is required at least every 12 months.
• 12-month eligibility for kids would allow Texas’ struggling private and
public eligibility systems to cut workload in half: from 4.2 million renewals
per year, to 2.1 million.
• As you have heard today, 12 month coverage dramatically improves
continuity of care for children, and reduces the average cost per child.
What Other States Do: Seventeen states offer 12-month continuous coverage
for children’s Medicaid, and 25 states do so for CHIP. Texas provides 6
months of continuous coverage in both children’s Medicaid and CHIP. (36
states including Texas operate separate CHIP programs, and the other 14 use
their CHIP funds to expand children’s Medicaid.)
Center for Public Policy Priorities
www.cppp.org
11
Implement 12 months continuous eligibility
for CHIP and Children’s Medicaid
• Does the shorter 6-month period reduce state budget costs
by shifting kids more quickly to CHIP, with its higher
federal match rate?
• HHSC data from 2004 showed that the number of kids
moving from CHIP to Medicaid (with a lower match) each
year is far higher than the number of children moving
from Medicaid to CHIP, resulting in a net loss in state
dollars.
• Achieving “savings” by leaving eligible children
uninsured should not be a public policy strategy.
Center for Public Policy Priorities
www.cppp.org
12
Most Kids who lose Medicaid or CHIP are
Uninsured Afterwards
The 12/2004 independent ICHP disenrollment report found:
– 52% of kids leaving CHIP remained uninsured.
– of the 47% who got coverage later, 31% went to Medicaid and only
11% got employer-sponsored insurance (ESI)
New ICHP studies of children losing CHIP or children’s
Medicaid in 2006 found:
– only 28% of kids who lost CHIP (and 24% of kids losing Medicaid)
had any kind of health coverage afterwards, and
– only 19% (i.e., about two-thirds of the 28%) moved to Medicaid.
Center for Public Policy Priorities
www.cppp.org
13
Eliminate bureaucratic roadblocks to
encourage personal responsibility and help
low income families achieve self-sufficiency:
– Fix problems with the Integrated Eligibility System
to prevent eligible kids from losing CHIP and
Medicaid coverage
– Eliminate the CHIP asset test
– Eliminate the CHIP 90 day delay of coverage for
uninsured children
– Deduct childcare and child support expenses when
calculating income for CHIP
Center for Public Policy Priorities
www.cppp.org
Fix problems with the Integrated Eligibility
System to prevent eligible kids from losing
CHIP and Medicaid coverage
•
Adequate numbers of state eligibility workers to process applications, renewals
within federal law timeframes –and preferably faster than that!
•
Zero tolerance for gaps in coverage when kids move from Medicaid to CHIP, or
CHIP to Medicaid.
More improvement needed in CHIP contractor performance: prompt processing,
eliminate staff policy errors, fix ongoing computer problems.
Set high performance standards in both the public and private systems to try to
minimize “missing info” requests, eliminate “procedural” denials, and raise renewal
rates.
•
•
In Louisiana:
– children’s Medicaid/CHIP cases closed for failure to return renewal forms
dropped from 17% to 2%,
– renewal rates increased to 92%, and
– children with gaps in Medicaid-CHIP coverage reduced from 18% to 6% over
2 years.
Center for Public Policy Priorities
www.cppp.org
14
15
Eliminate the CHIP asset test
• No asset limits are required in either children’s Medicaid or CHIP.
What Other States Do:
• Texas is one of only 4 states (Montana, South Carolina, Utah) with an
asset test for children’s Medicaid.
– And, Texas’ asset tests for both Medicaid and CHIP are far more restrictive than
those of the small group of states who also use asset tests.
– Montana and South Carolina’s assets limit for children’s Medicaid are $15,000
and $30,000 respectively.
• Texas is one of only 2 states (Oregon is the other) with an asset test for
CHIP,
– and Oregon’s CHIP asset limit is $10,000 -- twice as high.
– In a rush to implement the unplanned CHIP asset provision, HHSC simply
adopted the Food Stamp limits, designed for a population with half the income.
• In contrast, Texas children’s Medicaid limits assets to $2,000, and Texas
CHIP sets the limit at $5,000.
Center for Public Policy Priorities
www.cppp.org
16
Texas CHIP Asset Test, 8/2004-10/2005
9,446 children
10,000
9,000
8,000
7,000
3,993
6,205
6,000
5,000
2,637
4,000
4,791
3,000
2,000
1,000
Combined Assets
Cash Only
Vehicles Only
2,500
1,356
1,343
1,068
0
Disenrolled at
Renewal
3,843
1,610
542
Application
Denied
Total Children
Affected
Source: THHSC. Latest available data as of 1/26/07; 11/06-2/07 an average of 500-600
children/month denied CHIP due to assets.
Center for Public Policy Priorities
www.cppp.org
17
Eliminate the CHIP 90 day delay of
coverage for uninsured children
• Texas’ 2003 changes converted the original CHIP 90-day
crowd-out prevention policy into an across-the-board 90-day
delay of coverage
• This had the effect of delaying health care for newborns, and
for children who have been uninsured for years, or their entire
lives, instead of acting as a disincentive to dropping private
coverage.
• No other state has, or has ever had such a policy.
• The original Texas CHIP policy should be restored.
Center for Public Policy Priorities
www.cppp.org
Deduct child care and child support expenses18
when calculating income for CHIP
• Texas’ original CHIP policy gave parents credit for:
– A portion of their child care expenses,
– A small work expenses deduction (same as Medicaid)
– All child support payments to another household (a positive incentive to
make payments).
• 2003 elimination of income deductions has had unintended
consequences.
– Parents of youngest children (infants, toddlers, and pre-school age) face
the highest child care costs, & are much more likely to have to choose
between child care and health care than parents whose children are school
aged.
– No deduction for child support payments means that that 2 different
households have to claim the same child support income: both the
household of the parent who makes the payment, and the household that
receives the payment. Texas children have denied CHIP as a result of this
nonsensical policy.
• Texas’ original policy worked well, supported responsible
parental behaviors, and should be restored.
Center for Public Policy Priorities
www.cppp.org
Provide adequate reimbursement for
Medicaid and CHIP providers
• Many physicians, dentists and other providers severely restrict
participation in Medicaid & CHIP, or choose not to serve them
at all, because of inadequate reimbursement that is well below
Medicare and commercial payment rates.
• Rate cutbacks have reduced physicians’ fees to 1993 levels for
most services. Rate cuts were the largest HHS cut made in
2003; even larger than the CHIP cuts.
• TMA surveys of Texas doctors show that the percentage of
doctors taking new Medicaid patients dropped from 75% in
1996 to 39% in 2006.
• Restoration to 2003 rates has been requested as an HHSC
exceptional item; and rate increases are requested as part of
Consolidated HHS budget.
Center for Public Policy Priorities
www.cppp.org
19
20
Invest in outreach and education to ensure that all
eligible children get the care that they need
• Responsible parents need help understanding the complexity
of the health care system--what care is available for children,
and what the parents’ responsibilities are in enrolling and
accessing that care.
• Ongoing outreach and assistance programs are vital to
connecting children with a medical home and keeping them
healthy.
• The Coalition applauds HHSC’s recent marketing and public
education efforts to inform families about the availability of
children’s Medicaid and CHIP. These initiatives also educate
families about the importance of keeping their children
enrolled, and inform them about how to effectively and
appropriately use health care services.
Center for Public Policy Priorities
www.cppp.org
Invest in outreach and education to ensure that
all eligible children get the care that they need
• Texas should leverage this marketing spending by preserving and
expanding the role of Community-Based Organizations in outreach and
education, proven effective in the CHIP-building years.
• In 2002-2003, community-based organization (CBOs) outreach was
funded at $6.1 million, and direct marketing at $3.8 million.
• April 2006 HHSC announced $3 million in marketing of
CHIP/children’s Medicaid.
• HHSC has announced $3.5 million contract, but this will expand CBOs’
responsibilities for outreach to approximately 2 million adults, in
addition to the 2 million+ children already targeted.
• We must ensure that funding for children’s insurance programs
continues at or above 2002 levels, and provide additional funding to
support the new CBO responsibilities.
• Special resources are needed to remedy the higher lost CHIP enrollment
among preschool children, and rural Texas children.
Center for Public Policy Priorities
www.cppp.org
21
22
The Center for Public Policy Priorities encourages you to
reproduce and distribute these slides, which were
developed for use in making public presentations.
If you reproduce these slides, please give appropriate
credit to CPPP.
The data presented here may become outdated. For the
most recent information, or to sign up for our free
e-mail updates, visit www.cppp.org
© CPPP
Center for Public Policy Priorities
www.cppp.org
23
Texas Medicaid & CHIP Background
Information
Center for Public Policy Priorities
www.cppp.org
24
Age Distribution Of Children in CHIP
(FY 2003 vs. December 2006)
300,000
250,000
200,000
FY 2003
Dec-06
150,000
D
100,000
50,000
0
<1 Yrs
1-5 Yrs
6-14 Yrs
15-18 Yrs
In FY 2003, children aged 0-5 made up 23% of enrollment; as of 12/2006
they had dropped to 17%.
Source: HHSC
Center for Public Policy Priorities
www.cppp.org
Change in Texas CHIP Enrollment,
by Income (as percentage of Federal Poverty income Level)
November 2003* – December 2006
-68,413
<100%
-44,616
-14,010
101-150%
-4,866
151-185%
186-200%
-11.9%
-14.3%
-131,935
Total
Enrollment
-21.1%
-28.8%
* Enrollment dropped by 49,093 from 9/200311/2003; thus totals shown here understate full
decline number and percent since September
2003.
Source: CPPP analysis of Texas Health and Human Services Commission data
-72.5%
Center for Public Policy Priorities
www.cppp.org
25
26
Poorest Children Now Make up Much
Smaller Share of CHIP
186-200% FPL
186-200% FPL
7%
26%
<100% FPL
FPL
21%
151-185%
FPL
100-150% FPL
September 2003
Source: HHSC
9% 8%
32%
151-185% FPL
46%
Center for Public Policy Priorities
<100% FPL
51%
100-150% FPL
December 2006
www.cppp.org
27
Average Monthly Enrollment Growth for Texas Children
in Medicaid, FY 2001 – FY 2007*
2.2%
Simplification
of application
and renewals
Rolled back some
simplification
measures
1.4%
0.8%
0.7%
0.2%
Change in
Enrollment:
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
-0.16% -0.13%
68,189
285,584
280,594
122,402
67,084
-35,679
-15,058
*FY 2007 YTD; Avg. annual TX child population growth rate 1.2% (2001-2004)
Source: CPPP analysis of Texas Health and Human Services Commission data
Center for Public Policy Priorities
www.cppp.org
28
Texas CHIP Enrollment by Service Area, September 2003 and December 2006
CHIP Service Area
Sept. 2003
Dec. 2006
Decline
% Decline
1 Amarillo/Lubbock
13,541
6,639
-6,902
-51.0%
2 Dallas-Fort Worth
100,654
73,745
-26,909
-26.7%
25,038
17,011
-8,027
-32.1%
137,639
93,219
-44,420
-32.3%
7 San Antonio
38,060
25,810
-12,250
-32.2%
8 Corpus Christi
18,332
10,349
-7,983
-43.5%
10 Laredo
10,080
5,869
-4,211
-41.8%
11 El Paso
22,216
13,842
-8,374
-37.7%
Total EPO[1]
141,699
79,747
-61,952
-43.7%
Statewide Total
507,259
326,231
-181,028
-35.7%
5 Austin
6 Houston
Source: Texas Health and Human Services Commission
[1]
Exclusive Provider organization. All areas of Texas not served in one of the large areas listed above are served by the EPO.
All EPO regions have had CHIP declines significantly worse than the state average.
See HHSC web site for a map of service areas: http://www.hhsc.state.tx.us/chip/families/County_Map_090106.pdf .
Center for Public Policy Priorities
www.cppp.org
29
14000
800
12000
700
600
10000
500
8000
400
6000
300
4000
200
2000
100
0
Number of recipients per worker
Number of eligibility staff
Downsizing of Eligibility Workforce Increased Workload
1996-2004
0
1996
Number of staff
Center for Public Policy Priorities
2003
2004
Average workload per worker
www.cppp.org
30
HHSC Eligibility Staff Reductions, 2004-2006
Permanent vs. Temporary Staff
8,000
7,000
8,000
6,920
6,637
6,309
6,247
5,612
6,000
7,000
6,000
5,000
5,000
4,000
4,000
Temporary FTEs
3,000
3,000
Total
2,000
2,000
1,000
1,000
0
Permanent FTEs
0
Oct 04
Apr 05
Oct 05
May 06
Oct 06
Source: HHSC
Center for Public Policy Priorities
www.cppp.org
31
Texas Unspent CHIP Funds Lost to Other
States
FFY 1998 Federal SCHIP Funds Lost - $170 million
FFY 1999 Federal SCHIP Funds Lost - $324.5 million
FFY 2000 Federal SCHIP Funds Lost - $123.7 million
FFY 2001 Federal SCHIP Funds Lost - $85.3 million
FFY 2002 Federal SCHIP Funds Lost - $104.6 million
FFY 2003 Federal SCHIP Funds Lost - $23.8 million
FFY 2004 Federal SCHIP Funds Lost - $61.5 million*
Total lapsed to date (2000-2006): $893.4 million
Scheduled to lapse on March 31, 2007: $20 million, for a total of 913.4 million
• This total is more than 3 times the federal SCHIP funds Texas
used to run the program for an entire year in 2005 (total Texas
federal SCHIP spending in FY 2005 was $288 million).
Source: Center on Budget and Policy Priorities, analysis of CMS data. *Lapse of
2004 allocation based on Congressional Research Service reports as of
12/13/2006.
Center for Public Policy Priorities
www.cppp.org
32
Texas Needs the Federal SCHIP Block Grant
to Grow - Or Else Texas CHIP Cannot Grow!
• Had CHIP enrollment stayed at 2003 levels (or grown),
Texas would need more federal funds TODAY
• In order for Texas CHIP to grow, and to cover the
hundreds of thousands of eligible, but not enrolled, kids,
we WILL need Congress to increase the block grant.
• The new Texas CHIP perinatal program will also speed
up Texas’ need for more federal SCHIP funds.
• BUT, Texas’ CHIP allocation (share of the pie) will likely
be targeted for cuts by some in Congress based on our
recent lower enrollment.
Center for Public Policy Priorities
www.cppp.org
33
Federal SCHIP Reauthorization, 2007:
The National Picture
• The Original SCHIP block grant did not grow with
population or inflation, so more funds are needed JUST
to let states keep serving their current children with the
same income limits
• Federal CHIP officials estimate that without more money
in the block grant CHIP enrollment will have to be cut by
one-third—from 4.4 million to 2.9 million children
nationwide.
• Many other states also want to reach their eligible, but
not enrolled children! More Block Grant funds will be
needed to allow us to provide all eligible kids with costeffective health care.
Center for Public Policy Priorities
www.cppp.org
34
Too Close to Turn Back:
States Move to Give Every Child Access to
Comprehensive Health and Mental Health Coverage
• Inspired by the success of Medicaid and SCHIP, three
states have begun implementing programs with a goal of
covering all children with no upper income limit.
• Building on their child Medicaid-CHIP programs
Massachusetts, Illinois, and Pennsylvania provide
subsidized coverage of children up to 300% to 400% of
poverty, and allow buy-in for children at higher incomes.
• A number of other states (CA, CO, MN, NM, NY, OR,
WA, WI) are currently considering similar major
expansions of access to care for children, designed to
ultimately reach coverage for every child.
Center for Public Policy Priorities
www.cppp.org
35
What Texas Kids Need
Federal SCHIP Reauthorization, 2007
• SCHIP Block Grant must grow to allow states to:
– Keep their current programs, without cuts to enrollment or
benefits
– Cover all eligible/not enrolled children @ current eligibility
thresholds. Texas needs this to cut the number of uninsured
children in half!
• If Texas only focuses on the issue of how long we
can carry unspent funds forward, and NOT on the
need for a bigger block grant overall, we will win a
small battle but suffer a major overall loss--we will be
forced once again to cut CHIP back.
• As recent exciting new state-level initiatives to cover all
children show, Americans are ready today to take steps
to cover more uninsured kids.
• CHIP stands on Medicaid’s broad shoulders: NO cuts to
Medicaid to offset SCHIP.
Center for Public Policy Priorities
www.cppp.org