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

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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 – PowerPoint PPT presentation

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Title: Progress Enrolling Children in Medicaid and CHIP: New Estimates from the American Community Survey


1
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)

2
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

3
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.

4
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

5
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
  • 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 ___________________________

6
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
    childrenrevised 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.

7
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.

8
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 Childrens Health
Insurance Program? Health Affairs. 29(10)
1920-1929.
9
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 Number of children (0-18) by Survey and Coverage Type, after Logical Coverage Edits, 2008 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 dont know, refused,
not ascertained
10
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.

11
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
Centers 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.
12
Uninsurance Rate and Number Uninsured Among
Children (0-18) Eligible for Medicaid/CHIP, 2008
and 2009
2008
2009
Number
Rate
11.7
4.7 million
10.2
4.3 million
Source Analysis of Urban Institute Health Policy
Centers 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.
13
Changes in Medicaid/CHIP Participation Rates
between 2008 and 2009
Source Analysis of Urban Institute Health Policy
Centers 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.
14
Medicaid/CHIP Participation Rates by Region, 2008
and 2009
2008
2009
82.1
Source Analysis of Urban Institute Health Policy
Centers 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.
15
Increases in Medicaid/ CHIP Participation Rates
Among Children (0-18) by State, 2008 to 2009
URBAN INSTITUTE
16
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
Centers 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.
17
Number of Eligible but Uninsured Children for
Selected States, 2009
Source Analysis of Urban Institute Health Policy
Centers 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.
18
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
Centers 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.
19
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.

20
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.

21
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


22
National Covering Kids and Families
Network Webinar September 13, 2011 Tricia
Brooks Georgetown University Health Policy
Institute Center for Children and Families
Simplification and Coordination in 2014
23
Building a Better System Based on Lessons Learned
from Covering Kids
  • Technology-enabled
  • Coordinated
  • Consumer-friendly
  • Simplified

24
Simple, Plain Language
  • Forms, notices, websites
  • In all formats (paper, electronic, verbal)
  • Accessible
  • Persons with limited English proficiency (LEP)
  • Disabled (meet 504 standards)
  • More guidance expected

25
Consumer Assistance
  • Exchange
  • Medicaid/CHIP
  • Call center
  • Robust website
  • Navigator program
  • Outreach beyond Navigators (not specified)
  • Outreach to vulnerable, underserved groups
  • Guidance expected
  • Assistance in person, over the phone, online
  • Applicant may elect for assistance through person
    of choice

26
Simplified Eligibility
  • All children and adults covered in Medicaid up to
    133 FPL
  • Collapses multiple Medicaid groups into 4
  • Excludes eligibility groups not based on income
  • Replaces disregards/deductions with flat 5
    percentage points (138 FPL)
  • No more asset tests
  • Same excluded groups as above

27
Simplified Eligibility
  • Presumptive eligibility
  • For adults, family planning services now
  • Hospitals gain prerogative in 2014
  • Provisions for express lane eligibility decisions
  • Assumes ELE does not sunset in 2013 according to
    CHIPRA (will require legislation)

28
New Income Household Rules
  • Consistent standards for all coverage options
  • Applies also to premium and cost-sharing
    subsidies in the Exchange
  • Modified Adjusted Gross Income (MAGI)
  • Its a methodology (formula), not a number
  • Household size tax filing unit (taxpayer(s)
    plus tax dependents)
  • A few exceptions (i.e. custodial parents not
    claiming child as tax dependent)

29
Childrens Eligibility
  • Eliminates stair-step eligibility based on age
  • States must convert current eligibility to
    effective MAGI standard and maintain level
    until 2019
  • Parent cannot enroll in Medicaid unless children
    have coverage

30
Single, Streamlined Application
  • No wrong door applicants are determined
    eligible for all options regardless of point of
    entry
  • Ability to apply online, over phone, via mail,
    in-person
  • Verification through electronic sources including
    new federal data hub
  • Real or near-real time determination

31
The Role of the Exchange
  • Authorized to make Medicaid decisions
  • Will transfer enrollment data to agency for
    Medicaid/CHIP
  • Must have robust website with electronic
    application using electronic signature
  • Regulations stop short of requiring
  • My account functionality
  • Third party access (navigators, application
    assistors)

32
Simplified Application Process
  • Minimal information
  • Cant ask questions not needed for eligibility
  • Cant require SSN for non-applicants (Medicaid)
  • No premium tax credits without SSN
  • No paper documentation
  • Cant require paperwork unless unable to verify
    through electronic sources
  • Establishes reasonable compatibility concept
    for differences in reported vs. electronic data

33
Coordination
  • 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
  • Seek comment on extending coverage through end of
    next month to align with Exchange

34
Renewal
  • Every 12 months
  • Automatic renewals if data is available
  • Report changes online, phone, mail, in person
  • Cannot require signature
  • Otherwise use pre-populated renewal forms
    Response online, phone, mail, in person
  • Electronic signature must be available

35
Challenges/Outstanding Issues
  • Timeline for developing IT infrastructure
  • Electronic sources for current income
  • Navigator tug of war
  • Brokers vs. community organizations
  • Access to affordable employer-based family
    coverage
  • Affordability lt 9.5 household income for
    individual coverage
  • CHIP waiting periods

36
Georgetown Health Policy Institute Center for
Children and Families
  • Tricia Brooks
  • Assistant Professor Georgetown HPI
  • Senior Fellow HPI Center for Children and
    Families
  • pab62_at_georgetown.edu
  • 202-365-9148
  • Our Website http//ccf.georgetown.edu/
  • Say Ahhh! Our child health policy
    bloghttp//www.theccfblog.org/
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