center for public policy priorities 1 the nuts and bolts of the t exas chip coalition/ insure texas...

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1

The Nuts and Bolts of the The Nuts and Bolts of the TTexas CHIP Coalition/exas CHIP Coalition/

Insure Texas Kids CampaignInsure Texas Kids CampaignAgenda for the 80Agenda for the 80thth Texas Legislature Texas Legislature

Building on the Success of Texas Medicaid and CHIP Building on the Success of Texas Medicaid and CHIP

House Committee on Human ServicesAustin, TexasMarch 1, 2007

Anne Dunkelberg, Associate Director([email protected])

900 Lydia Street - Austin, Texas 78702Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org


2

Uninsured Texas Children:We CAN Cut the Number in Half by Enrolling

Kids Who are Eligible Right Now

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

•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)).


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.


4

Income Caps for Texas Medicaid and CHIP, 2006

0%

50%

100%

150%

200%

250%

PregnantWomen

Newborns Age 1-6 Age 6-18 TANFparent of

2, noincome

WorkingParent of

2

SSI (agedor

disabled)

LongTermCare

CHIP

Mandatory Optional

$22,078/yr

$30,710/yr $30,710/yr

185% 185%133%

$16,600

100%$2,256 $3,696

13.6% 22.3%74%

$7,476

222%

$21,708$33,200

200%

Income Limit as Percentage of Federal Poverty IncomeAnnual Income is for a family of 3,

except Individual Incomes shown for SSI and Long Term Care


5Texas Kids’ Uninsured Rate Drops, Thanks to CHIP and Medicaid

BEFORE CHIP and streamlined Children’s MedicaidIn 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) .


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 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 • 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


7

Texas Child Medicaid Enrollment(February 2001-February 2007)

now:1,769,244

1,000,000

1,300,000

1,600,000

1,900,000

Feb-0

1

Jun-

01

Oct-0

1

Feb-0

2

Jun-

02

Oct-0

2

Feb-0

3

Jun-

03

Oct-0

3

Feb-0

4

Jun-

04

Oct-0

5

Feb-0

5

Jun-

05

Oct-0

5

Feb-0

6

Jun-

06

Oct-0

6

7-Feb

Source: Texas Health and Human Services Commission

Simplified Enrollment begins High:

1,838,239


8

Texas CHIP Enrollment(May 2000-February 2007)

0

200,000

400,000

600,000

May

-00

Sep-0

0

Jan-0

1

May

-01

Sep-0

1

Jan-0

2

May

-02

Sep-0

2

Jan-0

3

May

-03

Sep-0

3

Jan-0

4

May

-04

Sep-0

4

Jan-0

5

May

-05

Sep-0

5

Jan-0

6

May

-06

Sep-0

6

Jan-0

7

Source: All figures from Texas Health and Human Services Commission;Compares most recent month with September 2003

Highest, 5/02: 529,271 9/03:

507,259

2/07: 325,479


9

Texas Child Medicaid and CHIP Enrollment

1.5

2.0

2.5

3.0

En

rollm

en

t (m

illio

ns

)

0.5

1.5

2.5

3.5

4.5

5.5

6.5

Ch

ild p

op

ula

tio

n (

mill

ion

s)

Sources: Enrollment from Texas Health and Human Services Commission; Texas State Demographer's 0-17 Population Estimates

Sept. ’03: 2,150,543

Feb. ’07: 2,094,723

Estimated child population growth of almost 70,000 per year

Combined CHIP/Child Medicaid Enrollment


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.)


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.


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.


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


14Fix 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.


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.


16

1,068 5421,610

2,500

1,343

3,843

2,637

1,356

3,993

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Disenrolled atRenewal

ApplicationDenied

Total ChildrenAffected

Combined Assets

Cash Only

Vehicles Only

Texas CHIP Asset Test, 8/2004-10/2005

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.

9,446 children

6,205

4,791


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.


18Deduct child care and child support expenses 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.


19

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.


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.


21

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.


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


23

Texas Medicaid & CHIP Background Information


24

Age Distribution Of Children in CHIP(FY 2003 vs. December 2006)

0

50,000

100,000

150,000

200,000

250,000

300,000

<1 Yrs 1-5 Yrs 6-14 Yrs 15-18 Yrs

FY 2003

Dec-06D

In FY 2003, children aged 0-5 made up 23% of enrollment; as of 12/2006 they had dropped to 17%.

Source: HHSC


25

-72.5%

-21.1%

-11.9% -14.3%

-28.8%

<100% 101-150% 151-185% 186-200%

Change in Texas CHIP Enrollment, by Income (as percentage of Federal Poverty income Level)

November 2003* – December 2006

Source: CPPP analysis of Texas Health and Human Services Commission data

Total Enrollment

* Enrollment dropped by 49,093 from 9/2003-11/2003; thus totals shown here understate full decline number and percent since September 2003.

-68,413 -131,935-4,866-44,616 -14,010


26

Poorest Children Now Make up Much Smaller Share of CHIP

26%

7%

21%

46%

100-150% FPL

151-185% FPL

<100% FPL FPL

186-200% FPL

September 2003

32%

9% 8%

51%151-185% FPL

186-200% FPL <100% FPL

December 2006

100-150% FPL

Source: HHSC


27

0.8%

2.2%

1.4%

0.7%

0.2%

-0.13%-0.16%FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007

Average Monthly Enrollment Growth for Texas Children in Medicaid, FY 2001 – FY 2007*

Source: CPPP analysis of Texas Health and Human Services Commission data

68,189

Change in Enrollment:

285,584 280,594 122,402

Rolled back some simplification measures

Simplification of application and renewals

67,084

*FY 2007 YTD; Avg. annual TX child population growth rate 1.2% (2001-2004)

-35,679 -15,058


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%

5 Austin 25,038 17,011 -8,027 -32.1%

6 Houston 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%

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 .


29Downsizing of Eligibility Workforce Increased Workload

1996-2004

0

2000

4000

6000

8000

10000

12000

14000

1996 2003 2004

Num

ber of

elig

ibili

ty sta

ff

0

100

200

300

400

500

600

700

800

Num

ber of

rec

ipie

nts pe

r w

orke

r

Number of staff Average workload per worker


30

Permanent vs. Temporary Staff

6,920 6,6376,247

5,612

6,309

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

Permanent FTEs

Temporary FTEs

Total

Oct 04 Apr 05 Oct 05 May 06 Oct 06

HHSC Eligibility Staff Reductions, 2004-2006

Source: HHSC


31

Texas Unspent CHIP Funds Lost to Other States

FFY 1998 Federal SCHIP Funds Lost - $170 millionFFY 1999 Federal SCHIP Funds Lost - $324.5 millionFFY 2000 Federal SCHIP Funds Lost - $123.7 millionFFY 2001 Federal SCHIP Funds Lost - $85.3 million

FFY 2002 Federal SCHIP Funds Lost - $104.6 millionFFY 2003 Federal SCHIP Funds Lost - $23.8 millionFFY 2004 Federal SCHIP Funds Lost - $61.5 million*

Total lapsed to date (2000-2006): $893.4 millionScheduled 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.


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.


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 cost-effective health care.


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.


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.

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