AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
DONNA COHEN ROSS: You're taller than I am. Thank you, Joshua.
Good morning, everyone. It's still morning, right? It is. Great. Great. Because sometimes I get all confused with things going as fast as they are these days.
I'm Donna Cohen Ross. I'm the outreach director at the Center on Budget and Policy Priorities, which is a private non‑profit organization here in Washington , D.C. We conduct research and policy analysis on a whole range of issues of relevance to low and moderate income families. I have the privilege of directing our outreach division, which in addition to working on policy issues related to low‑income tax benefits and health coverage for children and families, we also for the last now, gosh, close to a dozen years have spearheaded a national outreach campaign to work with state and local organizations around the country to help enroll children and families into health coverage programs, primary Medicaid and CHIP programs.
I guess for me, the place over the past dozen years where outreach and policy have come together has been in working with states and with advocacy organizations trying to influence states on making it as easy as possible for eligible children and families to get enrolled in coverage. And as we'll see, over this period of time there's been tremendous change in procedural changes primarily in terms of enrollment and renewal procedures, which has had a very profound effect on enrollment and pretty much for a long period of time in a very positive way. As we'll see, there are some things, you know, some red flags going up. And those of you who are familiar with Medicaid and CHIP programs in your state, this will not be, I think, a surprise to you.
What I'm going to talk about over the next couple of minutes is the most recent findings from a survey that we do every year under the auspices of the Kaiser Commission on Medicaid and the Uninsured. The survey that I'm going to be reporting on is the fourth in a series of surveys that we've been doing to compile information on eligibility rules, enrollment procedures, renewal procedures, and now also cautionary practices in Medicaid and CHIP for children and families. And what I'm going to do is highlight what we've learned in our latest survey with respect to pregnant women and children.
So without taking any more time on introductions, I'll just go right ahead.
And just one other note, though. On the table outside there were hard copies of this presentation, along with two recent papers, one by the Center on Budget, one by Georgetown University , one of our longstanding partners on these issues on what is going on with respect to coverage for children in the president's budget. There also was a hard copy of the full survey that I'm going to be talking about today, and if you didn't get one, afterwards I can tell you how you can, because we still have plenty of them.
So moving ahead, before I talk about where we are and where the states stand, I wanted to talk a little bit about where we've come from just to give us a little bit of a refresher and also so that we can be all on the same page as we talk about the situation as we see it today.
What we've learned from our work over the past number of years, and certainly our survey work over the last four to five years, is that there's certain ingredients, three ingredients, a trio of effective strategies that really has helped boost enrollment in Medicaid and CHIP. And these three ingredients are as follows. The first thing that happened ‑‑ and we began to really look at this in earnest when the CHIP program came on board in 1997. The first thing that happened was that states now had the opportunity to expand eligibility for children. They in fact always had the opportunity to do that, but now they had some incentives, particularly financial incentives with a favorable federal match rate. And so expanding eligibility was first ingredient.
But as undoubtedly many or most of you know, expanding eligibility by itself does not necessarily turn into improved enrollment and increased enrollment. There are some other things that need to happen.
Simplification is a big issue. A those of you who have experience with the Medicaid program from years past I think will know very profoundly what I mean when I say that without simplification, you have the opportunity for health coverage but no real access, that the procedures for getting into the program were so difficult and oftentimes so onerous, particularly with the amount of verification and additional paperwork that families were asked to do, that it was probably as good as having no coverage at all.
The third ingredient was outreach. And, again, states always could do outreach, but we never really saw much of it going on with respect to the Medicaid program until CHIP came on board, and there was a focus on outreach and getting children into the program, and, of course, there was a very important spillover effect in both the second and third areas, the simplification and outreach spillover into the Medicaid program, which helped enroll children in health coverage regardless of which program they were eligible for. And, in fact, states were making steady progress on all of these areas since the late 1990s.
The most recent census data we have tell us that Medicaid and CHIP have really done the job that they were designed to do. They have prevented millions of children from becoming uninsured during weak economic times. And that's one of the purposes of the Medicaid program. It acts as a counter‑cyclical force that when families are in tough financial situations, when they may lose their jobs and lose health coverage, employer‑based health coverage, that if they or their children qualify, the Medicaid program is there to fill in the gaps. And, in fact, we found this to be true, particularly for children. To a much lesser extent for families, for parent coverage, which we can talk about. But we really found that Medicaid and CHIP did the job that they were supposed to do.
Here we go. And this graph kind of illustrates just that, that between 2000 and 2004 when employer‑sponsored coverage was greatly reduced because of the economy, we saw Medicaid and CHIP moving in to pick up the slack and really acting as a buffer for children.
We began to get some signals that the trends we saw over a number of years might be reversing. And these signals began to become clear to us in our survey two surveys ago, in 2003. And, again, this is a Center on Budget survey that's conducted for the Kaiser Commission on Medicaid and the uninsured. We began to see in that year that state budget pressures were beginning to lead to retractions in coverage either in the expanded eligibility side of things, but also in the simplification side of things. We particularly saw a profound scaling back in some states of parent coverage, and we began to see simplified procedures being reversed.
What we did see late that year and into the next is that the federal fiscal relief package that provided increased Medicaid funds for states to help them through, to help them weather this difficult economic period, actually prevented or mitigated cut‑backs in some states. And I think what we were looking at here is that we did see some cut‑backs, but what we would have seen would potentially been much worse had it not been for the federal fiscal relief. And the federal fiscal relief that I'm talking about is the Jobs and Growth Reconciliation Act. And again, many of you will remember that this piece of legislation increased the federal share of Medicaid costs. It lifted a lot of the burden from the states, and it helped them either avert or postpone some state cuts.
There was another thing operating here, and we're going to see this in some later slides, is that in addition to providing additional money, the legislation had some very important provisions; namely, the legislation prohibited states from cutting eligibility between September 2003 and June 2004. And so that was the thing that in some states held back this retraction.
And we're going to take a look, too, at what happened in the differences between Medicaid and CHIP, because again, those of you familiar with Medicaid know that Medicaid restricts to some extent what states can do in terms of, you know, how they must protect beneficiaries with respect to cost sharing and enrollment freezes. Neither of those things are allowed except under federal waivers, and so we're going to see in a moment some of the things that we saw happened in state CHIP programs and not in Medicaid.
So what were our major findings? I just want to be sure I got that right. When we looked at changes in eligibility, enrollment and renewal procedures and cost sharing in Medicaid and CHIP for children and parents, we found that on the surface, when you just ‑‑ and this was basically because of this federal fiscal relief legislation ‑‑ on the surface, it looked like things remained pretty stable. Income eligibility in particular remained pretty stable.
But our survey is designed to go beneath the surface and really look at how programs operate across states. And what we found is that beneath the surface there was a lot going on from state to state. Nearly half the states, 23 of them during this period of time, made it harder for eligible children and families to secure and retain coverage. So after all these years of making it easier, making programs more attractive and easier to access, we began to see a reversal.
Many states imposed financial barriers, particularly premiums. Some states in their CHIP programs froze enrollment, which had some pretty harsh outcomes for people, for families. And we also began to see states reinstating some of the procedural barriers that they had enacted in the past to make things easier.
And we then began to see adverse effects on enrollment. Where we had been seeing enrollment improve and increase, we began to see in some states in some very, I think, very profound ways. And I say profound because it happened so quickly, you know. When the procedures are made more difficult, you see the effect on enrollment pretty quickly.
Again, this slide just illustrates some of those major findings that I talked about a moment ago. You can see how many states enacted different new procedures or new rules. You can see that mostly these changes happened in the CHIP program, which is the white part of the bar, except for the procedural barriers, which were pretty much split between Medicaid and CHIP programs. And, again, this is because the Medicaid law has rules about what you can do in cost sharing and enrollment freezes, but procedures, states have a lot of flexibility in what they can do. And so you can see that on that third bar, what was going on happened in a mixture of Medicaid and CHIP programs.
I want to talk for a moment about what happened with premiums, or in some cases they're enrollment fees because they're not monthly or quarterly payments, they're one‑time payments, in children's health coverage programs. 16 states imposed premiums for the first time in their CHIP programs. And, also, some of them targeted those premiums to lower income families than they had been targeting premiums to in the past. 11 states imposed premiums on families with income just over the federal poverty line. So these are very, very low‑income families.
Just to give you some examples, Texas had previously charged these low‑income families, the families just over 100 percent of the federal poverty line. And these are children ‑‑ families with children in the state's CHIP program. So here we're not talking about Medicaid, we're talking about CHIP, but still pretty low‑income families.
They had charged them a $15 annual enrollment fee in CHIP. The premium was increased twelve fold. It went from a yearly $15 enrollment fee to a $15‑per‑month premium. And what happened soon thereafter was that there began to be great concern about the enrollment consequences of the premium policy, and the State of Texas then suspended the collection of all premiums. Connecticut and Maryland were two other states that had been slated for increased premiums during this survey period but rescinded them also during that same period because of concerns about sharp enrollment declines.
In addition to increasing premiums, our survey also looked at other provisions that were being enacted in states. Things like lock‑out periods, which are rules that say if a family doesn't pay the premium on time or within a certain period of time, the child is disenrolled from the program and can't come back into the program for anywhere between 60 days and in some cases six months. So even if the family is able to mass together the premium payment, you know, make good on its debt, the child is still not allowed to enroll in the program, and so you have a situation of an eligible child being denied coverage.
This map shows you, during the survey period, a number of states had enacted CHIP enrollment freezes. We did another report for the Kaiser Commission called Out in the Cold, which looked at the procedures that were in place during the enrollment freezes in these states. Tennessee is included in here. Although Tennessee did not have a CHIP enrollment freeze, it actually had a Medicaid enrollment freeze under the TennCare, program but we included it here for you to see what had happened.
I will say that if you're interested in talking about what occurs during enrollment freezes, we can talk about that later. I don't want to take a lot of time here now. And we do have a separate report on it.
What I do want to say is that the federal fiscal relief legislation that I talked about earlier helps some states, so to speak, thaw out their freezes. Montana , for example, was able to lift its freeze because of the federal funds that it received. Right now we only have two states that have freezes in place, and that's Florida and Utah . And both of them have open enrollment periods for short periods of time. You know, there's really no rhyme or reason to when they open enrollment. There's no set period of time for it. But Florida , during the month of January, just did open enrollment. I don't know when Utah is opening enrollment again, but.
UNIDENTIFIED SPEAKER: (Inaudible).
DONNA COHEN ROSS: In Utah ? Thank you. Thank you.
And we can talk about what happens during those open enrollment periods. It's very difficult for families and also for program administrators to handle the influx of applications all at once.
I want to talk a little bit about the procedural changes right now and just to kind of get us looking at this sort of very responsive change in enrollment due to changes in procedures. I want to ‑‑ I put this slide in, and this is an old slide from a presentation from ‑‑ it might have ‑‑ it wasn't our first survey, it was probably our second survey. And it showed that during the year 2000 in Ohio , there were some procedural changes made to make it much easier for children and families to enroll in Ohio 's Medicaid program. And you can see that right at the point where the graph starts to go up, the line starts to go up, that was where a simpler application was adopted, reduced verification requirements, they had addressed some other issues that were making it difficult for families to enroll. And you can see the result was increased enrollment at a pretty rapid pace. So that's what ‑‑ if we were to graph the activity in a number of states around that period of time, that was pretty much what we were seeing.
Last year, this is what we saw in Washington state. And it was pretty much a mirror image, you know, the flip of what we just saw. We saw that the state had increased verification requirements, they had gone from a system that was allowing self‑declaration of income to one that increased verification requirements. A little bit later on they began to ask families to renew coverage more frequently, which we know from experience and other studies that have looked at this that the more often you ask families to renew their coverage, the more risk there is that children and families will fall off of the program, not because they're not eligible but because they can't comply with very complicated procedures.
And here is what you saw in Washington state. You saw a drop in enrollment during this period of time of tens of thousands of kids. Now, I will say things have turned around a little bit in Washington state as well.
Is anyone here from Washington state?
Well, my understanding is that when your new governor took office, one of the very first things she did was reverse some of these procedures to put them back the way they were. And we're watching now to see what effect that will have on enrollment. And I know that was a long time coming. I'm sure you braved all of that with your fellow Washingtonians.
This one just looks at what has happened over time. And this is why we thought the trend that we were seeing was quite serious, because once a state reversed a simplified procedure, it stayed reversed. Except in Washington . That was our kind of ray of sunshine there. And so you can see that between 2001 and 2004, we had 11 states that had reversed procedures.
So let's just look now at having learned what we learned from the most recent survey, where are the states now on income eligibility?
This map shows us children's eligibility for Medicaid and CHIP by income. This is all based on July 2004 data. I should say, we're doing a fifth version of the survey starting in May so we'll update all of these figures this summer. But you can see which states, the states that are white are ‑‑ have income eligibility greater than or equal to 200 percent of the federal poverty level, no enrollment freezes. You can see the states that are less than 200 percent and the states that are colored in the dark coloring were states that were subject to enrollment freezes.
We also looked at Medicaid eligibility for pregnant women by income, and we see that there's a variation here, too. As you may know, you probably know the federal minimum for pregnant women in Medicaid is 133 percent of the federal poverty line. We had a large number of states between 134 percent and 185 percent. We have 16 states, including D.C., that cover pregnant women up to 185 percent of the federal poverty line.
The situation for working parents is very, very different than what we see for children and pregnant women. We have many fewer states covering families with incomes above the federal poverty line. And why do I talk about this in the same conversation as we do for children and pregnant women? Certainly low‑age working parents need health coverage just like everybody else. But if you only cared about the effect on children, I think we have several studies that show that when parents are eligible and enrolled in Medicaid, it's more likely that their children will be enrolled, and it's more likely that those children will get the preventive health care services that they need.
So many states that have worked to advance parent coverage, in the conversations that have occurred in making that happen they have talked about the effect on children when the whole family is covered. And just to see kind of what the differences are, this graph shows the median income eligibility thresholds for children, pregnant women, and parents, and you can see the median for parents across the country is 69 percent of the poverty line. And that's, I guess, saying in half the states you can have earnings of less than this and ‑‑ sorry ‑‑ in half the states, if your earnings are more than this, you earn too much to qualify for Medicaid. And our report goes into this in a lot greater detail.
We also learned that some key simplifications are still under utilized. You know, some of the simplifications we looked at are simplifications that were made optional for states before CHIP ever came on board. States could always do this in the Medicaid program, and in the late 1980s, early 1990s, many states availed themselves of these options, again, to get young children and pregnant women into the program.
I'm talking about things like getting rid of the asset test. In other words, just looking at a family's income but disregarding what they might have in a bank account, the value of their car, other assets. And that was done pretty much across the board, but not completely. There are still some states that have not adopted these very what are, I think, now recognized as very basic options. And we'll take a look at those.
This is ‑‑ the states that still have asset test requirements for children's coverage in Medicaid in CHIP are colored in the dark color. Interestingly, a number of states have just instituted ‑‑ have just introduced legislation to get rid of the asset test. So we're looking hopefully at Utah , at Montana , and also possibly Colorado . And I think some of the experiences of neighboring states have influenced them. The new tobacco taxes have been influential in some places in looking at getting rid of the asset test, and we've been working with states on how they might achieve this in the environment that they currently have.
And I think one of the things that's really compelling to state legislators has been sort of looking at what our policies are in Medicaid when you also look at what the policies are in welfare programs. We're trying ‑‑ we're still saying that we want people to go to work. If you live in a place like Utah or Idaho or Montana and you don't have a car, it's very difficult to get to work and keep working. And so if we're going to limit the value of someone's car to ‑‑ in some states it's the value of the car being $1500. That sort of puts a damper on the reliability of your vehicle and your reliability as an employee. We've been trying to look at how these different policies across programs mesh or don't mesh, and that, I think, has been helpful.
These states still have Medicaid asset test requirements for pregnant women. Some of the same states have asset test requirements for kids, but there's also some different ones. And so this is an area that I think people are not ‑‑ there used to be a lot of attention paid to this. There's less attention being paid, but it's still a huge problem. And, again, most states, as you can see, got rid of their asset tests, many of them long ago.
The other one that I would just mention is Medicaid presumptive eligibility for pregnant women. 29 states have implemented presumptive eligibility for pregnant women, but the remainder have not. And I would just go back to a GAO study from ‑‑ it was a long time ago. I think it was 1989 or '90 ‑‑ that looked at states that had availed themselves of new options at the time and what was the impact on enrollment. And that study showed that if a state did nothing else, if it got rid of the asset test and adopted presumptive eligibility for pregnant women, you were going to see an improvement in enrollment among pregnant women in the Medicaid program and all of the, you know, other outcomes that you would be looking for, women getting prenatal care, getting prenatal care earlier, and that kind of thing.
So I just point this out because I think people are not so focused as they once were on encouraging states to take on these options. But there's still a lot of work to be done here. I might also say that there is a presumptive eligibility option for children. Very few states have taken that one on.
The other thing that I think is really crucial, I talked early on about expanding eligibility for parents having an effect on enrollment of children. Well, the same is true ‑‑ it's not just expanding eligibility to make more people eligible but it's, again, what are the procedures that are in place that either encourage or discourage families from getting into the program? And while there's been a tremendous amount of attention paid to simplifying enrollment for children, you can see that states have not simplified their health coverage programs for parents to the same extent that they have for children.
So if you think a family's going to come in to apply for Medicaid for the whole family and you have an easy route to getting your children covered but a difficult route for the parent, have you really accomplished anything? That parent is there to get the entire family covered if the entire family is eligible. And our report goes into a lot more detail about what some of these disparities are in procedures and why they make a difference. But suffice it to say that we make it much harder for eligible parents to get covered than we do for kids.
I don't want to leave you on a sour note. I want to leave you with an optimistic story from last year.
Robin, this one is for you.
It's the story of Illinois . Last year, you know, Illinois was one state that, over the past couple of years, and they've continued to do this, has continued to advance eligibility, simplification, and outreach activities. And this slide tells you what Illinois has done in just the last year or so. Continued to increase CHIP eligibility up to 200 percent of the federal poverty line, continued to increase parent coverage so that now parents at
133 percent of the federal poverty line are covered. There's another expansion being contemplated, if we can hold on, because there's a budget to deal with. They've also adopted new simplifications, reduced income verification requirements, just adopted presumptive eligibility for children, and, very important, has continued to conduct outreach activities.
One of the areas we looked at in the survey, which I didn't report on, is what is happened to outreach funding across states in the past year. There's a very profound story to be told here, and that is that most states, or many, many states, have gone from a pretty robust outreach budget to nothing. Illinois is not one of them. Illinois continues to support and expand community‑based enrollment assistance, which I think is probably the most important thing a state can do with respect to outreach.
These Kid Care application agents that are helping families on a one‑to‑one basis, the state tells us, have a 90 percent approval rate, which is really important when you think that so many states have mail‑in applications. And people still really do need help in completing this.
And then you can see what the difference was made and what difference all of this made in enrollment between January 2003 and September 2004. Increased enrollment of children in Medicaid and CHIP, over 1000,000 kids, 72,000 parents as well.
So just to wrap up, and I probably have taken way more than my time, and I apologize for that, Medicaid and CHIP have played an essential role in preventing an increase in the number of uninsured children over the last three years. But barriers to coverage, whether they're new barriers or ones that have been reinstituted, they're surfacing at a time when there's a need for public programs to be more available, not less available, and this is a huge problem.
For continued progress on reducing the number of uninsured children ‑‑ big surprise ‑‑ sufficient funding, both state and federal, are needed to support current caseloads and also additional enrollment of eligible people.
And just from the outreach side, we have to remember that a lot of the people who are now eligible for these programs could be people who have never been eligible before because of what's happening to their jobs in this economy. And so we have to really be thinking clearly about what kind of outreach messages we're conveying.
Proposals that are currently being debated in some states and certainly at the federal level could result in cuts in eligibility and benefits for pregnant women and children. And we're really looking at that now. The two papers that I mentioned earlier out on the table talk about those proposals in great detail.
I want to thank for your time. I'm going to sit down now and let my colleagues talk, and we can answer questions later.
Thank you.