Transcript Progress Enrolling Children in Medicaid and CHIP: New Estimates from the American Community Survey G.

Progress Enrolling Children in
Medicaid and CHIP: New
Estimates from the American
Community Survey
G. Kenney, V. Lynch, J. Haley, D.
Resnick and M. Huntress
(http://www.urban.org/publications/412379.html)
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Background
• Major policy initiatives (i.e. CHIPRA,
Connecting Kids to Coverage Challenge)
against backdrop of ongoing recession
• Prior research found geographic,
socioeconomic, and demographic variation
in participation
• Critical that programs monitor participation
patterns and uninsurance among eligibles
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Data
• American Community Survey
– Annual survey fielded continuously over a twelve months period.
• Approx. 700,000 children sampled
• Include health insurance, household and income data.
• Allows more precise state and local estimates than previously
possible.
– Health insurance coverage questions added in 2008.
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What Information is Included on
the ACS?
• Based on the long form from the decennial census:
• Income, marital status, education, occupation, functional
limitation, etc.
• Income and household structure information is more
limited than on the CPS but appears quite robust
• Activity limitations/disability status
In 2008, for the first time, households were asked about
insurance coverage status
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ACS Mail Questionnaire Health
Insurance Item
Is this person CURRENTLY covered by any of the following health insurance or
health coverage plans? Mark “Yes” or “No” for EACH type of coverage in
items a-h
a.
b.
c.
d.
e.
f.
g.
h.
Insurance through a current or former employer or union (of this person or
another family member)
Insurance purchased directly from an insurance company (of this person or
another family member)
Medicare, for people age 65 and over, or people with certain disabilities
Medicaid, Medical Assistance, or any kind of government-assistance plan for
those with low incomes or a disability
TRICARE or other military health care
VA (including those who have ever enrolled for or used VA health care)
Indian Health Service
Any other type of health insurance or health coverage plan- specify
___________________________
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Methods
• Concern that the ACS may understate Medicaid and CHIP
coverage.
– Edit rules were applied that build on those developed by the
Census Bureau to account for this. Result was an increase in
estimated number of children with Medicaid/CHIP and a reduction
in the estimated number of uninsured children—revised ACS
uninsured estimate for children very close to NHIS estimate
• Simulation model uses state-level eligibility guidelines to
determine eligibility of each child based on family-level
characteristics, including income.
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Methods, cont.
• Participation rates are defined as the ratio of eligible
children enrolled in Medicaid/CHIP to those children plus
uninsured children who are eligible for Medicaid/CHIP.
• Variation in participation within states can be addressed
using public use microdata areas (PUMAs) which are
mutually exclusive areas that do not cross state lines and
that generally follow the boundaries of county groups,
single counties, or census-defined "places”.
• All estimates use weights provided by the Census Bureau
and standard errors use replicate weights that take into
account the complex nature of the sample design.
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Face Validity: New Medicaid Estimates are Closer to
Counts from Administrative Databases
Millions
Medicaid/CHIP* among children (0-18), 2008
Source: Kenney, G., V. Lynch, A. Cook, and S. Phong. 2010 “Who and Where Are The Children Yet To Enroll In
Medicaid And The Children’s Health Insurance Program?” Health Affairs. 29(10): 1920-1929.
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Face Validity: ACS and CPS Distributions Similar to
NHIS After Logical Coverage Editing
Number of children (0-18) by Survey and Coverage Type, after
Logical Coverage Edits, 2008
ACS
NHIS
Total (millions)
78.4
78.3
Medicaid/CHIP
25.6
24.1
ESI
42.5
43.4
Nongroup
3.0
2.6
Medicare
.1
.2
Uninsured
7.2
7.4
Other
.6
Source: Urban Institute Tabulations of the 2008 ACS and NHIS; ACS estimates reflect an adjustment for the
underreporting of Medicaid/CHIP and military coverage and an over-reporting of non-group coverage on the ACS.
Notes: Coverage type shown hierarchically. Medicaid includes Medicaid, CHIP, and other public. ESI includes
military. Other includes “don’t know”, “refused”, “not ascertained”
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Changes Between 2008 and 2009
•
2.5 million additional children were eligible in 2009
due to changes in eligibility rules and changing
economic circumstances
•
The participation rate in Medicaid/ CHIP increased by
2.7%, from 82.1% to 84.8%.
•
The uninsured rate among children fell from 9.2% to
8.4%.
•
The number of eligible but uninsured children fell by
340,000 to 4.3 million; the uninsured rate among
eligible children fell from 11.7% to 10.2%.
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Increase in Number of Children (0-18) Eligible for
Medicaid/CHIP Between 2008 and 2009
Increase Due to
Decline in Income
Distribution
Increase Due to
Eligibility
Expansions
1.3 million
1.3 million
Total Increase: 2.5 million
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American
Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS. Numbers may not
sum to total due to rounding.
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Uninsurance Rate and Number Uninsured Among
Children (0-18) Eligible for Medicaid/CHIP, 2008 and
2009
2008
2009
Number
Rate
11.7%
10.2% *
4.7 million
4.3 million*
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on
American Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.
"*" indicates that the change is statistically different from zero at the (.10) level.
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Changes in Medicaid/CHIP Participation Rates between 2008 and 2009
2008 Rate
United States
2009 Rate
Difference
Total
82.1%
84.8%
2.7% *
Age (years)
0 to 5 ^
6 to 12
13 to 18
85.9%
82.7%
76.3%
88.9% ~
85.6% ~
78.3% ~
3.0% *
2.9% *
2.0% *
English Speaking Parent in Home
At Least One ^
None
Child Not Living with Parents
83.3%
78.3%
77.1%
85.6% ~
83.2% ~
80.0% ~
2.3% *
4.9% *
3.0% *
Family Income (As Percent of Poverty)
0-132% ^
133-199%
200+%
84.5%
76.0%
72.0%
87.1% ~
79.6% ~
74.7% ~
2.5% *
3.6% *
2.7% *
Ethnicity or Race
Hispanic ^
White
Black or African American
Asian/Pacific Islander
American Indian/Alaskan Native
Other/Multiple
79.4%
81.8%
87.2%
79.7%
68.8%
86.8%
82.6%
84.4%
89.4%
82.7%
74.5%
88.7%
~
~
~
~
~
~
2.5%
2.6%
2.2%
3.1%
5.8%
1.8%
Citizenship Status
Citizen Child with No Citizen Parents ^
Citizen Child with Citizen Parents
Non-Citizen Child
Child Not Living with Parents
78.3%
83.8%
76.0%
77.1%
83.2%
86.1%
76.3%
80.0%
~
~
~
~
4.9% *
2.3% *
0.3%
3.0% *
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on
American Community Survey (ACS) 2008 and 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.
"*" indicates that the change is statistically different from zero at the (.10) level.
'“^" indicates reference group.
'"~" indicates the estimate is significantly different from the reference group at the (.10) level in 2009.
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*
*
*
*
*
*
Medicaid/CHIP Participation Rates by Region, 2008 and 2009
2008
2009
82.1%
Source: Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on data from the 2008
and 2009 American Community Surveys.
Note: Estimates reflect an adjustment for the underreporting of Medicaid/CHIP on the ACS.
*Indicates that 2009 percentage is statistically different from the 2008 percentage at the .10 level.
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Increases in Medicaid/ CHIP Participation Rates Among Children
(0-18) by State, 2008 to 2009
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INSTITUTE
Eligibility of Uninsured Children for Medicaid/CHIP Coverage, 2009
Of the 6.6 million uninsured children in the nation 4.3 million are eligible for Medicaid/CHIP
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on
American Community Survey (ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.
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Number of Eligible but Uninsured Children for Selected States, 2009
Number
United States
4,349,000
Texas
California
Florida
Georgia
New York
Ohio
Arizona
Illinois
Pennsylvania
Indiana
693,000
661,000
381,000
189,000
175,000
127,000
125,000
120,000
118,000
113,000
Share of Total US
Eligible but Uninsured
Cumulative Share of Total
US Eligible but Uninsured
-----
-----
15.9%
15.2%
8.8%
4.4%
4.0%
2.9%
2.9%
2.8%
2.7%
2.6%
15.9%
31.1%
39.9%
44.3%
48.3%
51.2%
54.1%
56.8%
59.5%
62.1%
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based on American Community Survey
(ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.
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Simulated Effect of Increases in Participation Rates on the
Number of Uninsured Children (0-18) Who Are Eligible for
Medicaid/CHIP, 2009
Source Analysis of Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, based
on American Community Survey (ACS) 2009 data from the Integrated Public Use Microdata Series (IPUMS).
Notes Estimates reflect an adjustment for the underreporting of Medicaid/CHIP and military coverage on the ACS.
Figure simulates the effects on the number of children who are eligible for Medicaid/CHIP but remain uninsured if
states with participation rates below specified thresholds were to attain those thresholds.
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Related Findings
•
Research on the factors that influence variation of participation rates across
states and within states:
• Preliminary findings suggest underlying demographic characteristics of
eligibles not the primary determinant of state participation rates.
•
Participation rates vary substantially within states: In California, for example,
the top quartile of PUMAs have participation rates above 89%, while
participation is 52% in the area with the lowest participation rate. In Texas, the
highest and lowest participation rates by PUMA are 94% and 58%
respectively, and in Florida, they are 94% and 38%.
•
New research on participation rates for adults:
• Finds lower participation than for kids, but the number of eligible but
uninsured adults appears slightly higher nationally than the number of
eligible but uninsured children.
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Limitations
•
Despite considerable improvements from unedited ACS
estimates, our coverage estimates may still include
measurement errors, which could introduce bias into our
estimates.
•
Our Medicaid/CHIP eligibility simulation model also has
measurement error.
•
Small state estimates (such as North Dakota, Vermont, and
Wyoming) are less precise because of the relatively smaller
sample sizes available for them.
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Final Thoughts
• Key to develop effective strategies that increase public
coverage among: adolescents, non-citizen children,
Hispanic and Native-American children, etc.
• National progress hinges on achieving gains in a
relatively small subset of states
• To monitor progress and identify needed policy
responses and priorities, would ideally use a
combination of household survey and administrative
data sources
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Simplification and Coordination
in 2014
National Covering Kids and Families Network
Webinar
September 13, 2011
Tricia Brooks
Georgetown University Health Policy Institute
Center for Children and Families
Building a Better System Based on
Lessons Learned from Covering Kids
o Consumer-friendly o Technology-enabled
o Coordinated
o Simplified
Simple, Plain Language
o Forms, notices, websites
o In all formats (paper, electronic, verbal)
o Accessible:
• Persons with limited English proficiency (LEP)
• Disabled (meet 504 standards)
• More guidance expected
Consumer Assistance
o
o
o
o
Exchange
Call center
Robust website
Navigator program
Outreach beyond
Navigators (not
specified)
Medicaid/CHIP
o Outreach to vulnerable,
underserved groups
• Guidance expected
o Assistance in person,
over the phone, online
o Applicant may elect for
assistance through
person of choice
Simplified Eligibility
o All children and adults covered in Medicaid
up to 133% FPL
• Collapses multiple Medicaid groups into 4
• Excludes eligibility groups not based on income
o Replaces disregards/deductions with flat 5
percentage points (138% FPL)
o No more asset tests
• Same excluded groups as above
Simplified Eligibility
o Presumptive eligibility
• For adults, family planning services now
• Hospitals gain prerogative in 2014
o Provisions for express lane eligibility
decisions
• Assumes ELE does not sunset in 2013
according to CHIPRA (will require legislation)
New Income & Household
Rules
o Consistent standards for all coverage options
• Applies also to premium and cost-sharing subsidies
in the Exchange
o Modified Adjusted Gross Income (MAGI)
• It’s a methodology (formula), not a number
o Household size = tax filing unit (taxpayer(s)
plus tax dependents)
• A few exceptions (i.e. custodial parents not claiming
child as tax dependent)
Children’s Eligibility
o Eliminates stair-step eligibility based on age
o States must convert current eligibility to
“effective” MAGI standard and maintain
level until 2019
o Parent cannot enroll in Medicaid unless
children have coverage
Single, Streamlined Application
o No wrong door – applicants are
determined eligible for all options
regardless of point of entry
o Ability to apply online, over phone, via
mail, in-person
o Verification through electronic sources
including new federal data hub
o Real or near-real time determination
The Role of the Exchange
o Authorized to make Medicaid decisions
• Will transfer enrollment data to agency for
Medicaid/CHIP
o Must have robust website with electronic
application using electronic signature
• Regulations stop short of requiring:


“My account” functionality
Third party access (navigators, application
assistors)
Simplified Application Process
o Minimal information
• Can’t ask questions not needed for eligibility
• Can’t require SSN for non-applicants (Medicaid)

No premium tax credits without SSN
o No paper documentation
• Can’t require paperwork unless unable to verify
through electronic sources
• Establishes “reasonable compatibility” concept for
differences in reported vs. electronic data
Coordination
o
o
o
o
Single eligibility system/shared eligibility service
Consistent standards for eligibility
Data exchanges between agencies
Medicaid can maintain eligibility if projected
annual income is expected to remain below limit
• Not quite 12 month continuous eligibility
o Seek comment on extending coverage through
end of next month to align with Exchange
Renewal
o Every 12 months
o Automatic renewals if data is available
• Report changes online, phone, mail, in person
• Cannot require signature
o Otherwise use pre-populated renewal forms
Response online, phone, mail, in person
• Electronic signature must be available
Challenges/Outstanding Issues
o Timeline for developing IT infrastructure
o Electronic sources for “current” income
o Navigator tug of war
• Brokers vs. community organizations
o Access to affordable employer-based family
coverage
• Affordability = < 9.5% household income for
individual coverage
o CHIP waiting periods
Georgetown Health Policy Institute
Center for Children and Families
Tricia Brooks
Assistant Professor – Georgetown HPI
Senior Fellow – HPI Center for Children and Families
[email protected]
202-365-9148
Our Website: http://ccf.georgetown.edu/
Say Ahhh! Our child health policy
blog:http://www.theccfblog.org/