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Progress Enrolling Children in Progress Enrolling Children in Medicaid and CHIP: New Medicaid and CHIP: New

Estimates from the American Estimates from the American Community SurveyCommunity 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. Insurance through a current or former employer or union (of this person or another family member)

b. Insurance purchased directly from an insurance company (of this person or another family member)

c. Medicare, for people age 65 and over, or people with certain disabilitiesd. Medicaid, Medical Assistance, or any kind of government-assistance plan for

those with low incomes or a disabilitye. TRICARE or other military health caref. VA (including those who have ever enrolled for or used VA health care)g. Indian Health Serviceh. 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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Medicaid/CHIP* among children (0-18), 2008

Millions

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.

Face Validity: New Medicaid Estimates are Closer to Counts from Administrative Databases

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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”

Face Validity: ACS and CPS Distributions Similar to NHIS After Logical Coverage Editing

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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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1.3 million 1.3 million

Increase Due to Decline in Income Distribution

Increase Due to Eligibility Expansions

Total Increase: 2.5 million

Increase in Number of Children (0-18) Eligible for Medicaid/CHIP Between 2008 and 2009

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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11.7%10.2% * 4.7 million

4.3 million*

NumberRate

Uninsurance Rate and Number Uninsured Among Children (0-18) Eligible for Medicaid/CHIP, 2008 and

2009

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.

2008

2009

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Changes in Medicaid/CHIP Participation Rates between 2008 and 2009

2008 Rate 2009 Rate Difference

Total 82.1% 84.8% 2.7% *

Age (years)0 to 5 ^ 85.9% 88.9% ~ 3.0% *6 to 12 82.7% 85.6% ~ 2.9% *13 to 18 76.3% 78.3% ~ 2.0% *

English Speaking Parent in HomeAt Least One ^ 83.3% 85.6% ~ 2.3% *None 78.3% 83.2% ~ 4.9% *Child Not Living with Parents 77.1% 80.0% ~ 3.0% *

Family Income (As Percent of Poverty)0-132% ^ 84.5% 87.1% ~ 2.5% *133-199% 76.0% 79.6% ~ 3.6% *200+% 72.0% 74.7% ~ 2.7% *

Ethnicity or RaceHispanic ^ 79.4% 82.6% ~ 2.5% *White 81.8% 84.4% ~ 2.6% *Black or African American 87.2% 89.4% ~ 2.2% *Asian/Pacific Islander 79.7% 82.7% ~ 3.1% *American Indian/Alaskan Native 68.8% 74.5% ~ 5.8% *Other/Multiple 86.8% 88.7% ~ 1.8% *

Citizenship StatusCitizen Child with No Citizen Parents ^ 78.3% 83.2% ~ 4.9% *Citizen Child with Citizen Parents 83.8% 86.1% ~ 2.3% *Non-Citizen Child 76.0% 76.3% ~ 0.3%Child Not Living with Parents 77.1% 80.0% ~ 3.0% *

United States

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

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.

82.1%

2008

2009

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Increases in Medicaid/ CHIP Participation Rates Among Children (0-18) by State, 2008 to 2009

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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

NumberShare of Total US

Eligible but UninsuredCumulative Share of Total US Eligible but Uninsured

United States 4,349,000 ----- -----

Texas 693,000 15.9% 15.9%California 661,000 15.2% 31.1%Florida 381,000 8.8% 39.9%Georgia 189,000 4.4% 44.3%New York 175,000 4.0% 48.3%Ohio 127,000 2.9% 51.2%Arizona 125,000 2.9% 54.1%Illinois 120,000 2.8% 56.8%Pennsylvania 118,000 2.7% 59.5%Indiana 113,000 2.6% 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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• 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.

Related Findings

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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

National Covering Kids and Families NetworkNational Covering Kids and Families NetworkWebinar Webinar

September 13, 2011September 13, 2011

Tricia BrooksTricia BrooksGeorgetown University Health Policy InstituteGeorgetown University Health Policy Institute

Center for Children and FamiliesCenter for Children and Families

Simplification and Coordination Simplification and Coordination in 2014in 2014

Building a Better System Based on Building a Better System Based on Lessons Learned from Covering KidsLessons Learned from Covering Kids

o Consumer-friendlyo Simplified

o Technology-enabledo Coordinated

Simple, Plain LanguageSimple, Plain Language

o Forms, notices, websiteso In all formats (paper, electronic, verbal)o Accessible:

• Persons with limited English proficiency (LEP)• Disabled (meet 504 standards)• More guidance expected

Consumer AssistanceConsumer Assistance

Exchangeo Call centero Robust websiteo Navigator programo Outreach beyond

Navigators (not specified)

Medicaid/CHIPo 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 EligibilitySimplified 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 EligibilitySimplified 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 New Income & Household RulesRules

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 EligibilityChildren’s Eligibility

o Eliminates stair-step eligibility based on ageo 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 ApplicationSingle, 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 ExchangeThe 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 ProcessSimplified 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

CoordinationCoordination

o Single eligibility system/shared eligibility serviceo Consistent standards for eligibilityo Data exchanges between agencies o 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

RenewalRenewal

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 IssuesChallenges/Outstanding Issues

o Timeline for developing IT infrastructureo Electronic sources for “current” incomeo 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 InstituteGeorgetown Health Policy InstituteCenter for Children and FamiliesCenter for Children and Families

Tricia BrooksAssistant Professor – Georgetown HPI

Senior Fellow – HPI Center for Children and Families

pab62@georgetown.edu

202-365-9148

Our Website: http://ccf.georgetown.edu/

Say Ahhh! Our child health policy blog:http://www.theccfblog.org/