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CENTER ON BUDGET
~ AND POLICY PRIORITIES
December 6. /996
MILLIONS OF UNINSURED AND UNDERINSURED
CHILDREN ARE ELIGIBLE FOR MEDICAID
by
Laura Summer, Sharon Parrott and Cindy Mann
Summary of Findings
A new study completed by the Center on Budget and Policy Priorities finds that
millions of children who are likely to be eligible for Medicaid are not enrolled in the
program.
•
Nationally, in 1994, one-fifth of all poor and near-poor children under age 11
who were income-eligible for Medicaid - nearly 2.7 million children - were
neither enrolled in Medicaid nor covered by any other form of health
insurance.
•
These 2.7 million children accounted for nearly one-half of all the children
under age 11 who were uninsured in: i 994. If these children had been enrolled
in the Medicaid program, the number of uninsured children under age 11
would have been reduced by as much as 45 percent.
•
Nearly 80 percent of these uninsured children who were income-eligible for
Medicaid lived in families with earnings.
•
An additional 2.1 million children under age 11 who were income-eligible for
Medicaid but not enrolled in the program had some form of private health
insurance coverage at some time during the year. These children also could
have benefitted from Medicaid either because their private health care coverage
was not continuous throughout the year or because the services covered under
their private plan were much more limited than coverage available under
Medicaid. Additionally, Medicaid could have helped their families pay
premiums, copayments and deductibles that can create barriers to care
particularly for very low-income children..
Of particular significance, in light of the changes in welfare and Medicaid program
rules that result from the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, is the very low Medicaid participation rate among children who are not receiving
cash assistance (either AFDe or 551).
Tel: 202-408-1080
820 First Street, NE, Suite 510, Washington, DC 20002
Fax: 202-408-1056 center@center.cbpp.org http://www.cbpp.org
"~21
HN0026
�i.
•
In! 1994, only 38 percent of the Medicaid-eligible children under age 11 who did
nQt receive cash assistance were enrolled in the Medicaid program. In other
words, almost two-thirds (62 percent) of all chiidren who were not receiving
welfare but who were income-eligible for Medicaid were .not enrolled in the
pn)gram. More than half of these children were wholly uninsured.
Welfare law changes are likely to give rise to even lower Medicaid participation rates.
in the future, unless states revamp their Medicaid application procedures and outreach
strategies. Under the new law, the eligibility link between Medicaid and welfare is ended,
and states a:re no longer required to enroll all children who are receiving TANF-funded aid
onto the Medicaid program. Although Medicaid eligibility guarantees are maintained,
Medicaid enrollment could plummet if steps are not taken to maximize coordination
between welfare- programs and Medicaid.
Even if st~tes continue to enroll children who receive aid funded with TANF block
.grant dollars onto the Medicaid program, Medicaid enrollment is likely to be adversely
affected by other welfare law changes. Over time fewer children are expected to receive cash
aid because welfare rules will be more restrictive and because a large number of families are
expected to leav~ the welfare rolls as parents find work. Children who no longer qualify for
cash aid due to time limits and other restrictions, as well as many of the children whose
parents find low:-wage jobs, will continue to be eligible for Medicaid, but the data examined
here strongly suggests that if current patterns persistonly a small portion of these children
will actually be enrolled in the Medicaid program.
It is particularly important for states to devise new systems for reaching children
whose parents find work because these children are unlikely to be covered by employer
based health insu;rance. Department of Labor data show that in Apri11993, only roughly 40
percent of workers earning less than $5 an hour had employers that offered any of their
employees healtl} care coverage, and many of these workers were not eligible to enroll in the
employer-based plans because they worked part-time. Only 13 percent of all workers
earning less than $5 an hour had employer-based coverage for both themselves and their
families.
The Center's study also includes tables with estimates of Medicaid participation rates
for young children in all fifty states, based on data covering the years 1992 through 1994.
Participation rates across states vary considerably. A variety of factors influence these rates,
including. the scope of coverage under the state's welfare program, the uninsured rate within
the state, as well ~s steps the state has taken to make the Medicaid.program accessible to
diverse populations. Due to limited sample sizes in a number of states, however,
comparisons bet'teen individual states should generally be avoided.
The national and state data examined in this report demonstrate the potential for the
Medicaid program to provide health care coverage to a large portion of the children who are
uninsured or underinsured. The program is falling short of its potential, however, and the
changes in the welfare law and trends in the private market are likely to widen the gap
between eligibility and enrollment unless the states undertake aggressive new strategies to
reach out to eligible children.
�I;;'
CENTER ON BUDGET
~~\~......... AND POLICY PRIORITIES
~~
December 6,1996
MILLIONS OF UNINSURED AND UNDERINSURED CHILDREN
ARE ELIGIBLE FOR MEDICAID
by Laura Summer, Sharon Parrott and Cindy Mann
Overview
In 1995, some 3.1 million poor children under age 18 - approximately 21 percent
of all poor children - had no health insurance coverage. 1 Yet, many of these children
could have been insured because they were eligible for Medicaid, but were not enrolled
in the program.
Medicaid now offers health insurance coverage to a broad group of poor
children as a result of expansions in eligibility that began in the late 1980's and that are
being phased in over time. Under federal law, children under age six are eligible for
Medicaid if their family income is below 133 percent of the federal poverty line.
Children between the ages of six and 13 are currently eligible if their family income is
below 100 percent of the poverty line. Each year a new age group of children is
"phased in" so that by the year 2002, all poor children under age 19 will be eligible for
Medicaid.
Eligibility for coverage, however, does not necessarily translate into actual
coverage. This analysis examines national and state-specific Medicaid participation rates
for children under age 11 and finds that large numbers of income-eligible children were
not enrolled in the program. 2 Many of these children lacked any health insurance
1
U.S. Bureau of the Census, Current Population Survey, 1996.
2 National participation rate estimates are for 1994 based on data from the Census Bureau's 1995
Current Population Survey which provides income and health insurance information for 1994. For this
analysis, participation rates for children under age 11 were considered because in 1994, federal law
mandated Medicaid coverage for poor children under age 11. State-specific estimates were calculated
using data from Current Population Surveys for 1992, 1993, and 1994. Three years of data were used to
assure larger sample sizes. While some states have expanded coverage to older children or to children
with higher incomes, only the federal minimum standards were considered for both the national and state
level estimates. A description of the methodology used for the analysis is presented in Appendix II.
Tel: 202-408-1080
820 First Street, NE, Suite 510, Washington, DC 20002
Fax: 202-408-1056 center@center.cbpp.org http://www.cbpp.org
HN0026
�coverage, whpe the rest had some health insurance but likely received less adequate
coverage than is available under state Medicaid programs.
•
Nationally, in 1994, one-fifth of all poor and near-poor children under age
.,11 who were income-eligible for Medicaid - nearly 2.7 million children
were neither enrolled in Medicaid nor covered by any other form of
1;lealth insurance.3 Nearly 80 percent of these children lived in families
with earnings.
•
These 2.7 million children accounted for nearly half of all the children
under age 11 who were uni'nsured in 1994. If these Medicaid-eligible
children had been enrolled in the program, the number of uninsured
children under age 11 would have been reduced by as much as 45 percent.
•
-1\n additional 2.1 million children under age 11 who were eligible for
Medicaid but not enrolled in the program had some form of private health
insurance coverage at some time during the year. Despite being covered
by private health insurance, many of these children could have benefitted
from participating in the Medicaid program. First/ private plans available
t~9 families with very lo~-paying jobs often provide only minimal
coverage and frequently require families to pay a high portion of the costs
coverage and services. Medicaid can supplement private insurance and
relieve families of unaffordable premiums, deductibles and copayments
that can create barriers to accessing health care. In addition, some of these
children had health insurance for only part of the year. Medicaid
coverage would have allowed them to be insured throughout the year.
. qf
This an~lysis also provides state-level estimates of the number and proportion of
children eligible for Medicaid but not enrolled in the program. These figures show that
there are substantial numbers of children in every state who are not currently reached
by the Medicaid program/ despite their eligibility for coverage. Participation rates
across all states do vary considerably. However, due to the limited sample 'sizes in a
. numper of stat~s, comparisons between individual states should generally be avoided.
3 In this analysis, children are defined as "income-eligible" for Medicaid if they meet the federal age
and income eligibility requirements of the Medicaid program. States also may impose assets tests, and
therefore, some poor and near-poor children who are income-eligible may not qualify for Medicaid
coverage if the coUntable value of assets the family. owns exceeds the allowable limits. The data did not
allow for consideration of assets, but consideration of assets would likely have had only a small effect on
the estimates here:; (Currently,only ten states impose an asset test for children.) For simplicity, this
analysis will hereafter refer to those children who are "income-eligible" simply as children "eligible" for
Medicaid.
2
�The new welfare law (the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 or "PRWORA") could lead to even lower Medicaid
participation rates in the future. The new law makes profound changes in the welfare
system and in the relationship between cash assistance and Medicaid. The AFDC
program is replaced with a block grant that allows states broad flexibility to develop
new rules for income support and work programs while imposing stringent new work
requirements and time limits. Large numbers of families may no longer be eligible for
assistance as a result of federally-mandated or state-imposed restrictions that will limit
eligibility for cash aid and work programs. While the new law preserves Medicaid
eligibility for families who would have qualified for Medicaid under the prior law, the
data show that children in families who do not receive cash aid are much less likely to
enroll in the Medicaid program.
•
In 1994, only 38 percent of children under age 11 who did not receive cash
assistance but were eligible for Medicaid were enrolled in the Medicaid
program. In other words, almost two-thirds - 62 percent - of all
children who were not receiving welfare but who were eligible for
Medicaid were not enrolled in the program. More than half of these
children were wholly uninsured. 4
Moreover, Medicaid participation may drop even among those children who
remain eligible for cash assistance under the new block grant programs. Under the new
law, states are no longer required to automatically enroll children who receive
assistance under the block grant in the Medicaid program. This could result in
significant numbers of eligible children not receiving Medicaid if states do not take
steps to assure that these very poor children are enrolled in the program.
The welfare changes also are expected to result in many families becoming
ineligible for cash assistance because more parents will find jobs. Children in these
families are likely to remain eligible for Medicaid if their parents have low earnings, but
participation rates among children in working poor and near-poor families are
particularly low. As noted above, nearly 80 percent of the uninsured children under
age 11 who were eligible for Medicaid in 1994 but not enrolled in the program lived in
families with earnings.
Children.in families that become ineligible for cash assistance because their
parents find jobs are unlikely to be covered by employer-sponsored health insurance.
4 Because children recC:!iving Supplemental Security Income (SSI) benefits are also automatically
enrolled in the Medicaid program, these figures represent the proportion of children living in families
that receive neither AFDC nor SSI benefits.
3
�"
•
"
In April 1993, only roughly 40 percent of workers earning less than $5 an
hour had employers that offered any of their employees health care
coverage, and many workers whose employers did offer coverage were
not eligible to enroll in the employer-based plans often because they
~or ked part time.
"
•
Only 13 percent of all workers earning less than $5 an hour had employer
};lased coverage for both themselves and their families. s
I,
,
The expansions in Medicaid eligibility, still being phased in, could offset the
reduction in coverage resulting from the decline in employer-sponsored coverage
among poor children and could allow millions of uninsured and underinsured children
greater access: to health care. These data indicate, however, that the changes in welfare
policy and deClining employer-based coverage are likely to result in even more children
being uninsur¢d despite their eligibility for Medicaid unless states improve outreach.
and redesign ~heir Medicaid enrollment procedures.
Eligibility For Medicaid Has Expanded In Recent Years
To consider Medicaid participation rates both nationally and in individual states,
it is important' to begin with a review of the Medicaid eligibility rules. Medicaid began
as a program that provided health care coverage exclusively to individuals and families
receiving cash; assistance. Over the last decade, bipartisan support for covering a
greater portion of uninsured children under the Medicaid program has allowed large
numbers of pdor and near-poor children who are not receiving cash assistance to
qualify for Medicaid coverage. The shift in the Medicaid caseload has been dramatic.
In 1990, fewer ;than one-third of the children covered by Medicaid did not receive cash
assistance. Four years later,45 percent ofthe children served by the Medicaid program
were not receiving cash aid.6
"
Recent c;:hanges in federal Medicaid eligibility rules are largely responsible for
the expansions, in Medicaid coverage among low-income children who do not receive
cash assistance~ Currently, under federal law, children under age six with income
below 133 perdent of the poverty line and children ages six through 13 with income
below 100 percent of the poverty line are eligible for Medicaid. Eligibility for older ,
5 U.S. DepartIJ::lent of Labor, Social Security Administration, U.S. Small Business Administration, and
Pension Benefit Guaranty Corporation, Pension and Health Benefits of American Workers: New Findings from
the April 1993 Current Population Survey, 1994.
6
Calculations based on data from the Urban Institute.
4
�poor children is being phased in, so that by the year 2002, all poor children under age 19
will be eligible for coverage. 7
These minimum federal eligibility requirements, moreover, have been
augmented in many states; 40 states have expanded coverage beyond the federal
requirements to make the Medicaid program available to even more children who need
health insurance coverage. Currently, some 35 states and the District of Columbia
provide Medicaid coverage for infants at income levels above those mandated by
federal law, and eight states have raised the income limits for children through age six.
In addition, 21 states have speeded up the phase-in of eligibility for older children,
extending Medicaid coverage to children above the age limits required by federal law .
A table listing state Medicaid income eligibility standards for children, based on a
Center on Budget and Policy Priorities' survey of the 50 states and the District of
Columbia, is presented in Appendix I.
In addition, since the passage of the Family Support Act in 1988, Medicaid
coverage has been available to families who become ineligible for welfare because they
have new or increased earnings or child support. This "transitional" Medieaid coverage
is time-limited, but nonetheless is intended to assure that families do not lose their
health care coverage immediately upon finding a job or receiving child support that
makes them ineligible for welfare.s
Many Children Who Are Eligible for Medicaid Are Not Enrolled in the Program
Millions of children who are eligible for Medicaid under these expanded
Medicaid eligibility rules are not participating in the program. Although Medicaid
income eligibility standards vary among states, it is possible to examine Medicaid
participation rates across all states by determining the portion of children whose family
income is below the federal minimum standards who are participating in the Medicaid
program. In 1994, the most recent year for which data are available, children under age
six with family incomes below 133 percent of the federal poverty line and children ages
7 Under federal law, children age six and older and born after September 30,1983 are eligible for
Medicaid if their family income is below the poverty line. Thus, as of October, 1996, all states must cover
children who are 13, and the age limit rises over time. In addition to these income eligibility standards,
federal law allows states to impose an asset limit. Currently, only ten states impose an asset test for
children, and two of these states do not consider assets for very young children.
8 Transitional Medicaid coverage due to earnings is limited to 12 months while transitional Medicaid
coverage due to child support is limited to four months. Twelve states, however, have used the waiver
process to increase the number of months of transitional Medicaid coverage.
5
�six through li'with family incomes below 100 percent of the federal poverty line were '.
"
,
eligible for Medicaid.9
•
¥ore than one-third of all children under age 11 who were eligible for
¥edicaid were not enrolled in the program in 1994. This represented 4.8
million children.
•
¥ore than half of the 4.8 million children eligible but not enrolled in
¥edicaid - nearly 2.7 million children - were wholly uninsured. Stated
another way, one-fifth ofall children who were eligible for Medicaid lacked any
form ofhealth insurance.
"
•
These 2.7 million children account for 45 percent of the 5.9 million
children under age 11 who were uninsured in 1994.
•
Nearly 80 percent of the children who were eligible for Medicaid but who
were wholly uninsured - more than 2 million children -lived in
f~milies with earnings.
•
An additional 2.1 million children who were eligible for Medicaid but not
enrolled had some form of private health insurance. Despite having
private health insurance, many of these children could have benefitted
qom the Medicaid program. Medicaid pays for those benefits that are
cQveredby Medicaid but not covered by the private plan and helps
families afford the premiums, deductibles and copayments charged by
~eir private health insurance. '
"
It is not possible to determine from the data what type of insurance these 2.1
million children had. However, many PO(;>r children with private insurance coverage
are likely to have limited benefit packages that may not cover preventive care or
specialty services. Thus, while these 2.1 million children fall into the "insured" category,
they may lack (1ccess to routine care, and those with special health care needs may not
be able to access the medical care they require. In addition, some of these 2.1 million
children were covered by private health insurance for only part of the year. (The
Census data do not distinguish between children covered for part and all of the year.)
"
The follOWing data are based on the Census Bureaus' 1995 Current Population Survey. The '
calculations reflect, Medicaid income eligibility rules in effect in 1994.
9
6
".
�•
Medicaid coverage would have ensured that these children were not left uninsured
during those months when they were not covered by private insurance. lO
5ince cash assistance recipients in 1994 were automatically enrolled in Medicaid,
the Medicaid participation rates among children who did not receive cash aid are
particularly telling. These rates are quite low:
•
Nationally, in 1994, only 38 percent of poor and near-poor children who
did not receive AFDC or 55I but who were eligible for Medicaid were
enrolled in the program. In other words, almost two-thirds - 62 percent
- of all children under age 11 who were not receiving welfare but who
were eligible for Medicaid were not enrolled. More than half of these
children were wholly uninsured.
These very low participation rates among children who do not receive cash
assistance are particularly worrisome given program changes prompted by the new
welfare law that are likely to result in many fewer children receiving cash aid.
State Estimates
Table I shows estimates for each state of the number and proportion of Medicaid
eligible children who were not enrolled in the program. These estimates are based on
data from 1992-1994. While small sample sizes make comparing participation rates
across states ill-advised, taken as a whole, the data do show significant state variation in
the participation rates among eligible children in the Medicaid program.
There are many reasons for such variation. One reason why participation rates
will vary is that states in which a larger proportion of poor and near-poor children
participate in the AFDC or 55I programs will tend to have a larger proportion of
eligible children participating in the Medicaid program. Table II addresses this issue
and show the number and proportion of income-eligible children not receiving AFDC
and 55I who were not enrolled in Medicaid.
In addition, states in which a larger portion of Medicaid-eligible children have
private health insurance coverage may have lower Medicaid participation rates. Table
III shows the number and proportion of eligible children not receiving AFDC or 55I
who were wholly unirtsured.
10 A May 1996 Census report, "Who Loses Coverage and For How Long," shows that while 93 percent
of all people had health insurance at some point during 1993, some 15 percent pi these "insured"
individuals lacked health insurance for at least one month during the year.
7
�The variations in Medicaid participation rates across states may also be due in
part to state administrative procedures and outreach efforts. Some states, for example,
use one-page application forms and allow applicants to submit their forms by mail.
Such simplifie,d procedures are particularly important for working poor families unable
to take time o~f from their jobs to apply in person and to families in rural areas or other
communities ~here a lack of public transportation makes it difficult for families to
come to the Medicaid office. In some communities, child care agencies, schools and
health care providers, such as visiting nurses, community health centers, and hospitals
help to enroll eligible families onto the program. In addition, some states have taken
advantage of opportunities to improve participation rates by linking Medicaid
eligibility dete,rminations to other programs with similar eligibility rules, such as the
WIC program~ Head Start, and other child care programs.
~.
More Eligible Children Could Be Uninsured In the Future
Provisions in the new welfare law coupled with low and declining rates of
employer-proyided health care coverage for children could mean even greater numbers
of Medicaid-eligible children not participating in the program in the future. A large
portion of the~e children will likely be wholly uninsured.
New Welfare Law Could Affect Medicaid Participation
Although it is commonly believed that the welfare law enacted in August 1996
did not include any significant changes in the Medicaid program, the.new law does
affect Medicaid eligibility arid participation in fundamental ways. These changes could
result in great¢r numbers of children who are eligible for Medicaid but not enrolled in
the program. ;
I
Sinceth~ beginning of the Medicaid program, eligibility for AFDC and Medicaid
have been linked. Families receiving AFDC have been automatically eligible for
Medicaid and e,nrolled in the Medicaid program. The Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, however, replaced the AFDC program
with the Temporary Assistance to Needy Families ("TANF") block grant. Under the
block grant, states have broad flexibility to design income support and workprograms
for low-incomefa~ilies with children and are required to impose federally-mandated
restrictions, suCh as. time limits, on federally-funded assistance. The law does assure,
however, that children and parents who would have qualified for Medicaid based on
.their eligibility ;tor AFDC continue to be eligible for Medicaid regardless of whether
they qualify for assistance under a program or programs that states establish with block
8
�Continued Phase-In of Medicaid Coverage for Poor Children Will
Increase the Number of Children Eligible for Medicaid and the Need for Outreach
In addition to the changes in the new welfare law, the continued phase-in of the
recent Medicaid expansions means that large numbers of additional children will become
eligible for Medicaid in the future. Under federal law, children under age six below 133
percent of the poverty line and poor children ages six and older born after September 30,
1983 are eligible for Medicaid. As a result, in 1994 poor children ages six through 11 were
eligible for Medicaid while currently poor children ages six through 13 are eligible. By 2002,
poor children under the age of 19 will be eligible for Medicaid.
In 1994, there were nearly 2.4 million poor children ov~r the age of 11 who did not
receive Medicaid, a rough estimate of the number of additional children who will become
eligible and could be enrolled in Medicaid in the corning years.
grant funds. This is accomplished by carrying over to the Medicaid program certain
eligibility rules from state AFDC programs. ll
While children will not lose eligibility for Medicaid due to the new law, other
changes in the law may cause Medicaid participation rates to drop substantially.
•
Fewer children are likely to receive cash assistance under the new law due
to restrictions placed on receipt of aid. States are required to impose a
maximum five-year time limit on assistance funded with federal block
grant dollars and are permitted to impose shorter time limits. States are
also given vast new authority to limit access to assistance in other ways,
such as by lowering income-eligibility limits and by limiting aid to teen
parents.
Children who no longer receive cash assistance due to such restrictions
generally will be eligible for Medicaid, but they are likely to have low
Medicaid participation rates. As noted above, close to two-thirds of the
11 Under the welfare law, children and parents whose income and assets are below the state's AFDC
income and resource standards in effect as of July 1996 and who meet the AFDC family composition rules
in effect as of July 1996 will qualify for Medicaid. If a state has an AFDC waiver.that affects these
eligibility rules, the state may have the option to continue applying its waiver rules. States also have
certain options to vary their income and asset standards and their rules for calculating financial eligibility.
A state may lower the income standards for determining eligibility for older children and parents, but not
below the levels that were in place in the state's AFDC program in May 1988. States may also raise their
income and asset standards, but not by an amount that is greater than the raise in the Consumer Price
Index. For more discussion of these new rules see, Cindy Mann, An Analysis of the AFDC-Related Medicaid
Provisions in the New Welfare Law, Center on Budget and Policy Priorities, revised November 7, 1996.
9
�~hildren eligible for Medicaid who did not receive cash assistance - 62
percent - were not enrolled in the program in 1994.
•
Medicaid participation may decline even among children who remain
eligible for cash assistance and work programs funded under the block
grant. Under the new law, there is no requirement that states
automatically enroll children who receive aid funded under the TANF
plock grant in the Medicaid program. States have a number of options,
however, under the law that allow them to keep Medicaid and welfare
program rules aligned and to assure that children who receive cash aid
and who are eligible for Medicaid are enrolled in the Medicaid program.
(See box on page 11.)
.
•
Fewer children may also qualify for cash assistance because their parents
find jobs. The new law requires states to place increasing numbers of
parents in work activities, and the law is expected to result in greater
humber of parents finding employment. While many of the children'
whose parents become employed are likely to remain eligible for
Medicaid due to the low earnings of their parents; Medicaid participation
rates among children in poor and near-poor working families are quite
low.
.
In addition to these welfare-related changes, the new law makes significant
changes in eligibility for children under the federal Supplemental Security Income (SSI)
program. Unqer the law, a substantial number of children will lose SSI benefits - and,
therefore, their automatic eligibility for Medicaid - due to new restrictions in the
definition of disability. A majority of the children who are no longer eligible for SSI will
be eligible for Medfcaid under alternative avenues of coverage - many, for example,
will meet the age and income eligibility criteria for Medicaid - but enrollment of these
poor children jvho have significant medical problems will no longer be automatic.12
The extent to which states develop new approaches to assure that eligible
children are enrolled in Medicaid thus will have a considerable effect on Medicaid
12 Children who are currently receiving 55! but who become ineligible under the new disability
standards should, not·be terminated from Medicaid coverage unless and until the state determines that
they are not eligible under an alternate eligibility category. See HCFA fact sheet entitled "Link Between
Medicaid and 55I!Coverage of Children Under Welfare Reform." The Medicaid enrollment issue
discussed here, tllerefore, concerns children who would have qualified for 55I in the future, not to current
SSI recipients.
.
10
C
�States Can Coordinate Medicaid and Welfare Program Enrollment
Although the new law does not require states to enroll all children who receive cash
assistance under the TANF block grant into the Medicaid program, states could design their
welfare and Medicaid systems so there is a single eligibility determination for both programs.
The new law allows states flexibility in determining how they will administer their Medicaid
program and the extent to which Medicaid rules and the rules for the program(s) funded
with TANF block grant dollars will be the same.
The more closely the eligibility rules for the welfare arid Medicaid programs are
aligned, the easier it will be to coordinate program enrollment. For example, if a state keeps
the basic financial eligibility rules for its new welfare program and for Medicaid consistent, a
single application form can be used to determine eligibility under both programs and a single
agency could make the eligibility determination. Coordination also can be achieved even in
states that choose to change their welfare rules as long as the new rules are no more
restrictive than the rules that were in effect in July 1996. The new welfare law maintains
current rules as the minimum standard for Medicaid; states can modify and simplify their
rules so long as the changes do not result in families losing coverage under the Medicaid
program."
Even if a state imposes restrictions or lowers eligibility standards for its TANF-funded
program in ways that would not be allowed under Medicaid rules, a single application could
still be used for the two programs since all TANF program recipients would likely still be
eligible for Medicaid. The state could maximize participation in Medicaid (and limit state
administrative costs) by coordinating eligibility between the two programs. The state would,
however, have to ensure that children and parents who did not qualify for TANF-funded
assistance are separately evaluated for Medicaid eligibility.
a States that keep welfare and Medicaid rules consistent may be able to minimize their state
administrative costs and maximize their federal reimbursement. States can claim federal Medicaid
administrative matching funds to cover the cost of determining eligibility under Medicaid, whereas
under the TANF block grant, states do not receive additional federal funds for administration. If the
eligibility process for the two programs remains closely linked, the work done on Medicaid could
significantly simplify the administrative tasks required to determine eligibility for aid under TANF.
participation rates both among children who remain eligible for cash assistance and
those who no longer qualifyY
13There are other changes in the new welfare law affecting Medicaid. Most significant is that most
legal immigrants of any age who enter the country on or after August 22, 1996 (the day the new law was
enacted) will not be eligible for Medicaid. Immigrants who are already in the country can be covered at
state option. States that choose to withdraw Medicaid coverage for legal immigrants could see significant
increases in the number of uninsured people.
11
�Declines in Employer-Based Health Care Coverage
. The number of low-income parents who work may increase as a result of
changes in w~,lfare programs and policies. However, few of the children in these
families are likely to be covered in an employer-sponsored health plan.
•
In April 1993, when the minimum wage stood at $4.25, only 21 percent of
workers between the ages of 25 and 34 who earned less than $5 an hour
were covered by an employer-provided health insurance plan.
•
•
Similarly, among all workers earning less than $5 an hour, only 13 percent
had employer-provided health care coverage for both themselves and
their families. Among those earning between $5 and $7.50 an hour, only
26 percent had employer-provided coverage for both themselves al}d their
families.
Some low-wage workers who are not covered by an employer-based
health care plan are covered by other private health insurance plans,
. ~cluding employer-based plans of other family members. Among those
earning less than $5 an hour in private sector firms, however, nearly 60
percent worked in firms that did not offer any of their employees health
~surance coverage. Among those that worked in firms that offered
health insurance coverage to at least some of their workers, almost one
third reported being ineligible for coverage. The most common reason
cited for ineligibility was that the employee work~d part timeY
I
•
Census figures show that in 1995, only about two-thirds of children under
age 18 - 66.4 percent - had private health insurance coverage, down
from about three quarters '-. 73.8 percent - in 1988.
j
.
'
Conclusion
Already, large numbers of eligible. children are not enrolled in the Medicaid
program, and,~any ofthose eligible but not enrolled lack any form of health insurance.
Changes in the new welfare law coupled with low and declining rates of health
insurance cov~rage through the workplace could mean that more Medicaid-eligible
children will lack adequate health care coverage in the future. It is, therefore, more
important than ever for states to improve their efforts to inform low-income families of
their potential:eligibility for Medicaid and to reexamine their systems for enrolling
children and f~milies in the Medicaid program.
14 U.S. Department of Labor, Social Security Administration, U.S. Small Business Administration, and
Pension Benefit Guaranty Corporation, Pension and Health Benefits of American Workers: NI!'W Findings from
the April 1993 Current Population Survey, 1994.
1
•
12
�Table I
Percent and Number of Children Under 11 Who Were
Income-Eligible For Medicaid But Not Enrolled
Number
Percent
.l.Q.w
High
Alabama
Alaska
Arizona
Arkansas
Califomia
Colorado
Connecticut
Delaware
Dis!. of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
. Wyoming
U.S.
.l.Q.w
High
36.9%
24.7%
35.4%
36.2%
33.5%
28.9%
22.8%
30.2%
13.7%
29.6%
29.1%
34.5%
36.2%
24.0%
22.1%
39.7%
29.0%
17.8%
29.9%
21.1%
' 36.2%
25.3%
20.2%
25.0%
22.30/0
26.1%
23.4%
36.7%
51.6%
21.5%
28,0%
30.4%
25.4%
30.3%
25.7%
24.2%
43.5%
31.1%
32.1%
21.4%
23.8%
40.3%
17.1%
37.1%
40.5%
10.9%
40.2%
24.7%
20.6%
27.4%
34.0%
51.0%
38.7%
48.3%
49.7%
38.1%
46.2%
40.1%
49.1%
24.1%
35.7%
43.8%
51.8%
48.5%
30.7%
34.8%
56.2%
43.6%
28.9%
41.4%
36.7%
52.2%
34.4%
26.4%
40.5%
33.1%
39.8%
37.7%
52.6%
66.1%
39.0%
36.5%
42.7%
30.4%
37.6%
41.3%
31.0%
56.4%
47.4%
40.0%
38.2%
34.4%
53.8%
28.3%
43.2%
55.6%
25.1%
56.2%
39.6%
33.1%
42.7%
53.4%
72,000
4,200
74,700
42.000
673,700
29,100
22,900
5,400
5,700
216,100
70,200
12,800
18,800
135,200
55,500
34,800
25,500
33,400
92,400
8,700
62,500
41,500
93,200
35,500
33,800
62,000
7,300
18,600
27,200
7,200
68,400
26,700
230,600
87,000
4,600
116,400
75,400
32,200
144,900
6,200
46,300
11,800
37,000
427,100
26,600
1,800
66,400
40,600
18,200
41.900
4.700
130,000
8,900
130,800
75,200
838,100
66,200
58,600
13,000
13,000
296,500
142,500
26,800
32,400
200,400
116,600
68,100
51,900
70,700
160,500
21,100
124,400
68,500
141,100
80,100
63,300
125,800
15,600
36,400
46.500
19,200
106,800
47,600
307,300
125,300
10,300
173,600
125,700 .
68,400
212,400
16,300
84,100
20,500
80,500
560,900
48,800
·6,000
127,600
89,300
38,200
89,300
11,000
35.2%
37.5%
4,650,700
4.946,900
How to Read This Table:
In the period 1992-1994, between 37 and 51 percent 01 children income-eligible lor Medicaid were not
enrolled in Alabama. This translates into between 72,000 and 130,000 children who were eligible but
not enrolled in Medicaid in 1994.
Source: Center on Budget and Policy Priorities calculations based on pooled data from the Census
Bureau's 1993, 1994, and 1995 March Current Population Surveys.
13
�,.
Table I NOTES:
,
1:To detennine the Medicaid participation rates, children were considered income eligible for Medicaid
if 'they met the age and income-eligibility requirements lor Medicaid in the year they were interviewed for
the Current Population Survey. In each year, children under age six with incomes below 133 percent of
pOverty were considered income-eligible for Medicaid. Those interviewed in 1993 were considered
iricome-eligible for Medicaid if they were between the ages of 6 and 8 and had incomes below the
pOverty line. Those interviewed in 1994 were considered income-eligible for Medicaid il they were
between the ages of 6 and 9 and had incomes below the poverty line. Those interviewd in 1995 were
considered income-eligible for Medicaid if they were between the ages of 6 and 10 and had incomes
below the poverty line. To calculate the number 01 children income eligible lor Medicaid but not
enrolled, the Medicaid participation rates were multiplied by the estimate of the number of children who
would have met the 1994 Medicaid eligibility standards averaged over each of the three survey years.
2. For detailed description of the methodology used, see Appendix II.
�Table II
Percent and Number of Children Under 11 Who Did Not Receive AFDC or SSI
And Who Were Income-Eligible for Medicaid But Not Enrolled
Number
Percent
l.2w:
1fuJh
J.gy,£
1fuJh
126.900
8,900
132,700
66,600
820,100
65,300
53,900
12,700
12.500
290,300
143,100
25,500
32,400
195,800
116,900
64,300
50,000
70,900
150,200
20,800
120,800
65,700
140,900
65,600
116,200
15,200
34,900
44,700
20,500
106,600
46,700
298,900
121,500
10,400
165,300
125,400
66,900
206,500
15,200
82,900
20,800
79,900
545,000
48,500
5,800
125,900
86,800
38,100
87,600
10,600
4,768,000
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dis!. of Col.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
57.3%
64.0%
49.6%
44.6%
62.5%
36.1%
50.9%
54.7%
26.4%
56.7%
62.4%
43.3%
66.8%
60.9%
55.4%
58.2%
71.4%
57.2%
74.3%
81.0%
63.2%
85.9%
83.9%
70.000
4.100
76,000
35,800
657,900
28,800
21,100
5.500
5,100
209,900
70.600
12,300
18,900
130,600
54,400
33,100
24,100
32,700
85,400
8,500
60,900
39,300
91,600
33,400
34,500
55,500
7,000
17,700
26,300
7,900
68,400
26,000
222.700
83,500
4,600
108,900
76,800
31,500
141,000
5,500
44,700
12,300
35,300
413,400
26,500
1,500
66,300
41,500
17,800
42,700
4,600
U.S.
60.6%
63.6%
4,542,900
48.2%
50.1%
55.5%
47.8%
59.7%
51.8%
64.7%
55.1%
42.5%
50.4%
45.9%
60.5%
57.0%
57.3%
37.3%
65.7%
50.9%
38.2%
58.2%
39.7%
63.70/0
59.8%
50.3%
59.6%
46.3%
45.1%
41.5%
60.0%
65.9%
52.2%
62.9%
51.3%
63.0%
49.3%
47.8%
60.4%
~7.9"10
64.2%
71.5%
71.4%
64.2%
65.8%
73.9%
88.8%
n.1%
65.6%
58.9%
64.4%
81.4%
72.0%
68.6%
55.4%
84.2%
70.8%
56.7%
74.0%
62.5%
82.8%
74.1%
61.9%
83.1%
63:6%
64.2%
61.3%
79.3%
80.5%
78.7%
75.2%
67.6%
71.4%
59.2%
70.2%
72.3%
81.5%
78.0%
74.7%
n.3%
60.5%
n.9%
n,2oo
How To Read This Table:
In the period 1992-1994, between 48 and 62 percent of children who did not receive AFDC or SSI and
were income-eligible lor Medicaid were not enrolled in Alabama. This translates into between 70,000
and 126,900 children who did not receive AFDC or SSI and who were eligible but not enrolled in
Medicaid in 1994.
Source: Center on Budget and Policy Priorities calculations based on pooled data from the Census
Bureau's 1993, 1994, and 1995 March Current Population Surveys.
15
�TABLE II NOTES:
1. To detennine the Medicaid participation rates. children were considered income eligible for Medicaid if
ti1Ely met the age and income-eligibility requirements for Medicaid in the year they were interviewed for the
Current Population Survey. In each year. children under age six with incomes below 133 percent of poverty
were considered income-eligible for Medicaid. Those interviewed in 1993 were considered income-eligible for
Medicaid if they were between the ages of 6 and 8 and had incomes below the poverty line. Those
interviewd in 1994 were considered income-eligible for Medicaid if they were between the ages of 6 and 9
and had incomes below the poverty fine. Those interviewed in 1995 were'considered income-eligible for
Medicaid if they were between the ages of 6 and 10 and had incomes below the poverty line. To calculate
the number of children income eligible for Medicaid but not enrolled. the Medicaid participation rates were
multiplied by the estimate of the number of children who would have met the 1994 Medicaid eligibility
standards.
2. 'In this analysis, children whose families received any income from AFDC or SSI were excluded. Due to
dala limitations. we could not determine whether the child was an SSI recipient or whether someone else in
the family received SSI benefits.
'
3. 'For detailed description of the methodology used. see Appendix II.
"
I
i
\'
'I
�r
Table III
Percent and Number of Children Under 11 Who Old Not Receive AFDC or SSI
Who Were Income-Eligible For Medicaid But Were Not Covered by
Medicaid or Any Other Health Ins,urance Plan
Percent
.I..Iu!
Alabama
Alaska
Arizona
Arkansas
Cal~ornia
Colorado
Connecticut
Delaware
Dist.ofCol.
Aorida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
, Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakola
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
U.S.
,,
Number
tfuJh
Lm
' tfuJh
19.1%
5.8%
30.8%
20.8%
36.7%
15.6%
10.2%
6.9%
18.3%
26.6%
23.2%
17.0%
19.4%
23.2%
9.6%
21.8%
13.2%
15.0%
35.4%
4.7%
16.7%
23.1%
21.1%
5.1%
20.6%
12.2%
9.2%
12.0%
29.8%
19.1%
23.6%
30.8%
25.8%
19.7%
9.6%
23.5%
41.0%
17.9%
24.6%
19.4%
18.7%
12.6%
6.8%
31.4%
17.5%
0.9%
23.5%
19.1%
20.1%
25.9%
22.2%
33.1%
20.6%
46.6%
35.8%
42.9%
34.4%
35.9%
24.1%
36.9%
34.5%
40.4%
38.5%
33.2%
33.7"A.
22.9%
39.9%
29.9%
31.3%
51.8%
19.7"A.
35.7%
36.8%
31.4%
20.5%
36.4%
26.3%
22.6%
28.4%
45.7%
44.0%
35.9%
46.9%
33.9%
28.1%
27.2%
34.9%
56.9%
37.6%
35.2%
45.5%
32.5%
26.0%
20.2%
38.3%
32.4%
20.3%
40.8%
40.8%
38.3%
48.8%
46.9%
27,800
500
42.200
15,600
404,800
8,700
3,300
700
2,200
110.900
35.800
3,500
6.400
52.800
14,100
11,000
6,300
12,800
51,900
1,000
15,900
15,200
38,400
2,800
15.300
15,000
1,500
3.500
11.900
2,900
25.700
15.600
91.100
33.300
900
42,300
46.400
9.800
54,100
2.200
18,800
2.500
6.700
255.100
8,400
0
27,500
12,700
8.300
16.500
1,700
65,500
2.600
86,600
37.100
535.000
30,400
21,800
4.000
7,000
170.100
89.800
12,100
14.900
96.200
48,300
30.500
21,100
39,100
105.200
6,600
52,000
32.700
71,500
19,100
37,400
47,600
5,600
12,500
25.400
11,400
50.800
32,400
142.200
57.600
4.000
79,800
87.500
32.200
97,300
8.900
44.600
7,000
29,200
358.900
22.000
2.100
69,300
43,700
23,100
49.800
6.000
32.4%
35.3%
2,427.200
2;646.700
How To Read This Table:
In the period 1992·1994. between 19 and 33 percent of children who did not receive AFDC or SSI and
were income-eligible lor Medicaid were wholly uninsured in Alabama. This translates into between
27,000 and 65,500 children who did not receive AFDC or SSI and who were eligible for Medicaid but
lacked arry form of health insurance in 1994.
Source: Center on Budget and Policy Priorities calculations based on pooled data from the Census
Bureau's 1993. 1994. and 1995 March Current Population Surveys.
17
�.:
TABLE III NOTES:
1. 'To determine the proportion of Medicaid-eligible children who lacked health insurance, children were
considered income eligible tor Medicaid it they met the age and income-eligibility requirements tor Medicaid
in :the year they were interviewed tor the Current Population Survey. In each year, children under age six
with incomes below 133 percent ot poverty were considered income-eligible for Medicaid. Those intervieWed
in 1993 were considered income-eligible tor Medicaid it they were between the ages ot 6 and 8 and had
incpmes below the poverty line. Those interviewd in 1994 were considered income-eligible lor Medicaid it
th~y were between the ages ot 6 and 9 and had incomes below the poverty line. Those interviewed in 1995
we,re considered income-eligible for Medicaid it they were between the ages 016 and 10 and had iricomes
below the poverty line. To calculate the number ot children eligible lor Medicaid but laCking any health
in~urance, the estimates 01 the proportion ot Medicaid eligible children with no health insurance were
multiplied by the estimate of the number of children who would have met the 1994 Medicaid eligibility
standards.
2.:ln this analysis, children whose families received any income trom AFDC or SSI were excluded. Due to
data limitations, we could not determine whether the child was an SSI recipient or whether someone else in
the tamily received SSI benefits.
3. for detailed description ot the methodology used, see Appendix II.
I,
�·
Appendix I:
STATE
Medicaid Income Eligibility Guidelines for Children
Expressed As A Percent of the Federal Poverty Line
Infants (0_1)1
Children 11-6)1
Alabama
Alaska
Arizona
Arkansas
California3
133%
133%
140%
133%
200%
133%
133%
133%
133%
133%
Colorado
Connecticut
Delaware
D.C.
Florida
133%
185%
185%
185%
185%
133%
185%
133%
133%
133%
Georgia
Hawaii3
Idaho
Illinois
Indiana
185%
185%
133%
133%
150%
133%
133%
133%
133%
133%
Iowa
Kansas
Kentucky
Louisiana
Maine
185%
150%
185%
133%
185%
133%
133%
133%
133%
133%
Maryland3
Massachusetts3
Michigan
Minnesota3/4
Mississippi
185%
185%
185%
275%
185%
133%
·133%
150%
133%
133%
Missouri
Montana
Nebraska
Nevada
New Hampshire
185%
133%
150%
133%
185%
133%
133%
133%
133%
185%
New Jersey
New Mexico
NewYork3
North Carolina
North Dakota
185%
185%
185%
185%
133%
133%
185%
133%
133%
133%
19
Older Children 2
100% (under 14)
185% (under 13)
100% (under 19)
100% (under 19)
133% (under 19)
100% (under 17)
100% (under 19)
125% (under 19)
150% (under 15)
100% (under 19)
185% (under 19)
185% (under 19)
100% (under 18)
�-.
Infants (0 • 1) 1
STATE
Ohio
Oklahoma
Oregon
Pennsylvania)
Rhode Island
Children (1 - 6)1
133%
150%
133% '
185%
250%
133%
133%
133%
133%
250%
South Carolina
South Dakota
Tennessee
Texas
Utah
185%
133%
185%
185%
133%
133%
133%
133%
133%
133%
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
225%
133%
200%
150%
185%
133%
225%
133%
200%
133%
185%
133%
'
;
Older Children
100% (under 19)
, "
100% (born after 6/30/83)
100% (born after 6/30/83)
100% (under 18)
225% (under
100% (under
200% (under
100% (under
18)
19)
19)
19)
1. To be eligible in the infant category, a child is under age I and has not yet reached his or her first birthday. To be eligible in the 1-6
category, the child is older than age I and has not yet reached his or her sixth birthday.
2. If the last column in the 6hart is left blank, the state provides Medicaid coverage to children age six or older who were born after
September 30, 1983 and who have family incomes below 100 percent of the poverty line, as required by law. By October 1,2002 all
poor children under age 19 ~i11 be covered. If there is a notation in this column, it indicates that the state covers children in this age
group who have family incomes higher than 100 percent of the poverty line, or that the state covers children born before September 30,
1983, thereby accelerating ilie phase-in period. States that have taken such steps have done so either through Medicaid waivers or the
1902(r)(2) provision of the ~ocial Security Act.
3. The states noted operate state-funded health insurance programs available to children not eligible for Medicaid. Such programs may
provide benefits similar to ~e Medicaid program or they may provide a limited benefits package. State-funded.health insurance
programs for children are as follows:
California (under age 2): 300 percent of the poverty line
Hawaii (under age' 19): 300 percent of the poverty line; children older than 6 pay a premium
Maryland (under age 13): 185 percent of the poverty line
Massachusetts (under age 19): insurance buy-in program with sliding fee scale
Minnesota (under age 19): 275 percent of the poverty line
New York (under 1;5): insurance buy-in program with sliding fee scale
Pennsylvania (und~r 15): 185 percent of the poverty line
Colorado and Florida have state-funded health insurance programs for children, but these programs only are available to children in
certain counties.
4. The Medicaid program.in Minnesota covers infants and children under age 2 with family incomes below 275 percent of the poverty
line.
.
Cenler on Budgel and Policy Priorities
November 1996
.
20
2
�Appendix II: Methodology for Calculating State Estimates
'.
In this analysis, the March Current Population Surveys for 1993, 1994, and 1995
were used to develop state estimates of the number and percent of children eligible for
Medicaid who were not enrolled in the program and who lacked any form of health
insurance. 1 Three years of data were pooled to increase the sample size, and therefore
the accuracy; of state estimates. The methodology for pooling the data and calculating
the appropriate standard errors used in this analysis follows the Census Bureau's
recommended procedures.2
Estimating the Proportion ofChildren Eligible for Medicaid
Who Were Not Enrolled or Who Lacked Health Insurance
This paper looks at two different groups of children. Medicaid participation
rates and overall insurance coverage are reported for each of these two groups of
children.
The first group is comprised of all children who appear income-eligible for
Medicaid. Children were considered income-eligible for Medicaid if they met the
federal age and income eligibility requirements of the Medicaid program in place
during the year about which they were interviewed. For example, children interviewed
in 1993 about their income and health insurance coverage in 1992 were considered
income-eligible for Medicaid if, in 1992, they were below age 6 and had incomes below
133 percent of the poverty line or if they were between the ages of 6 and 8 and had.
incomes below the poverty line. For those children interviewed in subsequent years,
the Medicaid eligibility rules for the subsequent years were applied to determine if the
child was income-eligible for Medicaid.3 For each state in each survey year, estimates
were made of the proportion of income-eligible children who received Medicaid or had
some other form of health insurance. Following the methodology of the Census
Bureau, these estimates were averaged and then the "standard error" of that estimate
calculated in order to detennine the appropriate range or "confidence interval" around
the estimate.4
1 The Current Population Survey is conducted in March of each year and asks respondents about their
income and health care coverage for the prior year.
25ee the revised source and accuracy statement for the March 1995 CPS Microdata File.
3 Children above the age thresholds were not considered Medicaid-eligible even if they received AFDC
or 55!.
4Ninety percent confidence intervals were used.
21
�f
ji
!',
I
"
The second group is a subset of the first group and is comprised of those children
who both appeared income-eligible for Medicaid and lived in families that received
neither AFDC nor SSI benefits. Due to data limitations, it was impossible to determine
whether child~en were SSI recipients or whether other family members were receiving
SS!.
;,
Estimating the Number of Children Eligible for Medicaid
who Were Not Enrolled or Who, Lacked Any Form of Health Insurance
I,
,
The es~tnates of the proportion of Medicaid-eligible children who either were
not enrolled in, the Medicaid program or wholacked.any form of health insurance were
then applied t6 estimates of the number of children who met the 1994 Medicaid eligibility
rules. s This was done for both all children who were Medicaid eligible and those
children who "o/ere Medicaid eligible and whose families did not receive AFDC or SSL
"
For example, suppose that using the methodology described above, it is
estimated tha{in a particular state between 20 and 30 percent of children who were
income e1igibl~ for Medicaid did not receive Medicaid coverage. To translate 'that
estimate into the number of children lacking Medicaid coverage, the number of children
in that state who would have met the 1994 Medicaid eligibility guidelines was
calculated. Tl}is was done by determining the number of children in each of the three
survey years who would have met the 1994 Medicaid eligibility rules, averaging those
estimates, and creating a confidence interval around that average. Suppose in this state,
over the three:year period, an average of between 130,000 and 160,000 children would
have met the 1994 eligibility standards. The estimate that between 20 and 30 percent of
these children would have failed to actually receive coverage was used to calculate that
in 1994 rough~y 26,0006 to 48,000 7 children in this state lacked Medicaid coverage.
"
j
,
'
.5These are th~ eligibility rules used in the calculations to determine the proportion of children not
receiving Medicaid or lacking health insurance for those children interviewed in 1995.
6
Calculated by taking 20 percent of 130,000 children.
II
~
.
!
.I
7 Calculated
,?y taking 30 percent of 160,000 children.
22
JO)
"
.
'. " \
'
~
..
'<
I
I
�fPosr
1U/f51f//</4?pV
Democrats to Seek Expansion of Hf'.althCoverae.;~for·Chil~eI?-
.~
,c
,
, ' F e w would dIsagree. but Repubh
Stan Dom of the Children s Ut
callS, whose support w~!Jld be cru ienseFund. another backer of Kk
cial for any of these efforts to ·suc dycare, said the 1987 National Mec
.ceed. say they want to see the actual ical Expenditure Survey. the mo~
proposals before signaling their sup· recent; found that ont~third of unir
port.
sl,Ired children with two or more ea
"Senator Roth is concerned th.. 1 infedions .and' a' majority of unir.
health care be available to children.~ sured Child(eil With asthma "neve
said an aide to Senate Financt' Com· saw a physici~n."
,
mittee Chairman William V. Roth Jr,
Vespite the emotional appeal (
i CR-Del.). "He would like to see tilt" broadening coverage for childrer
idetails of the proposals befort' com· the propo..-;als could beg down in di}
Inenting."
pules over how much to spenc'
ii Already. thougn,acoalitiono( where to get the mon~y" whethe
Ctlildreu's groups is gathering behind the plans would affect eXlstmg ~or~
i the "Kiddycare" concept. the label place insurance ro~e~~ge, of chddre
being attached to many of these pro and whelher the 1I11t1a~lves woul
posals. And. as their Democratk create a new federal entltle,ment.
backers rt'alize. the concept ha:,' The mllst frequently cIted c?n
strong political appeal for the mil- n'rn i:; the potential for somet~n
_
.;;~~~~~~~~:;=~
liolls of families \\'ithout ("()\·era~t'. nilled"substitution"-the not!o
,
,Within the administration, Secre- people such a:; R~ and Elaine Gaith- that emoloyers may st~p o,ffenn
tary of Health and Human
er or
Md.
. coverage' for children of their wod
".;
Donna E. Shalttla ~ made It knotyn
111e Gaithers eam about $40,000 ers if they know thegc1vernment wi
.,: ~king for a more measured "YBYShe strongly ~N,~ ,. ~e<. acti~' to a year, but they dOll~t get health il!- provide it.
.
,
to:..exJl8I1d health c::are to those Wlth- expand cov~ge j) '.chi!~' ~d 'on surance on the jOb and sa)" tht'y can t
"My only concern is that whateve
~9t it. congressional D~mocrats ~veral ~o~ Presl~~t Clint~n afford the $3,600 to $4,500 that Ithey do, it should not weaken the e>
~,~ decid~ to malre ~edical cover- linnself. has !Ildicated. ~ ~tere~t: III .buying ~surance would ~st them. )sting employer system," said Bi
~ for ~'~m:~ o~e of ~~
.g~Ht#,~*en.:as. The SIZE:' of the family payche,rk :Gradison. president of the H~th.lr
their, top legislative pnonties m the~ as it
. ""tHe .~9~~exf.;~f;sounds p~ett)" r.. spe~~tabl~. admit:' Isurance Association of Amenc,
e
lJItW:.Coogress.
•.
' ;•. balanced \ . ~'?::}, ;:.::',. Elaine G~lther. But It shrinks verY.:"They might say, 'We don't have t
The pro~. bemg drafted by;":, About l~ 1llillioq)'¢e~can chtl- substantially after taxe~, houst:! Ido it. The government will do it.' ..
~te' Minonty Leader
.A.~tlren, a;e WlthO~t 6¢aJ,t}l msurance,;. costs, cars 10 go to work, .food~lId ~ Gradison and others are also COl
~,.Schle (S.D.), House M,nonty~.",rding to e;sti1l¥1t :~J,the Gen- clothing for three really fas~·growmg :cerned that if insurers. are require
£:.eader Richa,rd A. Gephardt (Mo,) fal Accountmg'{?f,1<;e.}3e~a~se children and other day·to~day ex., Ito take any subsidized child who af
1.jicl other key: Democrats, essential- . " Y ~ l11!lIion of .those: ai'~,eUgJ.bl~ pellseS.~ she said, "I get very ("re: Iplies to them, part ofthe cost of COl
icOuIdaeate·a new class offt;d~, M~d, ~ of the De.mocrats ative'Vt,th how far a pound ,of meat lering these'chiJdren may be pushe
iodal supporL Some of tJ:e lWtia.. ~~rt wiD be aJJlled at spumng t.hese can go,"
':
.
onto existing policyholders..
~ would offer a ~ credit to help1W'ents ~o ~e advantage of thIS al ,Once they had lllsurance i>ased on i On the political front, obstacles a'
hfamily bt,tythelr chUdren a health,J.ea!iy exISting federal pr?wam .
a job she held. but when she lefn~e fso loom
" ,
:ire policy, while others would offer"~ .But many more ambitious plans 'oba few years ago, they lost., It. Con ~essional Repl!lblicanaide
1 dir~ federal subsidy of some :are
the works: Among the m?st Since then they hav~ been searc~1Ilg
te ~t conservativeH have geneI
:ype.
. . detailed thu~ Iilr IS a proposal bemg for a modest-co.<;~ Insurance pohcy, no
f' Although the details are still beingld,rafted by !XII';. Edward M, Kennf> or at least somethmgthat would pro
any shown a resistance to initiative
torked out. most of the measures'i!t (D..Mass.) and John F~ Ke.rry (I" !tel't their children. But ~) far th~y that involve mass federal subsidies.
Deus 00 dUldren in families that fall Mass,) that would provide grants t~ha\'en't foundil 'good pobey that I'; "Republicans generaUy prefer ta
credits that would allow the marke
~tween the crack~: They're. n~t the states to help families afford .. 1:-:) affordable., .'.,
lOOI'.enough to qualify for MedicaJ~ health insurance for their children.
I w()r~y eH'r~ da~, ~"'~Id t h~ system to work," said one aide.
Jut DOt affluent enougt;a to pay for The PIan would target families in Hnwilr~ C()unt~' ~voman. I \'e, ~?t While some conservative polie
mvate inSurance entlrely out of that no man's land-that is, those three ki~s. one \\,th asth~la,\\ hl~ h groups such as the Heritage FQ1.tnd2
6eIr own pocket.
h
t poor enough to be eligi- re,llIy fnghtens me, Once. III (I while
ed tha th
bI
f chiJ
;J3y focusing on chUdren's health, ~e°f~~e~~dicaid but who don't get he ~l't,s, a ~U\d attack, II S ;1 scary ::n?:~:Uth ~ on~ ~:~rt~~:die&;
lae Democrats believe:: the~ .have insurance on the job and can't afford proposltton, , . '
ing. they were quick to ,challengeth.
~ on an issue that IS politically to pay for it themselves. Under the Group::; hlllng up III suPP?rt or
poe palatable than the ambitious Kennedy-Kerry plan. families would Ihese init!atives say that children Kennedy plan or anything like it tha
tealth care reform plan that col- be paid a federlll sub$;idy that would who aren t (~overed often end up establishes what they view as a ne\
~ In CIiDton'lil first tenn. And by gradullUy decrellse ..s their income Il{'\ er g~tting treatment when they federal entitlement.
itdng a ,more tempered approach, went uo.
ht',ollw I I I . '
,"We hope to draft a plan or polic:
Bey bope to build ~ the ~~ The plan would cost between $20 ~What happe~s to ~nill~u:ed .chll concepts that conl'iervativ~s coull
~ f!st year m the bipartisan billion to $24 billion over five years dren? Usua!l! their flllancially accept." said Heritage':; Carrie Ga
1fort to pass the Kassebaum-Ken- and would allow tiubsidies for a rna strapped fanuhes, tel!d 10 ~elay or \'ora. That plan. she asmred. woolf
~ biD that strengthened coverage jority of uncovered children. accord iorgo needed pedIatriC medl~1 car~ bear little resemblance to the Ken
lfthe unemployed,
iitg,to one estinlate. As conceived. ~t bel~<lU~e ~f the ,out-of-pocket ex_ nedy proposal.
\'"'We will be attempting to inlprove would be paid for through an addi l>t:lIse. said, DaVid Tayloe, a P~ysl
:Cess to health care. especially for donal 75-cent-a-pack cigarette tax. cian slH~aklllg f?' ,the, ~mencan
lildren.. in the l05th Congress," :"Every American child deserves II ;\cademy (~f Pedlatncs, III a, re~en(
lid Dasch1e after his reelection to healthy start in life. and every family plea f(?~ action on the Kidd~~re l:Cm~
Ie leadership post last week., He should have· the opportunity to help ct'llt. Ihey tend t,o get I,e~s, pre~t:!I~
,0...11 .L:A one of his top priorities.
that child get that start," Kermedy Iin· care, ff'wer ml1lllllllh7;ttlo~ds ,Ill
wcu UUl)
":lin
contract more diseases.. e sal ,
I
,,' ,,~~'!.
~rvices
Tho:nas
Cla~ks\·iIIe.
h:
!n
M
.,
"
•
.
"
.
�UNINSURED CHILDREN
1.
Background
2.
Challenges to Covering Children
3.
Options for Covering Children
4.·
Current Budgetary and Political Environment
5.
Next Steps
�BACKGROUND
Numbers and Trends
•
Currently: 10 million, or 14 percent, of all children are uninsured
•
In the past: The proportion of uninsured children has remained constant
o
Employer coverage has declined (from 67 percent in 1987 to 59
percent in 1995), due to:
Increased outsourcing and part-time work
Shift to industries less likely to Qffer insurance
More workers in small firms
o
•
But, Medicaid coverage has increased (from 16 percent in 1987 to 23.
percent in 1995), stabilizing the proportion of uninsured children
In the future:· The proportion of uninsured children may increase
2
�. Who Are Uninsured Children
•
Working families: 80 percent of uninsured children are in working
families.
•
Income varies: Uninsured children are hot just poor children (see chart).
•
Concentrated in the south and southwest:
.0
o
In 1995, about 43 percent of all children but 55 percent of all
uninsured children resided in the south and southwest.
Reasons why these states have higher proportions of uninsured
children include:
Lower use of Medicaid options to expand children's coverage
Higher prevalence of:
Low-income families
Industries that don't provide health insurance
Racial and ethnic groups less likely to be covered by
insurance, and
Noncitizens
3
�Chiidren'sHealth Coverage, 1995
Proportion of Children Covered by Different Sources
100%
-y----,
14%
Private
80%
• Private
60%
EI Uninsured
• Medicaid
40%
20%
0%
-+1--
Poor
Near Poor
Middle Class
·Poor" means < 100% of poverty; "Near Poor" means 100-199% of poverty;."Middie Class" means> 200% of poverty. ·Private" includes nongroup arid other coverage.
Source: EBRI,1996
.
�Why Are Children Uninsured
1.
Parents change jobs. Nearly half of all children who lose health insurance
do so because their parents lose or change jobs
2.
Parents earn too much for Medicaid but too little for private coverage.
Whenjob-related insurance loss is put to the side, the most important reason
why children lose insurance is that it is too expensive for the family.
3.
Eligible but not enrolled in Medicaid. An estimated 3 million uninsured
children are eligible but not enrolled in Medicaid.
�CHALLENGES TO COVERING CHILDREN
•
Costs: Although children are the least expensive population to insure,
policies to cover them are expensive. This results from two major
challenges:
1.
2.
•
Substitution or "crowd out". Costs rise when a policy substitutes
Federal dollars for employer or state contributions for kids' coverage.
Administration. Policies have to strike a balance between complex
administrative rules and enforcement - which limit crowd out - and
the goals of simplicity and small government.
Covering all uninsured children is prohibitively expensive. Given these
issues, it is iinpossible in a voluntary system to cover more than two-thirds to
three-quarters of the 10 million uninsured children without large-scale
substitution of Federal dollars for current employer health insurance
payments.
5
�OPTIONS FOR COVERING CHILDREN
1.
Tax Credits
2.
State Grants
3.
Medicaid Expansion
o
o
Making optional coverage more attractive
o
4.
Improving the current program
Requiring expansions
Vouchers
6
�•
CURRENT BUDGETARY
AND POLITICAL ENVIRONMENT
e
Groups
e
Governors
e
Congress
e.
Departments
�.
.
.
NEXT STEPS
•
Internal strategy
o
o
Review in detail evolving policies in Congress
Prepare for porus meeting
Deputies meeting for principals meeting
Principals meeting for POTUS meeting
o
o
•
Policy process for:
Responding to criticisms of our policy
Modifying Congressional alternatives
Developing bottom-line positions on alternatives
Review our position on size and sources of funding
External strategy
o
Develop and implement a validator and group strategy to support the
general goals of our policies
o
Develop and implement communications strategy including events to
highlight the need for coverage expansions
o
Develop and implement strategy to attract gubernatorial support for
our state-based approach
o
Develop Congressional strategy to ensure that:
Republicans are invested and/or worried about not supporting
expanSIons
Democrats are committed to support policy and not just an issue
Budget resolutions contain an investment for expansions
Members and staff rely on us for technical assistance
8
�,/
•.
(l,
jIlo.;r
~
i
t..:>
"
"
c:r:;
iO
(0
(0
~
Number of Uninsured Children
Ma'rch Supplement CPS
....
--1
"'"
(0
t1
t..:>
iO
Number In Millions
10.5
r:-:>
o
"'"
....
--1
10.0
10.0
c.=o
....
t..:>
9.5
m
9.0
1J)
;...
1J)
~
8.5
til
"'0
8.0
7.5 .
7.0
6.5 -'-
March 1992 March 1993
. 1980 weights
March 1993 March 1994 March 1995 March 1996
1990 wmghts
r
New quesflons In Match 199+1996 msk6 conparfs0n8
with ear1i9r ~ lnspproprIa,e
.I§J
'0
iO
t..:>
o
"
"'"
iO
�/
,.
~,
..... i f
N
"
o
a:>
"
Percent of Children Covered by Private Insurance, 1987-1994
. \ ".'
(Includes those ~~o report both private coverage and Medicaid)
a:>
<»
....
.....
(;1
o
Percentage
cj
80%
N
78°,4
.....
t,)
o
"'"
o
....
(..;>
....
N
76%
74%
174%
74%
74%
72%
~
Vl
;.
Vl
700/0
69%
~
......
89'Yo
~
68%
86%
64°,4
62%
:.
60%
1987
1988 .
1989
1990
1991
1992
Years
1992A
1993
1994
I§I
o
-0
II>
1892A reftects fmplarnan1allon or 1990census population weights. which affected the estfmates.
Source: GAO. HEH8-96-129• .AJna. 1998.. Data from the CulTsnl PopJlation Survey.
"
o
-0
II>
�'.
~
.....
N
"
<:)
<II)
Percent of Children Uninsured
.
,
March Supplement CPS
"
<II)
<»
....
-:a
(Jl
<:)
15%
'tt
N
<:)
...
N
....
<:)
14.2%
, -:a
, c.o
.....
N
14%
130/0
-t
1-
-"--_.
...
i _
12%
..I-
- -.. ..
§
VI
>
VI
"1:l
1:11.
"1:l
==
11%
March 1992 ,':March 1993
1980 weights
March 1993
March 1994
March 1995
March 1996'
1990 weights
I§I
<:)
<:)
..
c.o
Newquesflons In March 1994-1996 make 0fJ11fNJds0ns
MfIh 6B.rlier }9IJrS Inspproprfate
"
<:)
...
<:)
�~2/05/96
19:25
1aI002
OPC TAX POLICY
'5'202 622 9260
II
DEPARTMENT OF THE: TREASURY
WASHINGTON, D.C. 20220
December 5, 1996
,;
. MEMORANDUM FOR NANCY-ANN MIN
ASSOCIATE DIRECTOR FOR HEALTIl
OFFICE OF MANAGEMENT AND BUDGET
FROM:
ERIC· TOUER
(2.ec ~t.->
DEPUTY ASSIStANT SECRETARY (TAX ANALYSIS)
SUBJECT:
F....stimates of Health Insurance Subsidies for Children
At a meeting on November 12th, the Treasury was asked to prepare estimates of two health
insurance subsidy proposals for children. Because details of these proposals have not yet been
specified, the e~timates are very preliminary. In addition to providing revenue estimates, I .!llm
including a list of caveats which givc an indication of how the estimates might change dependilllg
on further specification ofthe proposal. As noted below. the estimates are for a proto-type plan.
It was assumed that the proposal is administratively feasible and that families would receive
subsidies in a timely manner. There are concerns in both these areas, but these conc~ms have
not been identified nor taken inrn account in the eSlimates due
the nature of the estimatil)n'
to
exercise.
Under both proposals, health insurance providers "that do busine.ss with the Federal government"
would be· required to offer child health insurance policies to all families with eligible children.
Eligible children include all children under the age of thirteen, who are not ehgible for
Mt~iicaid, and whose families are not eligible to ,obtain an employer contribution towards a
health insurance policy that could·include children. Families would purchase a separate polk:y
for each child. These policies would provide benefits similar to those found, in the Blue
Cross/Blue Shield Standard Option plan available through the Federal Employees' Health
Benefits Program (FEHBP). Each insurer would establish a separate risk pool for these spada!
child policieJ::. Subsidies would be made avallable in the form of a refundable tax credit for
health insunmce purchased after December 31, 1997. Estimates are provided for two option s.
Option 1; Under the first option an 80 percent taX credit would be available up to 'the
EITe income cut-off. Above the EJTC income cut-off, the tax credit would he phast~1
down to reach a.10 percent tax credit in the neighborhood of 275 percent of poverty.
Familie~ with incomes above this level would be eligible for the 10 percent tax credit.
Option 2: Under the second option a 50 percent tax cn....dit Would be available up to the
EITC income cut-off.·. Above the ElTC income cut·off the tax credit would be phased
down to reach a 10 percent tax credit in the ne.ighborhood of 275 percent of poverty.
Families with incomes above this ~evel would be eligible for the 10 percent tax crook
�,11/05/96
19:26
'6'202 622 9260
OFC TAX POLICY
~003
Preliminary F&timates
The estimates are for a proto-type plan. It was a.ssumed that a tax credit subsidy program could
be made to be administratively feasible. The estimates do not take into account many Clf the
problems that might be encountered in administering the subsidy thr~ugh the tax sY:ltem.
Furthermore, it is assumed that families would benefit from the subsidy in a timely manne~r, so
that they may participate in the program.
The first option is estimated to lose $4.8 billion in revenue in the period FY 1998 ~ FY 2002
and $17.0 billion if) the period FY 1998 - FY 2006. Under a fully phased-in program,
incorporating 2002 law but estimated at 1998 levels (e,g. population etc.), 2.7 million children
are estimated to obtain health insurance through the subsidy program. Actual panicipatil)n in
1998 would be much lower than this fully phased-in number. For comparison, a fully phasc~~in
program would lose $2.1 billion in revenue in 1998. Because it would take a number of years
before ,the program is likely to reach full level,actual revenue loss in FY 1998 would be very
small by comparison.
In contrast, the second option is estimated to lose $1.9 billion in revenue in the pe:riod
FY 1998 - FY 2002 and $5.7 billion in the period FY 1998 - FY 2006. Under a fully phas~:d-in
program, under 2002 law and at 1998 levels, 1 million children are estimated to participate. A
fully phased-in program would lose $0.7 billion in 1998. Actual partiCipation and revenue loss
in FY 1998 is estimated to be much lower than these fully phased-in numbers.
Caveats
•
There is great uncenainly around the premiums under both the proposals. The premium
depends upon the amount of adverse selection,. which in tum depends on the amour:lt of
the subsidy and the amount of the premium. High premiums arc likely.to result in low
participation. which in turn is likely to r.elnforce high premiums, as participants are likely
to be less healthy than average. More moderate premiums are likely to cause a small,
but significant, number of employers fo drop health insurance coverage for children. As
a result of employer dropping, and because premiums are moderate, panicipation would
b~ higher under this scenario than under the previous scenario..
Revenue and participation estimates are based on the long~run estImate of
premiums with the exception that premiums in the early years are expected tel be
somewhat higher than long~run premiums because it will take time for employers
to drop health coverage for children.
If insurers begin by pricing policies at higher levels than estimated the long-run
estimate of premiums may never be reached. Participation would be lower than
estimated. Revenue loss may be higher or lower than estimated depending upon
the interaction of parhcipation and premiums. Higher premiums would result in
g'l'eater revenue loss· per policy. . Lower participation would result in lower
revenue loss.' Insurers may price policies at higher levels because they fi~r
underestimating adverse selection.
�,1';/05/96
19~26
fr202 622 9260
.
OFC TAX POLICY
[4J 004
The long-run estimate of premiums' also might not be reached if employers and
.employees believe that the initi~l high levei of premiums reflect the long-nm
equilibrium premium.
Mechanisms may nee.d to be put into place to increase the likelihood that these
targets are hit. However, it has not been determined whether any such
long~run
mechanisms could achieve this goal.
•
The premiums were estimated based on benefits similar to the Blue Cross/Blue 'Shield
$tandard Option, a fee for service plan with some managed care features. Allowing staff
model Health Maintenance Organizations (HMOs) may affect both premiums as well as
participation.
•
The estima,tes assume that families are able to pay for premiums on a current basis.
Some individuals may be able Lo adjust their withholding to eliminate potential cash-flow
problem~. Many othe.r individuals may not ~e able to adjust withholding to accommodate
their premium payments. Without effective mec·ha""lisms to relieve cash·f1ow probk~ms,
participation is likely to b~ lower, perhaps even sUbstantially lower than the cunent
estimates. Premium and tax credit estimates would also have to be adjusted, although
the direction of the adjustrnt!nt ha!\ not been determined.
•
. Employer dropping is likely to result in increased Medicaid participation. The effc.m of
the proposal on Medicaid ha~ not been included in the estimates.
•
Employer dropping could result in employees becoming uninsured. Several factors may
lead to this result. Employers that drop coverage may be slow to increase wages LO
compensate employees. Some employees, particularly low-wage employees, :may
currently receive implicit cross-subsidies from other workers. If so, these low-wage
employees would be unlikely 10 recehre wage increases when employers drop coverage.
Under both these situations, employees may not be able to afford health insurance. or
they may not value health insurance enough to purchase insurance for th~ir children.
Other workers that receive wage increases as their employers drop coverage may dedde
to allocate these wages to other family needs. with the result that their children become
uninsured.
Although the estimales assume that almost all currently insured children remain
insured. there is a great deal of uncertainty in this area.
•
Because. the subsidy is designed in the form of a tax credit. the subsidy is phased down
based on adjusted gross income (AGI). The Earned Income Tax Credit (EITC) income
cutoffs determine the beginning of the phase·down of the tax credit. The tax credit is
phased down to 10 percenl at an AGI level in the neighborhood of the poverty }e;vel
targets. Due to rounding, the tax credit is phased down to the 10 percent level at slightly
dIfferent poveny level targets, depending on family size.
�,1)/05/96
19:27
'6'202 622 9260
OFC TAX POLICY
•
Premiums were assumed to irow at the rate of per capita premiums under the 1997
budget assumptions. The AGI thresholds that determine the beginning of tax credit
phase-down were assumed to grow at the rate of inflation as reflected in the, Consumer
Price Index (CPI). This is similar treatment to the EITe. The phase-down rate was
detennined in the first year. As a result of maintaining this phase-down rate in future
years, the income level at which the 10 percent subsidy is reached increases over dme.
These combined effects cause subsidies to grow slightly faster that the growth rate: of per
capita premiums.
•
The current estimate assumes that there is no cap on the tax credit. For example under
the first option, the tax credit· would be 80 percent of the premium regardless of the
premium. It has not been determined how a cap on the tax credit amount would effect
the estimates. The uncertainty in premiums, especially during the first years of a
program, would have to be taken into consideration in designing a cap.
•
The estimates are based on 1997 budget assumptions.
•
Estimates are likely to change as details become specified and as new information l,~ds
. to improvements. in modeling areas of great uncertainty, (including but not limited to
premiums and employer dropping).
�'IN
'""
"
0>
QI
Health Insurance Subsidies for Children
"
to
en
I-'
to
Participation
N
"'"
I.:
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the employer does not contribute, and other
private heal1h insurance.
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Health Insurance Subsidies for Children
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21%
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$20,000 - $30,000
1,136
$30;000 - $40.000
566
$40,000 - $50,000
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160
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151
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~-~-----
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to<:
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children coufd be in the $0 - $10,000 brackel because they would no1 be eligible for
Medicaid the entire year
J§I
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• ·11/26/96
17:10
"5'202401 7321
HHS ASPE/HP
...... !lIN
1410021019
November 26, 1996
Nancy-Ann Min
Chris Jennings
. TO:
Glen Roselli
Meredith Miller
Mark Miller
FROM:
Christy Schmidt
SUBJECT:
Child Health Proposals
The attached papers deal with the child health proposals that will be disc~ssed at tomorrow's
10:00 Al\1 meeting.
Attachments
1.
Enhan(~e
ChndlFamily Health Coverage and Services (an Ovell'iew)
2.
Fulfilling the Promise of Medicaid for Eligible Children and Working Families Who
are Already Eligible for Medicaid
3.
Grants to States to Support Innovative Partnerships to Insure Children
4.
Expand Investment in School Health Programs to Serve the Health Needs of
Children and Adolescents
5.
Partnership for Children and Working Families Through Targeted Funding for
Consolidated Health 'Centers (CHCs)
�11/26/96
17:10
'fi'202 401 7J21
HHS ASPE/HP
... -.... MIN
@00J/019
ENHANCE CHILDIFAMILYHEALTH COVERAGE AND SERVICES
Today, 10 million--14 percent--of children ar~ uninsured. Children may be uninsured because
their parents are unemployed, because their parents' employers do not offer health insurance to
their children, or because their parents cannot afford to purchase health insurance for themselves
or .their children.
Many more children areunderinsured, with limited access to critical preventive and primary care
services. They may live in urban or rural areas that are underserved by private providers, or they
may lack the insurance and other resources necessary to access care.
.
· To address the reasons why children may be uninsured requires a multi-dimensional approach:
· increase insurance coverage through Medicaid, enhance partnerships with the states and private
· sector to help provide insurance for children, and expand access t? ~ommunity based care.
1. Increasing Insurance Coverage
Work with states to continue tofulfill the promise of Medicaid for. children who are already
eligible under current law.
Fulfill the promise of Medicaid for eligible children and wNking families who are
already eligible for Medicaid through administrative and legislative changes that expand
enrollment of Medicaid eligible children; provide states with incentives and options for
expanding Medicaid to working families; create new optional eligibility categories for
individuals adversely affected by the new welfare law; and market Medicaid enrollment
to the public. Specific provisions include improve the eligibility process to ensure that
eligible children are enrolled; expand outreach; accelerate enrollment of children's
poverty-related eligibility groups; create new optional eligibility categories for legal
immigrants and non-pregnant adults with families; establish a marketing campaign.
II. Enhance Partnerships with States and the Private Sector to Help Insure Chlldren.
Provide grants to states to support innovative partnerships to insure children
•
Numerous states have joined forces with insurers, providers, employers, schools,
corporations and others to deVelop innovative ways to provide coverage to uninsured
children. Under this proposal, the federal government would provide matching funds to
expand the munber of states participating in such programs and to increase the number of
uninsured children who have access to such programs. States would be given Wid~
latitude in program deSign but would be required to assure the receipt of critical services
related to immunization, injury prevention, well-child care, and other related services to
reduce morbidity and mortality.
�111
196
17: 11
1l'202 401 7321
HHS ASPEIHP
~004l019
•III. Expand Access to Community-Based Services
Enhance funding for communities through school-based or school-linked health centers.
Expand funding for new school-based health centers. This initiative would provide
school age children Y.ith comprehensive primary care services including diagnosis and
treatment of acute and chronic conditions, preventive health services, mental health
. services, health education and preventive dental care. Communities would have the
option of expanding services to the parents and siblings of the school's students; would
be encouraged to link to other appropriate programs, including Healthy Start, state
Maternal and Child Health. Head Start, Community Schools, and Empowerment
lones/Enterprise Communities; and would be encouraged to develop billing systems to
collect third party payment and enable centers to participate in a community-v..ride health
care delivery system.
•
In addition this initiative would support school-linked health centers. School-based
health centers may not be the right choice for every community. School-linked health
centers can serve students from several schools in a particular catchment area and provide
continuity of care as students are promoted to the next school. School-linked health
centers provide services that might not be as comprehensive in scope as a school-based
health center, but can be targeted to specific community needs.
Create Partnerships for Chiidren and Working Families Through Targeted Funding for
Consolidated Health Centers (CHCs)
.
•
Provide increased targeted funding for CHCs to enhance and expand services to working
families and their children, including children enrolled in day care, Head Start programs,
and schools. These funds would be directed to communities Y.ith high levels of
uninsured children, including EZIEC communities. Funds would be used to increase
CHCs capacity to serve uninsured children and their families and to better meet the needs
of those in their community whose insurance coverage is fragmented or incomplete. lIDs
could include extended hours, locations, and range ofservices. In addition to increasing
their own capacity, CHCs would serve as a focal point for marshaling public and private
community resources directed at child health and, with their partners, taking.steps to
mesh child health and related services into local integrated systems that serve children
and their families.
Challenge tbe health care industry to workwith communities to improve integration of
school-based and school-linked health centers and consolidated health centers into a
community's health care delivery system.
•
Encourage managed care organizations and health insurers to work with communities to
develop health care delivery settings for children such as school-based/linked health
2
�III 6/96
17:11
'5'202 401 7321
HHS ASPE/HP
...... AIIN
141005/019
centers. Managed care organizations could collaborate with community sponsors to
create funding mechanisms to develop and operate school-based/linked health centers,
and/or to designate school-basedllinked health centers as a primary care delivery site.
Work with managed care organizations and health insurers to devise a range of
approaches for: (1) reimbursing school-based/linked health centers for the services they
provide; (2) developing model billing syst<?ms that support these approaches.
3
�....
....
"
"
"''"t»
a>
IMPACT OF INCREMENTAL NEW FEDERAL FUNDING FOR CHlLDIFAMILY HEALTH COVERAGE AND SERVJCES
~
a>
....
,-I
Federal Challenge Grants--Children Insured
l
....
Federal
Funding Level
Preventive Services
$25 million
500,000
Preventive Services!
Primary Care
70,000
Comprehensive
Coverage4
45,000
Children
Served--Scoool
Based Health
Centers 2
125,000
People (Children)
Served-
Consolidated
Health Centers 1
I
250,000 (110,000)
J-
~
N
o
N
..,.
o
J
$50 million
1,000,000
l40,OOO
90,000
250,000
500,000 (220,000)
$100 million
2,000,000
280,000
180,000
500,000
1,000,000
(440,000)
\
-.-.-~
............
-.-~
........-
-I
Co>
N
J
--
~
~
CI)
;...
CI)
'"0
tT1
"
~
'"0
Assumes 50 percent match from non-Federal sources.
.j.
.j.
J.
Covers costs of services received in SBHCs but not health care services re.c,eived at other locutions. Assume aJl costs borne
through Federal grant funds at start-up. Offsets from Medicaid reimbursement and other funding sources possible over time.
,
a::
......
z
-
Comprebensive primary and preventi ve health services. Based on average Federal grant share of CHC funding of approximately
30 percent, with ,Medicaid and other sources accounting for balance. Approximately 44 % ofCHC users are children through age 19.
Option
inciudes hospitalization coverage.
4
r§;J
o
o
a>
"
....
-0
~
. -"-, ... -------,
�11/2~/96
17:12
,t ~
'6'202 401 7321
I:
HHS ASPE/HP
......... AnN.
@007/019
Fulfilling the Promise of Medicaid for Eligible Children and Working
Families Who Are Already Eligible for Medicaid
. I. Description:
The Goal of this proposal is to increase Medicaid enrollment of eligible children and
working families.
II. Specific Provisions:
I.
Expand enrollment ofMedicaid eligible children.
InwrQve Eligibility process to ensure that eligible children are enroiled (Administratiye)
Working with States, HCFA will use the opportunity of the new Welfare Reform
legislation to re·think the current rules and regulations related to Medicaid eligibility.
The Welfare Reform legislation essentially creates a Medicaid-only eligibility system for
low-income children and working families. While this eligibility system is based on the
AFDC eligibility rules in place on July 16, 1996, the new law allows States to fOCllS on
simplifying and to some extent expanding eligibility using "less restrictive"
methodologies. HCFAwilIwork with States to ensure that these new methodologies are
encouraged and adopted.
Expand outreach (Administrative)
Develop Federal-state partnerships to improve outreach to enroll Medicaid eligible
children. HCFA will also work with others, such as the Public Health Services and its
grantees, and the Department of Education and local schools, to expand Medicaid
outreach to increase the enrollment of children who are already eligible for Medicaid but
who have oot actually been enrolled. Outreach efforts would be directed through schools
and other community service providers, as well as health care providers. Additional
Federal resources for implementation of expanded outreach would be considered.
Accelerate enrollment of children's poverty-related eligibility groups (Le&:'isJation)
Propose legislation for a State option to accelerate the phase-in of coverage (e.g. shorten
phase-in to cover two age cohorts ~thin a given year instead of one) so that more
children would receive Medicaid coverage sooner. Legislation passed in the lat~ 1980s
and early 19905 extends Medicaid coverage to all poverty-level children under ~ge 19, on
a phase-in basis by FY 2002. Currently all children under the age of 14, below poverty,
are eligible for Medicaid. Each year, approximately 250,000 additional children receive
5
�11/26/96
17: 12
'Zl'202 401 7321·
HHS
ASPE/HP
..,..,... MIN
~0081019
:'
Medicaid coverage through this phase-in. Over the next four years 1 million more
children will become eligible for Medicaid. This option would increase the time fTame for
enrollment by two years. .
. 2.
Provide states with incentives and options for expanding Medicaid to workingfamilies
1115 Demonstration waivers (Legislation)
Create a process for a "permanent extension" of statewide health care refonn
demonstrations. This proposal would allow states to "convert" demonstrations to state
plan amendments.
Cost-sharin~
(T .egislation)
Permit states to impose cost",sharing (e.g., premiwns) on expansion populations within
specific income brackets. The minimum level (floor) for this proposal would be 50
percent.
3.
Create new optional eligibility categories for individuals adversely affected by new
welfare l~w:
SSI and Legal Immigrants: Create an optional eligibility group for Medicaid for those
who lose SSI cash assistance due to their immigration s~atus. Some states are interested
in continuing Medicaid coverage to legal irrunigrants' who will lose Medicaid due to the
welfare refonn provisions, without having to use the current law options.
Non-pregnant adults with families: Create a new optional poverty-related category for
non-pregnant women with children. This popUlation is at the greatest risk of losing
Medicaid due to the severing of Medicaid and welfare eligibility rules.
4.
Market Medicaid enrollment to the public
to
Encourage/ develop partnerships between states, provider groups and foundations
develop public service announcements and appropriate print media to encourage children
and families to seek information about Medicaid eligibility, to enroll in Medicaid, and to
utilize appropriate services.
A "marketing campaign" wbuld be particularly beneficial for infonning families what
steps need to be taken to continue Medicaid coverage for children and working families
.
after implementation of the new welfare law.
6
�111
19.6
17: 12
'B'202 401 7321
HHS ASPE/HP·
...... MIN
~009/iH9
III. Impact
The purpose of these proposals is to increase the number of eligible individuals ( and
potentially eligible individuals) enrolling in Medicaid and to expand Medicaid coverage
to working families without health insurance.
In FY '95. there were approximately 41 million people ~ligible for medical assistance,
however, only 36 million actually received services that fiscal year. Approximately 21
million children were eligible, and only 18 million received services. s There are a
variety of reasons why this "gap" between eligibility and receipt of services exists and
limited enrollment is one reason. The outreach proposal, federal grant proposal and
marketing proposal would address this "gap" between eligibility and enrollment.
The state incentive proposals would encourage states to expand Medicaid coverage to
low-income working families. Since 1993, HHS has approved 13 statewide health care
reform demonstrations. Many of these demonstrations involve an expansion of Medicaid
coverage to working families with near-poor income levds. Once all of these
demonstrations are implemented, an additional 2.2 million individuals will receive
Medicaid coverage due to the expansions.
IV.
. Administration and Congressional History on Issue
During the late 1980s and the early 19905, congress passed legislation to expand
Medicaid coverage to children and pregnant women. The phase-in of Medicaid coverage
for children below poverty born after Sept 30, 1983 was part of this expansion.
Although 2.2 million additional individuals will receive Medicaid coverage due to the
st~tewide health care reform demonstrations, recent demonstration applications have
focused on enrollment in managed care and not on expanded coverage.
V.
Tables and Attachments
None
HCF A 2082 data
7
�III
196
17:1J
U202 401 7J21
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@010/019
Grants to States to Support Innovative Partnerships to Insure Children
1.
DESCRIPTION
The pwpose of this initiative is to assist States in assuring that children have access to primary
care, comprehensive health supervision and health promotion and disease prevention services
and, at a State's option hospitalization coverage in a continuous manner. Through a new grant
program, States would receive matching funds to work with communities, parents, providers,
employers, and payers to implement cost-effective approaches to providing insurance and
services for children who are uninsured or intermittently insured.
Numerous states have joined forces with insurers, providers, employers, schools, corporations
and others to develop innovative ways to provide coverage to uninsured children. Development
of some of these innovative efforts has been supported by the Federal Government through the
Maternal and Child Health Bureau of the Health Resources and Services Administration and the
Health Care Financing Administration. This new proposal provides federal matching funds to
expand the number of states participating in such programs and to increase the number cif
.uninsured children who have access to such programs .
. Despite expansions in Medicaid, significant numbers of children remain without any health
insurance. Others are covered only intermittently as their parents' coverage by private insurance
. or Medicaid changes or are underinsured, lacking coverage for preventive or other services.
II.
SPECIFIC PROVISIONS
The federal government would provide support to States to continue and expand innovative
programs to provide insurance for uninsured children. States would be given wide latitude in
program design, choosing whether their progrwns would provide insurance for preventive
services and medical supervision; preventive services, medical supervision and ambulatory care;
or more complete coverage induding inpatient hospitalization insurance. The mix of participants
and funding arrangements would vary from State to State. However, all projects would share
the following characteristics:
•
Encouraging the development of innovative and cost-effective approaches to provide
insurance coverage and related services for children, particularly for vulnerable children
and their families with limited access to quality health services. Initial efforts would
target currently uninsured children and children uninsured for preventive services.
•
Encouraging a seamless system that provides continuous health care for childreri;yv:ithout
regard to source ofpayment or enrolled health care plan for either the family or provider.
This would protect the link between child and health care provider regardless of changes
in family income, source of insurance or other change in child or family circumstances.
8
�111
196
17:13
'0'202 401 7321
HHS ASPE/HP
...... UIN
~ 011/019
This would be a logical next step for States which have expanded Medicaid coverage for
children through waivers and State only programs. All States would be encouraged to
reach out to uninsured families to help assure that eligible children are enrolled in
Medicaid and other families are aware of new insurance opportunities.
•
Partnerships among corrirnunity organizations, individuals, and agencies; Federal, State,
and local governments; professional organizations; HMO's, managed care organizations,
and insurance plans; foundations; employers and corporate leaders; and families to share
their knowledge and expertise and commit the necessary resources for mutual problem
solving, easy access to services and fair and timely reimbursement.
•
Partnerships of pediatricians and other pediatric primary care health professionals and
professionals in health, education, social services, government. and business to build self
sustaining programs to assure healthy children and f~ilies.
•
The Federal Government would work with States to extend waivers and other flexibility
to allow States to create innovative systems of health care for children.
Projects would be tracked so that information would be available on topics such ~s the
number of children covered by these programs, rates of uninsurance among children in
participating States, and trends in employer coverage of child preventive services etc .
.•
III.
Federal teclmical assistance would be available to assist in areas such as estimating costs
of providing additional levels of expanded coverage; information about successful public
private partnerships in insurance coverage; data system design; and program evaluation..
IMPACT
This proposal could be implemented in several ways, depending on the arnoW1t of Federal
funding available. The options presented below are built on the follo\1(ing estimates of the cOStS
of providing children. The cost of providing insurance for those prevenri ve services
recommended by the American Academy of Pediatrics is approximately $8 per child per month;
for primary care and preventive services, based on the Blue CrosslBlue Shield standard option
without hospitalization, is approximately $56 per child per month; when hospitalization coverage
is added the cost is $90 per child per month. Additional funds would be needed to support
collaboration building, data systems, administrative overhead and evaluation. In the grant
program options discussed below, Federal support would be matched on a dollar for dollar basis
by States through their choice of a mix of public, corporate and/or private contributions.
The number of children receiving coverage under grants from this proposal would depend on the
extent of insurance coverage a State selects.
9
�111 <!I)I IHS
17:14
Option 1
'Q';':O;': 401 7 J21
HHS ASPElHP
...... MIN
·1410121019
No new funding
Federal actions would be limited to publicizing successful State efforts, convening groups of
interested parties, providing information on the impact of State programs, providing technical
assistance to the States and encouraging use of Federal funds from existing programs, such as
111e Matemal and Child Health Block grant, for this purpose.
Option 2
Pilot Program
Grants would be awarded on a competitive basis to 5 to 10 States to implement activities on a
. demonstration basis, with the possibility of expanding the program to remaining States in the
future. Among criteria for selection would be factors such as need, as measured by rates of
uninsurance among children, the extent to which proposed activities complement State Medicaid
policies, support from State and private sector sources, innovative features, and diversity among
the size of States selected and models tested.
.
Option 3
National Program
Grant funds would be available to all States which meet basic program criteria.
The following table illustrates approximate numbers of children who could receive insurance
.. coverage of various types under this proposal at different funding levels, with an assumed 50
percent match rate.
Total Federal Grant
Support
Insurance for
Preventive Services
Only
Insurance for
Preventive Services
and Ambulatory Care
Comprehensive
Insurance Coverage
$25 million
500,000
70',000
45,000
$50 million
1,000,000
140,000
90,000
$100 million
2,000,000
280,000
180,000
i
Assuring the receipt of critical services related to immunization, injury prevention, well child
. care, primary care and other medical services will not only reduce morbidity and mortality and
save significant costs associated with these conditions but will enhance child and family well
being.
10
�111 6/96
.IV
17:14
'tl'20.2 401 7J21
HHS ASPE/HP
......... MIN
~01J/019
ADMINISTRATION HISTORY
Expanding insurance and other health coverage for children has been a theme of the Clinton
. Administration. Several States, such as Hawaii and Rhode Island, have used 1115 waivers to
. restructure their Medicaid programs to expand coverage for children. This initiative provides a
stepping stone for States who are seeking new ways of extending health insurance to the
. uninsured. This initiative differs from previolls effons by its strong emphasis on drawing into
expansion efforts participation and resources from all concerned parties, public and private
payers, providers, State and community leaders, and families.
11
�11/~~/9ij
17:15
~202
401 iJ21
HHS ASPE/HP
......... MIN
!41 014/019
Expand Investment in School Health Programs to Serve
the Health Needs of Children and Adolescents
1.
DESCRIPTION·
Students often experience compromised access to health care services because of the combined
barriers of poverty, a lack health insurance and, in some areas, a lack of primary care
. providers.
of
To address this problem, school health programs provide preventive, medical and mental health
services to elementary, middle and high school students around the country. They currently
operate in many states, with the majority in rural and inner city communities where there are
many medically underserved and uninsured children.
School health programs provide a wide range of services depending upon the needs of the
communities, including primary care, physical examinarions, injury treatment, immunizations,
dental treatment, counseling, chronic illness management, substance abuse prevention, and
health education.
II.
SPECIFIC PROVISIONS
•
Ex.pand the Healthy Schoo]sfHealthy Communities initiative to improve the health of
children in a school setting. Through this Health Resources and Servi~es Administration
program sponsored by the Bureau of Primary Health Care in collaboration with the
Maternal and Child Health Bureau, school-based primary health care sites have been
developed in 26 communities to provide services for 24,000 children who are at risk for
poor health, school failure, homelessness and other consequences of poverty. The
program has been funded at $16.8 million over a three year period. New funds would be
targeted to organizations to establish new school-based health centers in communities.
with high rates of uninsurance. Current sites link to both Healthy Start and Head Start
sites_ SBHCs funded under the new initiative would:
.. .
serve children of all ages from pre-kindergarten through grade twelve;
have the option of expanding services to the parents and 5ibUngs of the school's
students;
link to other appropriate programs, including Healthy Start, Head Start, and
community schools.
provide comprehensive primary care services including diagnosis and treatment of
acute and chrome conditions, preventive health services, mental health services,
12
�llnt5/9t5
17: 15
'1.)'202 401 7321
HHS ASPE/HP
........ MIN
~ 015/019
health education and preventive dental care as well as linkage to other health care
services and after-hours medical care;
provide reproductive health services at the option of the community; and
develop billing systems to enable center to participate in a community-wide health
care delivery system.
•
Expand the Healthy Schoo!slHea]thy Communities initiative to support schQol-linked
heaJth centers. SBHCs may not be the right choice for every community. School-linked
health centers can serve students from several schools in a particular catchment area.
They also can provide continuity of care as students are promoted to the next schooL
Such centers provide an opportunity to target out of school youth and aid th.em in
accessing health, psychosocial and other services. The location off school grounds allows
greater flexibility for extending operating hours or operating during school vacations and
the summer months. School-linked health centers can more easily avoid the controversy
in some ~ommunities associated with the delivery of particular services, such as family
planning or reproductive health services, on the school site.
Expand funding for Consolidated Health Centers (CHCs) to work with communities to
develop school-based or school-linked health programs. Recognizing the benefits of
interactions between education and health efforts, many communities have established
links between schools serving low-income children and CHCs to provide comprehensive
health services to underserved children. Approximately 250 CHCs have developed
school-based or school-linked health programs: approximately 75 school-based programs
and about 175 school-linked programs.
•
Encourage states to expand fimding for school health programs through the Title V
Maternal and Child Health (MCR) Block Grant. In 1994,25 states invested $12
million in MCH block graIl! dollars and $22.3 million in state general funds for school
health programs. Further funding targeted to the development of school-based/linked
health programs would directly benefit many of the children who lack adequate health
insurance coverage or access to health care services.
•
Encourage managed careorgaruzations to work with communities to develop and
implement school health programs. Managed care providers in several states authorize
SBHCs to provide health care services, then bill Medicaid directly. Managed care
organizations may collaborate with community sponsors to create fimding mechanisms in
order to develop and operate SBHC organizations that designate the SBHC as the primary
care clinic for school-aged children and their families.
•
Work with managed care organizations and fee-for-service health insurers to devise a
range of approaches for reimbursing school health programs for the services they provide
and develop model billing systems that support these approaches.
,
,
I
I
i I
13
�.L.LI
I~O
. •
.LI :.LO
HHS ASPE/HP
~ 016/019
In order to assure integration of school health programs into the broader health care
delivery system, the Department will provide technical assistance to help school health
programs create effective linkages to Medicaid, managed care organizations, other
insurers and private sector providers. The Department can:
•
identify steps the Department can take to facilitate Medicaid reimbursement for
health services delivered in school health programs;
.•
use the Medicaid Maternal and Child Health Tedmical Advisory Group to
improve commWlication between state Medicaid Directors and Maternal and
Child Health Directors on incorporating school health programs into Medicaid
managed care and other payment arrangements;
use the 1115 waiver authority in Medicaid to encourage states to mandate
Medicaid managed care providers to reimburse school health programs for
services delivered;
distribute guidance to communities fonning school health programs on becoming
Medicaid providers and establishing linkages l:vith health insurance and managed
care organizations· to devise a system of reimbursement for health services
provided to students;
encourage state Medicaid programs to provide out stationed eligibility workers to
schoels with health programs;
encourage States and communities to develop linkages v,ith private sector
providers of care to supplement services provided in school clinics;
e,,:pand State Level Partnerships for School Mental Health Services and Centers
for School Mental Health Technical Assistance and Training now supported by
the Maternal and Child Health Bureau and encourage other efforts which seek to
promote stronger linkages between schools and mental health and substance abuse
service providers in both the public and private sector.
•
Use the Special Projects of Regional and National Significance (SPRANS) Maternal
ang Children Health Block Grant set-aside to encourage states to conduct demonstrations
to ~evelop effective models which build the relationship between managed care
organizations (including Medicaid managed care providers) and schools to ensure access
to health care services for children and adolescents and to promote training and staff
development for health professionals engaged in school health activities.
14
�HHS ASPE/HP
. III
...... MIN
IMPACT
The following .chart presents total costs, numbers of clinics and numbers of students served
which would result from increments of new funding. For purposes of this chart, all funding is
assumed to come from grant support, although over time costs will be partially offset by
Medicaid reimbursement. These estimates are based on data from the HRSA Healthy
. SchoolslHealthy Communities Program and "School-Based Health Centers" by the National
Conference of State Legislatures.
Federal Support for School
Health Climes
Number. of Clinics
($200,000/c1inic)
Number of Students
($200/srudent)
$25 million
125
125,000
$50 million
250
250,000
$100 million
500
500,000
IV.
ADMINISTRA TION HISTORY
This proposal builds on the Administration's support for efforts to expand the availability of
health services for children through focused use of existing programs, including Medicaid, the
Maternal and Child Health Block Grant, the Consolidated Health Center program and l-»;ea!thy
Schools/He~thy Communities, a program implemented during this Administration.
15
141 0171019
�.l..l./":;O/l:10
1/:10
'0' :.!U :.!
4 0 1 7 J 21
HHS ASPE/HP
....... MIN
I4J 018/019
Partnerships for Children and Working Families through
Targeted Funding for Consolidated Healtb Centers (CHCs)
1.
DESCRIPTION
Federally funded CHCs provide comprehensive health care to 8.1 million people, the
overwhelming majority of whom are low income and 44 percent of wham are children through
age 19. Because CHCs must serve medically underserved areas and populations, they are
located in communities where people lack access to health care and where much of the
population lacks health insurance. Federal grant funds make up approximately 30 percent of
CHC revenues and are used in large measure to subsidize care for the uninsw-ed. Other sow-ces
of funding include Medicaid, Medicare, patient fees, and State, local and other sources. This
proposal would target increased CHC funding to areas where there are high levels of uninsurance
among children .
. II.
SPECIFIC PROVISIONS
Provide increased targeted funding for CHCs to enhance and expand services to working families
and their children, including children enrolled in day care, Head Start programs and schools.
These funds would be directed to communities -with high levels of uninsured children, including
EZIEC communities.
Funds would be used to mcrease CHCs' capacity to serve uninsured children and their families
and to better meet the needs of those in their community whose insurance coverage is fragmented
or incomplete. This could include extended hours, more locations, inCluding schools, and
expanded range of services provided.
In addition to increasing their own capacity, CHCs would marshall community resources
directed at child health and, with their partners, taking steps to mesh child health and related
. services into local integrated systems that serve children and their families well. CHCs would
receive targeted funds to form "Partnerships for Children and Working Families" by linking up
with other community organizations, such as:
--managed care organizations to create stronger linkages to community based
providers;
--community hospitals and academic health centers who are serving the targeted
popUlation and can provide stronger vertical integration of services;
-~public
health departments to assure that targeted populations receive appropria:t~
servlce~
--local providers, schools, and other service providers to assure integration of all
community service organizations; ~d
16
, ,1,
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. HHS ASPEI HP
...... MIN
@019/019
--local philanthropic organizations which may result from a shift in health care delivery
systems from non-profit organizations to for-profit entities. This transition often
establishes a foundation poised to serve the needs of disadvantaged populations.
Existing and new CHCs would work closely v.rith State Maternal and Child Health programs and
other community providers to identify special needs of children and working families in their
communities and tailor services to the needs of local populations. Special emphasis would be
.placed on enabling services, such as transportation. linkages with schools and social service
. programs, such as \VIc. Creative collaboration would be encouraged. For example, t<L'\i
, . companies could b~ encouraged to provide discounted fares to medical appointments .
. III.
IMPACT
By increasing Federal funding for CHCs, their capacity to serve the uninsured--children and their
families--is expanded. The average Federal grant cost per CHC user is about $100, an additional
investment of $1 00 million in grants to CHCs would expand their service capacity by 1,000,000,
assuming "average" clientele and funding streams. Nationally approximately 44 percent of CHC
. users are children through age 19. Because funds would be targeted to geographic areas or
population groups where levels of uniI1S'.lranCe among children are particularly high and/or
growing, the actual increase in numbers served would depend on rates of uninsurance in the sites
selected and could be somewhat smaller.
Federal Grant Support for CHCs
People Served--All
Ages
Children Served
$25 million
250,000
110,000
$50 million
500,000
220,000
$100 million
1,000,000
440,000
IV.
-
ADMINISTRATION AND CONGRESSIONAL HISTORY ON ISSUE
The Fiscal Year 1997 appropriation for CHCs is $802 million. In its preliminary submission to
OMB for FY 1998, the Department requested $817 million for CHCs, which includes plans for
50 new delivery sites. CHCs were recently reauthorized by Congress with broad bipartisan
support.
17
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I
�'.
Preliminary draft, 11/16/96
Not for citation
Children's health insurance and rates of enrollment into employer-sponsored plans
Helen Levy*
Department of Economics
Princeton University
Robert G. Hughes
The Robert Wood Johnson Foundation
and
The Robert Wood Johnson Foundation
...Author for correspondence. Please address any comments to The Robert Wood Johnson Foundation, College'
Road, P.O. Box 2316, Princeton NJ 08543-2316. Phone: (609) 243-5955. Fax: (609) 987-8746. Email:
hlevy@princeton.edu.
.
.
�"
., .
Introduction
,
Children~s
health insurance coverage comes from a patchwork of private and public
sources that left as many as 10 million children without health insurance in 1994. 1 As evidence
begins to mount that having insurance affects not only children's access to medical care but also
health outcomes :such as child mortality2, it becomes increasingly important that we, consider the
efficiency and feasibility of various policies to.reduce the number ofchildren without coverage.
There ar~ several reasons why the role. of employer-sponsored health insurance in
providing children's coverage deserves special attention: first, it is the largest source of their
I
coverage, covering about 60% of all children in 1993. Second, there is some evidence that
employer coverage has eroded in rece~t years; Newacheck et al. report that rates of employer
coverage for children decreased by 4.5 percentage points from 1988 to 19923. Finally; neither,
"
comprehensive coverage mandates (discussion of which effectively died with the Clinton plan)
nor expansions of Medicaid beyond those mandated in the late 1980s appears likely in the near
. future, so that policies focused on expanding the current system of voluntary employer coverage
deserve special ~ttention. Given the political interest in incremental approaches, such as the
recent "Health Ihsurance Reform Act of 1995", it makes sense for those concerned about
I
"Sources ofhealt~, insurance and characteristics of the uninsured: Analysis of the March 1995 Current Population
,I
.
Survey," Employee Benefits Research Institute Issue Brief Number 170, February 1996,
1.
Currie J, Gruber J. Health insurance eligibility, utilization of medical care, and child health. Quarterly Journal 0/
.Economics. May 1996:431-466.
i
3
Newacheck P. Children and health insurance: an overview of recent trends. Health AI/airs, Spring 1995, 245-254
1
�uninsured children to consider the potential of incremental employment-based reforms to affect
f
children's health insurance coverage.
Methods
We analyzed data on children's health insurance status from a 1993 household survey
sponsored by the Robert Wood Johnson Foundation in ten states: Colorado, Florida, Minnesota,
New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington. The
survey included 21,091 households in these ten states; the subsample we analyzed consists of
24,216 children living in 12,140 families. Children were defined as persons age 18 or younger.
Aggregate estimates of health insurance coverage were weighted to represent the total popUlation
of these children in the ten states included in the survey.
We first performed a tabular analysis of health insurance coverage rates for all children
by race, age, state of residence, employment characteristics of adults in the family, family
income, and family structure. We then used multivariate linear regression analyses to control for
the factors that might confound the effect of a single explanatory variable. Three separate
.,
regressions were estimated'with the dependent variable equal to one if the child had employersponsored insurance, Medicaid, or no insurance, respectively. Independent variables included
the child's age, sex, race, family income per family member, the highest grade ofeducation
attained by anyone in the family, whether the family had only a female head or only a male head,
whether at least one family head had ajob, whether at least one family head was offered
employer-sponsored insuranc~, and state of residence. -Standard errors were estimated using a
Huber correction for heteroscedasticity. We then repeated both the tabular and the multivariate
2
�analyses for the subset of children who were in families where at least one family head was
eligible for empl~yer-sponsored insurance; we included the industry of employment of the
primary working, adult in the family as an additional independent variable in these analyses. We
also estimated all multivariate analyses using probit models, which yielded very similar results to
those from the linear regression and are therefore not reported here, but are available upon
request.
Results
I
Health insuran~e coverage of all children
The primary source of children's coverage was employer-sponsored group health
insurance, whicl) covered 59.4% of all children (table 1). Rates of employer coverage generally
increased with family income: only 14.5% of children in families with incomes below poverty
had employer co;verage, compared to 82.8% of children in families with incomes greater than
400% of poverty. Whites had the higher rates ofemployer coverage than did Black, Native
American or Asian children. Children in families with more than one full-time worker had
higher rates of'e~ployer coverage (81.4%) than children in families without a worker (11.7%).
(Children may be covered by employer-sponsored policies of adults living outside the family.)
There was significant variation in rates of employer coverage by state, ranging from 45.3% in
Oklahoma to 76.3% in Minnesota.
The next largest source ofcoverage for children was Medicaid, which covers 17.0% of all
!
. children. Variation in Medicaid coverage mirrored the variation in rates of private coverage.
Rates of Medica,id coverage decreased as inconieincreased: Medicaid covered 58.9% of all poor
,.
3
�children, 14.4% of all children in families with incomes between 100 and 200% of poverty, and
less than 5% of all wealthier.children. Children in families without a worker were most likely to
have Medicaid (69.8%), those in families with more than one full-time worker the least likely
(1.8%.) Since eligibility requirements for Medicaid beyond the Federally mandated minimum
are determined at the state level, it is not surprising that there was substantial variation across the
ten states in rates of Medicaid coverage, from 11.6% in Oregon to 20.6% in New York.
Almost one-fifth(l7.2%) of all children had no health insurance. Those most likely to be
uninsured were children just above the poverty level, 28.8% of whom were uninsured; Asian
children (35.6%); children in families with only a male head (31.7%), and children in families
with only a part-time worker (31.2%.) Thoseleast likely to be uninsured were children in
families with income greater than 400% ofthe poverty level (6.0%); Native American/Alaskan
children (12.6%); and children in families with more than one full-time worker (11.1 %). These
patterns of non-coverage reflect the piecemeal nature of children's insurance: while employer
sponsor(:d coverage was the rule among high-income children in families with full-time workers,
and Medicaid .covered poor children in families without a worker, near-poor children and those
who live in families with part-time workers were most likely to be uninsured.
The multivariate analysis, presented in table 2, confirmed the results of the descriptive
analysis: children in families with higher family income, more highly educated family heads, or a
family head offered employer-sponsored. health insurance :were all more likely tohave employer
.
coverage, less likely to have Medicaid, and less likely to be uninsured.. Age, race and state of
residence were all significant determinants of children's insurance coverage as well; the
magnitudes of significant effects were the following:
4
�•
An additional $10,000 of family income per family member increased the probability of
I
employer coyerage by about 2 percentage points, decreased the probability of Medicaid
coverage by 1 percentage points, and decreased the probability of being uninsured by I
percentage ppints.
•
Each additional year of age increased the child's probability of employer coverage by about I
percentage points and reduced the probability of Medicaid coverage by about 2 percentage
points; the probability of being uninsured ,increased by about I percentage points.
•
Compared to whites, the probability of employer coverage was.7 percentage points lower for
Blacks~ 6 points lower for Native Americans/Alaskans, and 5 points lower for Asians. The·
probability of Medicaid coverage was 9 percentage points higher for blacks than whites;
however, for Native Americans and Asians the probability of Medicaid coverage was not'
significantly, different than for whites. Overall, the probability ofbeing uninsured was about
the same for Blacks andwhites. The probability of being uninsured was 10 percentage points
\~
lower for Native American than for white children (mostly due to public coverage through
the Indian Health Services, which accounts for the large difference in rates of Medicaid and
"
all public coverage for this group). Asian children were 6 percentage points more likely than
whites to be uninsured.
•
Hispanics were 3 percentage points less likely than non-Hispanics to hl;\ve employer
i
co~erage; t~ey were 4 points more likely to have Medicaid, and 2 points more likely to be
uninsured. ,:
5
�• Children in a family with only one head were significantly less likely than children in two
head families to have employer coverage; forfamilies with a female head only the difference
was 5 percentage points and for male head only. families it was 6 percentage points. Children
in female-headed families were far more likely (19 percentage points) than children in two
head families to have Medicaid coverage; in male-headed families the 9ifference was
significant but not as large (5 percentage points).· The net effect was quite different for the
two types of single-headed. families: children in female-headed families were 8 percentage
points less likely, and those in male-headed families were about 5 points more likely, to be
uninsured than were children in two-head families.
• The effect on insurance status of having a family member who worked depended heavily on
whether or not that family member was offered health insurance on the job. Children in
families with a worker who was not offered health insurance were 5 pe.rcentage points less
likely than those in a family without any worker to have employer coverage; they were 24
.points less likely to have Medicaid, and 21 percentage points more likely to be uninsured.
Children .in· families With a worker who was offered health insurance were 37 points more
likely than children in families without a worker to have employer coverage, 38 points less
likely to have Medicaid, and 4 points more likely to be uninsured.
• Variations by state were jointly significant.
• Sex of the child was not a significant determinant of insurance coverage.
Children and employer-sponsored health insurance
6
�The importance of having a family member who was offered employer-spon$ored health
"
insurance in determining whether:or not a child had group coverage suggests that expanding the
availability of employer-sponsored health insurance may help reduce the number of uninsured
children. In order to know how many children might be affected by such a measure, we need to
, know how many ~nsured children live in families with workers. Table 3 presents the
distribution of uninsured children in 1993 by demographic and family characteristics. 'Most
:.--;,
,
,(
uninsured children (86.2%) were indeed in a family with a worker; most of those (71.6% of the
i:'.:T"
total) were in a family with at least one full-time worker.
Many of these children, however, may already have been eligible for employer-sponsored
healthinsurance:'more than one-third (35.6%) 9fall uninsured children were in families where
one ofthe family heads is eligible for employer-sponsored insurance. And 9.4% ofchildren in
families with a h~ad eligible for employer-sponsored insurance remained uninsured. These facts
highlight the dist~nction between insurance eligibility and insurance coverage. Private health
insurance require~ enrollment well in advance ofan adverse health event, in order for the medical
!
>
bills associated with the event to be covered by the plan; Mostemployer-sponsored plans have a
waiting' period before medical bills will be paid, and/or limited periods during which it is
possible to enrol~, such as the end or beginning of the calendar year. Employer-sponsored
insurance typically also requires a premium contribution from the employee. As employee costs
, \ '
'.
increase, employees may be less likely to enroll, increasing the nun:tber ofeligible enrollees
without coverage. Therefore an important component of efforts to reduce the number of
uninsured childr~n by expanding the availability of employer-sponsored insurance must be
ensuring that chi,ldren are actually enrolled incoverage when it is available to them.
7
�Sources of health insurance for children who were eligible for employer-sponsored
insurance
In order to see how family characteristics affect enrollment rates, table 4 presents the
results of an analysis of sources of children's health insurance coverage similar to that presented
in table 1, but with the sample restricted to children in families where one or both family heads
reported that they were eligible for employer-sponsored insurance. This group is not exactly the
same as the population of children eligible for employer-sponsored health insurance for the
following reasons. First, not all policies offered by employers include the option to purchase
family coverage, although most do: our tabulations of the April 1993 Current Population Survey
Supplement on Employee Benefits suggest that at least 90% of all workers offered health .
insurance are offered the option of purchasing family coverage. Second, not all children in the .
,
sample were the children of family heads and therefore might not be eligible for coverage as
.
.
dependents under the tenns of the employer-sponsored insurance policy. Third, children may
have been eligible for coverage as the dependents of out-of-household adults who were not
included in the survey. The first and second reasons will lead to an overcount of the population
of eligible children, the third will lead to an undercount. If these errors are small, however, the
rate of coverage by employer group insurance for these children (column 2 of table 4) may be
regarded as the "enrollment rate" for employer coverage.
Overall, the enrollment rate was 84.2%, but this rate varied by family characteristics.
Most noticeably, eprollment rates increased with family income, from 48.1 % for childreIl: in .
families with income below the poverty level, to 94.1% of children in families with income
8
�greater than 400% of poverty. Enrollment rates also varied by state (from 73.4% in Oklahoma to
,
91.4% in Minnes:ota) and by industry of family head's employment, with children of government
Ii
'I
employees having the lowest enrollment rate (73.0%) and children of those employed in the
fmancial, insurruice and real estate industry the highest (94.0%).
Some chi~dren who were eligible for employer-sponsored insurance reported Medicaid
coverage (4.2%).! The option of Medicaid coverage corn:plicates our analysis of enrollment rates
".~: 1
j
.1
.
because it may make sense for parents not to enroll their children in private coverage if public
coverage through Medicaid is available: Medicaid is typically free, whereas employer-sponsored
insurance may require 'a substantial premium contribution for family coverage. The issue of dual
eligibility has prompted it debate about whether recent expansions of Medicaid eligibility has
I'
i
1
resulted in a net increase in rates ofchildren's insurance coverage, or has simply resulted in the
substitution of public for private coverage. 4,S,6,7 1t is clear that we cannot simply infer from
enrollment 'rates iess than 100% that children'must be remaining uninsured as a result, since
some ofthem may be, covered by Medicaid. Instead we rely on the presence ofa substantial
I
"
"
4
Cutler D" Gruber J. Does public insurance crowd out'private insurance? Quarterly Journal ofEconomics, May
J.I
1996,391-430.
5
•
•
I,
Shore-Sheppard, L. Stemming the tide? The effect of expanding Medicaid eligibility on health insurance coverage.
Princeton IndustriaI.Relations Section working paper #361, April 1996.
(j
Dubay L, KenneyG. The effects of Medicaid expansions on insurance coverage of children. The Future of
Children, Spring 1996, 152-161.
7
Center for Studyi~g Health Systems. Change. Medicaid eligibility policy and the crowding-out effect. Issue Brief
,:
,
#3, October 1996.1
9
�fraction ofchildren in this group (9.8%) who report being uninsured as evidence that some
. children who are eligible for private coverage remain uninsured.
This measure is imperfect, however, because children who report being uninsured 1.llay in
fact be eligible for but not enrolled in Medicaid. Why would Medicaid-eligible.children without
private health insurance not enroll in Medicaid? Their familiesmay be unaware of the program
or unaware oftheir eligibility for it; they may not enroll because of stigma; or they may, not
enroll because they know that they would be covered in the event that the child required medical
care. (Medicaid coverage is effective retroa~tively three months prior to the date of enrollment.)
From a purely economic perspective, these children are "insured" by the program in the sense
that their famjlies are not at risk of large financial losses due to medical expense; from a more
practical perspective, however, these children are likely to experience significant n~nfinancial
obstacles, or to perceive financial barriers (if they are unaware of the program) that may prevent
their getting necessary medical care. For this reason, and because it seems. unlikely that all
children who report being uninsured are in fact Medicaid eligible, we remain concerned that
some children who are eligible for employer-sponsored insurance are remaining uninsured, and
proceed with our analysis on that assumption.
Table 5 presents·the results of our multivariate analysis ofenrollment rates for this group
of children. We interepet the coefficients in the first column (the regression with employer
coverage=1 as the dependent variable) as the effect ofthe independent variables on enrollment
rates. We find that:
• An additional $10,000 of income per family member increased the enrollment rate by 4
percentage points.
10
�• Each year 6f~ child's age increased the enrollment rate by about 1 percentage point.
• Black children's enrollment rate was 9 percentage points lower than the rate for white
children: Rates for Native Americans were 13 points lower, and for Asians were 6 points
. lower, than for whites.
• Hispanic children had an enrollment rate that was 5 percentage points lower than that of non
. Hispanic children.
I
• Each year of ~ducation attained by the most highly educated family member increased the.
."
.
enrollment rate for children by 4 percentage points.
.
• Children in female-headed families had enrollment ra.tes that were 10 percentage points
i/
lower, and those in male-headed families had enrollment rates that were 8 points lower, than
I,
..
,
did children in families with two heads.
• State variables explained a significant amount of variation in enrollment rates.
• The industry in which the family's primary worker was employed also explained a significant
amount of variation in enrollment rates .
. Comment
The most important conclusion to emerge from this analysis is that efforts to reduce the
'.
~I
number of uninsured children by expanding eligibility for employer-sponsored coverage must
consider the likely rates of enrollment into those programs. The fact that enrollment rates are
below 100% will dilute the effect of any policy that aims to expand coverage by increasing
eligibility. While the potential for making currently uninsured children eligible for employersponsored coverage is very good (only 16.2% of all uninsured children are in a family without
.'
11
�any worker), even in homes with a worker who is currently eligible for insurance, nine percent of
children remain uninsured. Voluntary employment-based reform is an unpromising vehicle for
ensuring that all children are covered by health insurance. Policymakers must keep in mind the
distinction between eligibility and coverage in identifying goals for public intervention and in
I
choosing the policies that will best achieve them.
12
�Table 1
Health insurance coverage rates:
All children
1:
Fraction of children covered by:
Employer
group
Total
Medicaid
No h~alth
. insurance
59.4%
17.0%
17.2%
63.5
42.0
40.4
49.2
13.1
39.8
25.8
10.1
16.5
18.0
12.6
35.6
53.7
61.7
64.2
25.4
13.8
9.8
15.6
17.8
18.5
14.5
48.6
74.8
84.8
82.8
58.9
14.4
4.5
1.7
1.4
24.6
28.8
15.4
8.2
6.0
69.5
33.5
43.0
6.2
47.6
17.7
16.4
16.9
31.7
11.7
32.0
67.0
81.4
69.8
27.7
7.6
1.8
16.2
31.2
18.0
Il.l
11.7
19.7
11.8
69.8
30.2
15.0
16.2
36.4
44.4
9.6
27.8
55.6
16.0
20.7
88.2
20.4
17.1
3.3
28.5
45.4
7.5
Race
White
Black
. Native AmericarilAlaskan
Asian
Age
0-6
7-12
13-18
Family income
<100% of poverty
100-200%
200-300%
300-400%
400%+
Family structure ,
Two family heads
Female family h~ad only
Male family head only
Work status of adults in family
No worker
'
Part-time worker. only
One full-time worker
> 1 full-time worker
.Work/insurance offering status of adults in family
No worker
Part time worker in frrm that does not offer insurance
Full-time worker in firm that does not offer insurance
Worker in frrm that offers insurance but worker is
ineligible
Worker in firm that offers insurance but worker is
ineligible or declines
Worker in firm that offers insurance but worker declines
Worker c9vered by employer-sponsored insurance
13
�Heal~h
Table 1
insurance coverage rates:
All children
Fraction of children covered by:
Employer
group
Total
Medicaid
59.4%
17.0%
63.0
52.0
69.3
47.7
.62.0
59.8
45.3
65.1
65.0
64.4
12.7
15.2
15.3
17.6
20.6
12.7
19.2
11.6
19.7
15.2
No health
insurance
17.2%
State
CO
FL
MN
NM
NY
ND
OK
OR
VT
WA
Sample n
Weighted n
14
24,216
15.1 million
17.8
265
9.0
24.2
12.8
13.3·
22.0
17.4
7.7
14.4
�•
Table 2
Children's health insurance: all children
Linear regression (Huber standard errors)
Dependent variable=l if child has:
Independent variables:
Employer
coverage
'"
Age
.0071
(.0004)
Female
.0053
(.0047)
.0098
(.0053)
Black
-.0720
(.0081)
.0898
(.0102)
;:
Native American/Alaskan
-.0636
(.0090)
Asian
-.0514
(.0179)
Hispanic
-.0292
(.0069)
"
Family income per family member
($10,000)
.0247
(.0010)
Highest grade attained by anyone in
family
.0247
(.0010)
-.0208
(.0005)
..,
Male family
he~d only
-.0478
(.0059)
-.0585
(.0109)
At least one family head works
At least one family head is offered
employer-sponsored insurance -
.3743
(.0068)
COl
15
-.0520
(.0055)
-.0853
(.0115)
"
.
..,
.0100
(.0005)
-.0088
(.0093)
-.0973
(.0094)
'"
-.0155
(.0208)
.0587
(.0208)
'"
.0439
(.0083)
...
".
-.0237
(.0065)
-.0171
(.0012)
.,'
..
..
,
,
.,.
•••
.1899
(.0071)
.0463
(.0130)
-.2357
(.0082)
-.3762
(.0081)
.0831
(.0128)
,.,
.,.
..,
..,
•••
."
.,'
•••
...
-.0061
(.0050)
-.0126
(.0111)
I!
Female family head only
No health
insurance
Medicaid
.0227
(.0081)
-.0087
(.0020)
-.0120
(.0011)
-.0854
(.0064)
.0452
(.0131)
.2107
(.0076)
.0417
(.0070)
.0308
(.0127)
...
..,
...
,..
..
,
.,'
...
.,.
�16
�'.
Table 3
Demographic characteristics of all children, uninsured children, and children in a family where a family head is eligible
for employer-sponsored health insurance
;r
All children
Children in families
with a head eligible
' for health insurance I
Uninsured
children
15.1 million
24,216
'9.0 million
8,835
2.6 million
5,154
100.0%
80.3
13.6
2.9
3.2
100.0%
83.4
10.8
2.5
3.3
100.0%
76.9
14.3
2.1
6.7
,100.0 0/0
37.9
32.3
29.7
100.0%
35.4
33.0
31.6
100.0%
34.3
33.6
32.1
100.0%
21.5
21.3
21.4
13.3
22.5
100.0%
7.4
20.5
26.0
18.0
28.3
100.0%
30.8
35.7
19.2
6.4
7.9
Family structure
Two family head~
,
Female family h~~d only
Male family head only
,
Work status of adults in family
No worker
Part-time worker,only
One full-time worker
> 1 full-time worker
100.0%
70.9 '
25.0
4.1
100.0%
82.8
14.3
2.9
100.0%
67.9
24.5 '
7.6
100.0%
14.7
8.0
54.2
23.1
100.0%
0.0
3.4
64.9
31.7
100.0%
13.8
14.6
56.7
14.9
Worklinsurance offering status of adults in family
No worker
:i
'
Part time worker: in firm that does not offer insurance
Full-time workedn finn that does not offer insurance
Worker in finn that offers insurance but worker is
ineligible
Worker in finn that offers insurance but worker is
ineligible or declines
Worker in finn that offers insurance but worker declines
Worker covered by employer-sponsored insurance
100.0%
14.7
3.8
11.0
100.0%
0.0
0.0
0.0
100.0%
13.8
8.1
28.5
2.8
0.0
9.2
2.9
3.3
61.5
0.0
5.4
94.6
4.8
Total population
Sample size
Race
White
Black
,
Native American/Alaskan
,
Asian
Age
0-6
7-12
13-18
Family income
<100% of povertY
100-200%
200~300%
300-400%
400%+
"
\
17
8.7
26.9
�Table 3
Demographic characteristics of all children, uninsured children, and children in a family where a family head is eligible
for employer-sponsored health insurance
State
CO
FL
MN
NM
NY
ND
OK
OR
VT
WA
Industry of primary worker in family
No worker
Agriculture
Construction
Mining/manufacturing
Transportation, Comm & PU
Wholesale
Retail
Financial, Ins & real est.
Professional services
Other services
Government
No industry data provided
100.0%
7.0
21.7
8.8
3.6
34.2
1.2
.6.2
5.9
1.0
10.3
100.00/0
.. 7.7
22.0
10.0
3.0
31.9
13.3
5.9
6.2
1.1
10.9
100.0%
7.3
33.6
4.6
5.1
25.5
0.9
8.0
6.0
0.5
8.6
100.0%
14.7
2.9
7.8
11.3
8.2
1.0
9.9
5.3
16.8
7.1
7.2
7.6
100.0%
0.0
2.5
7.9
16.8
11:9
1.4
10.6
7.2
22.0
8.3
31.8.
100.0%
34.8
4.2
12.7
7.9
5.8
0.5
15.2
2.2
12.4
9.2
9.3
6.8
(I)
'Children in families with a worker with missing industry data are excluded from this column; there are 629 such children in
the sample (8.2% of children in a family with a worker who is eligible for employer-sponsored health insurance.)
18
�Table 4
Health insurance coverage rates:
Children in families with a head who is eligible for employer-sponsored insurance
Percent of children covered by:
Employer
group
Medicaid
No health
insurance
84.2%
4.2%
9.8%
86.2
77.1
65.3
73.2
2.9
13.5
8.9
2.1
9.0
11.6
10.0
24.7
81.6
85.8
85.6
6.8
2.6
2.9
10.0
9.9
9.7
Family income,
<100% of poverty
100-200%
. 200-300%
300-400%
400%+
48.1
72.5
86.9
93.1
94.1
28.9
6.2
1.8
0.9
0.5
23.1
19.1
10.1
4.3
2.9
Family structure
Two family heads
Female family head only
Male family head only
86.0
75.3
78.5
2.7
11.1
12.0
9.3
12.8
10.2
84.2
76.0
91.4
75.8
89.7
80.8
73.4
88.4
89.5
84.2
3.2
5.8
3.7
5.1
3.9
3.3
4.5
2.2
6.6
3.5
9.9
17.1
4.5
12.6
6.2
10.2
15.5
7.3
3.5
9.1
73.7
83.7·
86.4
3.8
2.9
4.9
16.9
12.3
7.1
Total
Race
White
Black
Native AmericantAlaskan
Asian
Age
O..()
7-12
13-18
State
CO
FL
MN
NM
NY
ND
OK
OR
VT
WA
Industry of primary worker in family
Agriculture
Construction
Mining/manufacturing
19
�Table 4
Health insurance coverage rates:
Children in families with a head who is eligible for employer-sponsored insurance
Percent of child ren covered by:
Emplo),er
group
Total
Transportation, Comm & PU
Wholesale
Retail
Financial, Ins & real est.
Professional services
Other services
Government
Samplen
Weighted n
20
84.2%
92.5
92.1
75.9
94.0
85.7
84.1
73.0
8,835
9.0 million
Medicaid
4.2%
1.9
2.6
7.4
0.9
5.4
5.7
2.4
No health
insurance
9.8%
4.2
4.1
14.6
2.8
7.5
8.6
22.6
�'.
TableS
i
Children's he~lth insurance: children with family heads eligible for employer-sponsored coverage
Linear regression (Huber standard errors)
"
Dependent variable=l if child has:
;
Independent variables:
Employer
coverage
Medicaid
•••
-.0195
(.0008)
Age
.0099
(.0009)
Female
-.0022
(.0095)
Black
-.0902
(.0209)
Native American/Alaskan
-.1255
(.0227)
Asian
,,;.0636
.(.0345)
Hispanic
-.0520
(.0175)
Family income per family member
,.
($10,000)
;0417
(.0058)
Highest grade attained by anyone in
family
.0395
(.0022)
Female family head only
-.1000
•••
(.0141)
.1278
(.0128)
-.0768
(.0254)
.0272
(.0216)
Male family head only
-.0005
(.0082)
•••
.1409
(.0198)
•••
...
•••
-.0310
(.0170)
•••
-.0169
(.0274)
.0612
(.0303)
.0477
(.0150)
-.0321
(.0047)
...
,
...
-.0179
(.0019)
.0973
(.0198)
-.1100
(.0226)
.0953
(.0195)
MN
.0240
(.0208)
...
.0230
(.0172)
...
.0124
(.0075)
-.1179
(.0160)
FL
21
.0048
. (.0007)
.0063
(.0202)
-.1545
•••
(.0234)
CO'
...
No health
insurance
...
•••
...
•••
...
•••
.0581
(.0153)
-.0186
(.0030)
-.0226
(.0018)
...
••
•••
•••
...
-.0068
(.0110) .
.0450
(.0222)
••
.0603
(.0192)
.0230
(.0183)
-.0366
(.0161)
..
�22
�Table 5
Children's he~lth insurance: children with family heads eligible for employer-sponsored coverage
Linear regression (Huber standard errors)
.
Dependent variable=l if child has:
Independent variables:
Government
Employer
coverage
.0555
(.0199)
...
Medicaid -.0602
(.0163)
Intercept
.0506
(.0400)
.5612
(.0352)
Number of observations
F statistic on state variables
F statistic on industry variables
R2
·8,835
27.68
14.29
.1567
8,835
21.61
5.54
.1561·
•••
•••
No health
insurance
.0070
(.0160)
.4362
(.0332)
•••
8,835
21.99
6.79
.0688
Explanatory notes:
Results are presented as: coefficient
(standard error)
'The omitted state category is NY.
2The primary family, head is the family head who works more hours. The omitted industry category is
professional services.
.
*The null hypothesis that the coefficient is equal to zero is rejected at the 1% (*U), 5% (.*) or 10% (*) level.
.,
)1
23
�., Table3
Demographic characteristics orall children, uninsured children, and children in afamily where a family head is eligible
,.
for employer-sponsored health insurance
All children
Childr<;n in families
with ahead eligible
for health insurance I
. Uninsured
children
15.1 million
24,216
9.0 million
8,835
2.6 million
5,154
Race
White
Black
Native American/Alaskan
Asian
100.0%
80.3
13:6
2.9
3.2
100.0%
83.4
10.8
2.5
3.3
100.0%
76.9
14.3
2.1
6.7
Age
0-6
7·12'
13-18
100.0%
37.9
32.3
29.7
100.0%
35.4
33.0
31.6
100.0%
34.3
33.6
32.1
Family income
. <100% of poverty
100-200%
200-300%
300-400%
400%+
100.0%
21.5
21.3·
21.4
13.3
22.5
100.0%
7.4
·20.5
26.0
18.0
28.3
100.0%
30.8
35.7·
19.2
6.4
7.9
Family structure
Two family heads
Female family head only
Male family head only
100.0%
70.9
25.0
4.1
100.0%
82.8
14.3
2.9
100.0%
67.9
24.5
7.6
Work status of adults in family
No worker
Part-time worker only
One full-time worker
> 1 full-time worker
100.0%
14:7
8.0
54.2
23.1
100.00/0
0.0
3.4
64.9
31.7
100.0%
13.8
14.6
56.7
]4.9
Work/insurance offering status of adults in family
No worker
Part time worker in fmn that does not offer insurance
Full-time worker in fmn that does not offer insurance
Worker in fmn that offers insurance but worker is
ineligible
Worker in fmn that offers insurance but worker is
ineligible or declines
Worker in fmn that offers insurance but worker declines
Worker covered by employer-sponsored insurance
100.0%
14.7
3.8
11.0
100.0%
'0.0
0.0
0.0
100.0%
13.8
8.1
28.5
2.8
0.0
9.2
2;9
3.3
61.5
0.0
5.4
94.6
4.8
8.7
26.9
Total population
Sample size
17
�Table 4
..
Health insurance coverage rates:
.
Children in families with a head wbo is eligible for employer-sponsored insurance
Percent of children covered by:
Employer
group
Medicaid
84.2%
4.2%
9.8%
Race
White
Black
Native AmericaniAlaskan
Asian
86.2
77.1
65.3
73.2
2.9
13.5
8.9
2.1
9.0
11.6
10.0
24.7
Age
0-6
7-12
13-18
81;6
85;8
85.6
6.8
2.6
2.9
10.0
9.9
9.7
Family income
;.
<100% of povertY
100-200%
200-300%
300-400%
400%+
.48.1
72.5
86.9
93.1
94.1
28.9
6.2
1.8
0.9
0.5
23.1
19.1
10.1
4.3
2.9
Family structure'
Two family heads'
Female family head only
Male family head only
86.0
75.3
78.5
2.7
11.1 .
12.0
9.3
12.8
10.2,
84:2
76.0
91.4
75.8
89.7.
80.8
73.4
88.4
89.5
84.2
3.2
5.8
3.7
5.1
3.9
3.3
4.5
2.2
6.6
3.5
9.9
17.1
4.5
12.6
6.2
10.2
15.5
7.3
3.5
9.1
3.8
2.9
4.9
16.9
12.3
7.1
Total
,(
l;
No health
Insurance
State,
CO
FL
MN
NM
NY
ND
OK
'OR
VT
WA
Industry of primary ;worker in family
Agriculture
11
Construction
Mining/manufacturing
\
19
73.7
83.7
86.4
.;
�Table 5
Children's bealth insurance: cbildren with family heads eligible for employer-sponsored coverage
Linear regression (Huber standard errors)
Dependent variable=l if child has:
Employer
coverage
Independent variables:
Age
.0099
(.0009)
Female
-.0022
(.0095)
Black
-.0902
(.0209)
Native American/Alaskan
-.1255
(.0227)
Asian
-.0636
(.0345)
Hispanic
-.0520
(.0175)
)
Family income per family member
($10,000)
.0417
(.0058)
Highest grade attained by anyone in
family
.0395
(.0022)
I
Male family head only
-.0768
(.0254)
-.1545
(.0234)
FL
-.\100
(.0226)
MN
21
-.1000
(.0141)
COl
I
-.0195
(.0008)
-.0005
(.0082)
•••
...
...
...
...
.1409
(.0198)
•••
...
.0048
(.0007)
.0124
(.0075)
-.0310
(.0170)
.0063
(.0202)
-.1179
(.0160)
-.0169
(.0274)
.0612
(.0303)
.0477
(.0150)
-.0321
(.0047)
-.0179
(.0019)
...
•••
...
.0581
(.0153)
-.0186
(.0030)
-.0226
(.0018)
•••
..
...
••
...
...
...
/
Female family head only
f
...
No health
insurance
Medicaid
.0240
(.0208)
...
...
...
...
.1278
(.0128)
.0272
(.0216)
.0973
(.0198)
.0953
(.0195)
.0230
(.0172)
•••
...
...
-.0068
(.0110)
.0450
••
(.0222)
.0603
(.0192)
.0230
(.0183)
-.0366
(.0161)
•••
..
�i
TableS
"
Children's health insurance: children with family heads eligible for employer-sponsored coverage
,
Linear regression (Huber standard errors)
Dependent variable=l if cbild has:
Independent variables:
Government
Intercept
Number of obseryations
F statistic on state variables
F statistic on industry variables
2 '
R
Employer
coverage
.0555
(.0199)
•••
Medicaid
-.0602
(.0163)
.0506
(.0400)
.5612
(.0352)
8,835
27.68
14.29
.1567
8,835
21.61
5.54
.1561
•••
•••
No health
insurance
.0070
(.0160)
.4362
•••
(.0332)
8,835
21.99
6.79
.0688
Explanatory notes:
Results are presented as: coefficient
(standard error)
IThe omitted state category is NY.
The primary family head is the family head who works more hours. The omitted industry category is
professional services:.
*The null hypothesis, that the coefficient is equal to zero is rejeCted at the 1% (*"),5% (..) or 10% (*) level.
:l
23
�10/24/96
.12:03
10/24/96 10:17;27 AM
Parashar B. Patal
Record
Record Type:
To:
~002
OMS AD HP
Nancy A. Min/OMl3/EOP, JENNINGS_C @ Al @ CD @ LNGTWY
. Barry T. Clendcnin/OMBJEOP. Mark E. Miller/OMB/EOP, Sarah A. Bianchi/OMB/EOP
Subject: Kids Estimates
CC:
I understand that Chris and YOll would like to set up a meeting with Andi King for Wednesday.
October 30th to review the status of the kids estimate. Such a meeting would be okay with us,
although given the schedule described in the summary below. you may wish to postpone th;. '-.
meeting until the week of November 4th.
__ ~
..1 . . .
W
In case you do want to meet with her next week. we have some preliminary numbers for her. In
this case, we could also use,her guidance on another policy-level issue (described below) that has
come up during our review of the estimates.
t. ,.J.
}
On Wedndesay, October 23rd, we had a conference call with HHS, Treasury, Labor, and the
Actuarial Research Corporation (HHS' consultants) to review their latest estimates for the kids
subsidy 3r'!d discuss additional refinements. Below is a summary of the cal!.
1)Their latest estimates fix a programming error which caused their premiums to be higher than
they should have been. This error has been fixed.
2) ARC h<Js completed the first stages of estimating the cost of subsidies llsing more generous'
subsidy schedules than orginally proposed by Andi King. These estimates must be re~ined by
changing the "employer dropping- assumptions (these assumptions must be refined because
this set of subsidy schedules provide more generous subsidies ... whici1 could cause more
employers/employees to drop coverage than we had been assuming) and smoothing the
eligibility cliffs (i.e., 50% subsidy from 100% to 200.% of poverty that immediately drops to
25% for individals with incomes more than 200% of poverty).
3) Treasury and olhers will think about how to revise the employer dropping assumptions and
reasonable ways to smooth out the eligibility cliffs (i.e., using a sliding scale that Jowers the
subsidy gradually from 50% to 10% for all folks above 300% of povertYl.
,
'>
.",+
~
We sugges:tthat HHS, Treasury, and Labor be invited to participate in the meeting jf possible.
"~
~~.L
av-,.,
'
4) We have set up' a conference call ;to discuss the as/sumptions that Treasury will develop.
Using these assumptions. ARC expects to be able to deliver a second round of estimates by
COB Thursday, October 31st.
5) One Question that arose is whetl)er children that are eligible under state-option for Medicaid
or for state-only kids programs would be eligible for this subsidy. Because we were unaware at
the time of the call that we might meet with Andi soon, we requested ARC to provide estimates
using both assumptions (i.e., these kids would remain with the state programs or these kids
would be eligible for the new subsidy).
~M..t
�10/24/96
12:04
mm
AD HP
Given this schedule. please let us know if you still wish to meet with Andi next week or would like
to postpone the meeting until 'the following week by which time we hope to have a second round of
estimates.
I4J 003
�FT
October 7, 1996
YUealth Financing Branch
ti
Office of Management and Budget
Executive Office of the President
Washington, DC 20503
Please route to:
Nancy-Ann Min
Chris Jennings
Through:
Barry Clendenin
Mark Miller
Subject:
Summary of Estimates for
Children's Subsidy
From:
Parashar Patel
Decision needed
Please sign
~
Per your request
Please comment
For your information _
With informational copies for:
HFB Chron.; HD Chron.;
Phone:
Fax:
E-mail:
Room:
202/395-4930
202/395-7840
pateLpa@al.eop.gov
#7001
Below is a summary of the most recent cost estimates for asubsidy program for children. These
estimates use assumptions which have been modified from earlier assumptions based on policy
guidance received onSeptember 20th from the staff of the Democratic House Leadership. Please
eep'in.mindthat these.estimates are. preliminary and subject to further refinement. As we have
indicated earlier, the average premium, participation levels, and costs are determined by a
number of policy factors. We can discuss a number of policy factors which may lower the
average premiums from those shown on the following two tables. While lowering the average
premium, most of these policy changes could also increase total costs. This will occur because,
for the most part, lowering the average premium is accomplished by increasing the number of
participants (and therefore lowering adverse selection effects).
�SubsidyJor Children:s Health Insorance, 1997
Option One (Low Subsidy:
250/. for ElTC Eligibles;
10% for All Others)
".
-
"~.
Option Two (High Subsidy:
50% for EITC Eligibles;
,
25% for All Others)
Partieipation:
(ActualfO/o of Total)
96,317
(22%)
304,926
(20%)
74,403
(17%)
438,656
(28%)
Other Private
119,754
(28%)
410,064
(26%)
Uninsured
139,341
(32%)
403,608
(26%)
Total
429,816
1,557,272
ESI
ESI-Self Employed
it llov
Costs:
'-'A.vu.age"premium
.Ii
IL.()@
.$3,112
$2,062
Total Costs
$1.3 billion
$3.2 billion
Total Subsidy Costs
$0.3 billion
$1.2 billion
-
.
�.:~ubsidyfor
Children's Health InsU1"ance, 2002
'~,
..
Option ODe (Low Subsidy:
25% for EITC Eligibles;
10% for.All Others)
Option Two (High Subsidy:
50% for EITC Eligibles;
25% for All Others)
Participation: .
(Actual/% of Total)
99,099
(22%)
314,972
(20%)
76,495
. (17%)
453,921
(28%)
Other Private
123,456
(28%)
423,276
(26%)
Uninsured
144,726
(33%)
419,729
(26%)
Total
443,774
1,611,889
.$4,518
$2,975.
Total Costs
$2.0 billion
$4.8 billion
Total Subsidy Costs
$0.5 billion
$1.7 billion
ESI
;ESI-Self Employed
Costs:
. Average Premium
�Factors That May Lower Premiums
. '1. . Lower the benefit package. Based on the experience with HSA, this will have a small
difference~ even if one uses a catastrophic benefit package.
" 2.
In~iease the subsidy leVels. This will have the greatest impact because this will help
increase the number of participants, including healthier individuals. The result will be
lower average premiums, but higher subsi~y costs.
3.
4.
Separate the risk pools for the uninsured and the insured. This would lower the
premiums for those currently purchasing coverage, but would be difficult to administer.
It would also result in relatively high premiums for the uninsured.
5.·
Increase the age to 18 years for eligibility. This would probably have a small impact on
premiums .... they may go up or down.
6.
.
Allow individuals whose employer contributes up to 50% of the premium to be eligible
for subsidies. This could also lower premiums slightly because more people would
participate. However it would increase total costs and lead to other problems such as
. increased employer dropping.
Eliminate eligibility for the uninsured. This may also lower premiums slightly .
",
.•. ,
7.
, Allow the currently insm:ed to subsidize their current coverage without having to
purchase a specific, kids-only policy. This could lead to lower average premiums, but
.could also increase total costs since more individuals are likely to participate.
�Cost and Coverage Estimates for Kids-only Insurance Program
The table below shows a range of preliminary cost and participation estimates for a health
insurance subsidy program for children. The table displays cost and participation ranges for the
years 1997 and 2002 for two subsidy levels. At both levels, eligibility is restricted to families
with 0% employer contribution to health insurance. The ranges are explained by variations in
assumptions regarding participation levels and employer dropping (see bullets below for
explanation of assumption differences). These estimates are not intended to be precise indicators
ofthe effects ofa kids-only subsidy, rather they are intended only to provide an idea ofthe
potential effects ofsuch a program.
Cost Estimates for Subsidizing Children-Only Health Insurance
0% employer contribution to health insurance required for eligibility
Low Level of Subsidies:
25% subsidy for families below 250% of poverty; 10% subsidy above 250% of poverty
Year
Average Cost
(Premium)
Total Takeup
(millions)
%of
participants
now uninsured
Annual Total
Cost (billions)
Annual Federal
Cost (billions)
1997
$1,900-$2,700
1.7-7.0.
3.0%-14.0%
$4-$13
$1-$2
2002
$2,800-$3,900
1.8-7.5
3.0%-14.0%
$7-$21
$2-$3
High Level of Subsidies:
50% subsidy for families below 250% of poverty; 25% subsidy above 250% of poverty
Year
Average Cost·
(Premium)
Total Takeup
(millions)
%of
participants
now uninsured
AnnualTotal
Cost (billions)
Annual Federal
Cost (billions)
1997
$1,800-$2,200
3.8-9.4
8.0%-11.0%
$8-$17
$3-$6
2002
$2,600-$3,200
4.0-9.9
8.0%-11.0%
$13-$26
$5-$10
The numbers shown here should be considered rough estimates of the effects of a kids-only
health insurance subsidy. Official estimation of cost and participation could vary from the
ranges shown here.
Key Assumptions
•
As the table indicates, we evaluated two potential subsidy programs:
"Low Subsidy": 25% subsidy to 250% of poverty, 10% thereafter; and
•
•
"High Subsidy": 50% subsidy to 250% of poverty, 25% thereafter.
1
�.•
To arrive at the ranges of estimates shown above, we developed low and high
participation scenarios for each of the two subsidy programs. The high participation
scenario differs from the low participation case.in two major ways: 1) the high
participat~on scenario assumes higher take-up rates across-the-board; and 2) the high
participation scenario assumes a substantially larger incidence of substitution -
individuals or employers changing their behavior to take advantage of the subsidy .
.•
The premium estimates in all cases were adjusted to reflect adverse selection associated
with bringing previously uninsured individuals into the insured pools. .
•
The costs and participation rates are influenced to a large degree by the policy choice of
whether the subsidies can be applied to a participant's current coverage or whether .
participants must join a separate insurance program and other factors. If participants can
purchase .current coverage we expect participation to be higher than if participants must
join a special risk pool.
.
•
These estimates assume that program participation is fully phased in by 1997.
Major Findings
•
In the low subsidy program, total take up ranges from 2-7 million children in 1997 (2-7.5
million in 2002), with an average cost of $1900-$2700 per child ($2800-$3900 in 2002).
These average costs reflect the il11pact of adverse selection and are heavily influenced by
participation assumptions. Federal costs would be $1 billion - $2 billion in 1997 ($2
billion -$ 3billion in2002).
•
In the high subsidy program, total takeup ranges from 4-9 million children in 1997 (4-10
million in 2002), with an average cost of $1800-$2200 per child ($2600-$3200 in 2002).
These ayerage costs reflect the impact of adverse selection and are heavily influenced by
participation assumptions. Federal costs would be $3billion - $6billion in 1997 ($5 .
billion -$ 10billion in 2002).
.
•
Both the high and the low subsidy programs draw in only a small proportion of the
uninsured population. The variations in the proportion of the currently uninsured
participants in the program are largely influenced by the assumption regarding the ability
to use subsidies for current coverage (and therefore, the number of persons with ESI
joining the program).
•
In the low subsidy program, approximately 200,000 previously uninsured kids
become insured in 1997. This represents about 1.6% of all uninsured kids and 3- .
14% of program participants.
•
In the high subsidy program, approximately 400,000-700,000 previously
uninsured kids become insured in 1997: This represents about 3.6-6.3% of all
uninsured kids and 8-11 %·ofprogram participants
2
�•
The implementation of a kids-only subsidy could result in some people losing coverage if
employers react to the incentive of the program by reducing or eliminating their
contribution to ESI.
•
As noted elsewhere, whether participants would be able to use the subsidy to pay for their
current insurance -- where the risk pool includes individuals not in the subsidy program -
or be required to join a special risk poolthat is dominated by individuals in the subsidy
program is a key aspect of this policy. We recommend clarification of certain policy
parameters prior to further estimation of the effects of this proposal.
Changing Parameters
Using background information, we have roughly estimated the impact on cost and participation
of changing the income threshold for subsidies to 200% of poverty (with no subsidy above 200%
of poverty -- we will probably need to design a phase-out of the subsidy over an income range if
this option is pursued) and the effects of limiting eligibility to children 13 years of age and under.
The following estimates are very rough. They do not account for the increase in the
average cost per child which would result from limiting the risk pool in a way that
increases the percentage of the currently uninsured in the program, and therefore increases
the effect of adverse selection .. It is not clear what impact this would have on these
estimates: costs may rise as premiums go up, but reductions in participation may offset this
increase.
Lowering the income threshold to 200% of poverty results in:
•
Participation of between 1.3 million and 2.3 million children the low subsidy case,
with a loss of approximately 18% of the previously uninsured category and a 22-67%
reduction in overall participation in 1997. Federal costs would be about $1 billion in this,
case, and the percentage of participants who were previollsly uninsured would rise to 8
14% of those participating.
in
•
Participation of between and 1.8 million to 3.7 million children in the high subsidy
scenario, with a loss of approximately 23% of the previously uni:l1sured category and a
53-60% reduction in overall participatiori in 1997. Federal costs would range from about
$2 billion to $3 billion, and the percentage of participants who were previously uninsured
would rise to 15-17% of those participating.
Lowering the age limit from the insurance definition of child to age 13 would result in:
•
Participation of between 700 thousand and 4.2 million children in the low subsidy case,
with a loss ofapproximately 45% of the previously uninsured category and a 40-55%
reduction in overall participation. Federal costs would range from about $500 million to
$1 billion,and the percentage of previously uninsured in the program would not change
much.
'
.
3
�•
Participation'of2 million to 5.8 million children in the high subsidy scenario, with a
, , loss of approximately 51-53% of the previously uninsured category and a 38-46%
reduction in overall participation. Federal costs would range from about $2 billion to $4
billion in the high subsidy case, and the percentage of previously uninsured' in the
program would go down slightly.
.£ '
4
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�HOWARD
DEAN. M.D.
(H)vA7'nor
, ,", State of VerJllont ,
OFFICE OF THE GOVERNOR
Mont.pelier 05609
Tel.: (802) 828-8333" '
Fax: (1102) 828-a339
TJ) D: (802) 828.334/;
"
EMBARGOED'lftIT,;".=,.;:.:IL=:;. "'=I1;...;a;.;.;.I.;;;;.;II.
;:
SEPTEMBER19, 1996
Gu~ernor Howard Dean,M~U., Calls fo~Health Care for Kids in 1997
WASHiNGTON, D.C.·· VSl"lnont Governo~ Howard Dean, a medlcw doctor, torl~y
challenged President Clinton and his chief rival, Dob Dole, to inject health care for kids
into the national debate.
··lne,re has been no discussion of hcalth,.;ale whatSoever during this campaign and we need
a comm(tment from both sides that health insurance for kids is a national priority,"
Governor Dean said in key note address to the American Assoclation.of H'etllth Plans.
It We can insure every child ill America under the age of 18 for peanuts.
a
,
\
"One in sevelldlildren in the Unif.en State.s lacks health insurance cover~ge and one·
quarter uf Anierican children ~re not immunized against diseases like measles, whooping
\;uugh. mumps' and pOlioo Providing he3,lth care for these kids is a concloele step IOwan;
unlversaillccess to health care that we cllntake in 1997."
UsiIi8 Vermont's~iiperitmce as a model, GoV:emOl: Dean proposed a plan to userevenue
frOm ta-x increases on cigarettes and other tobaccu products to provIde health care
coverage for nIl children up to 300 pen;eIll of the Federal Povertyl..e,ve.1 ($46.800 for a
family of four)
"Dr. Dynasaut" is Vellllollt'ssuccessfuI healt.h insuranceprogramforchildrcnwhosc
.
families either uu no't have health care benefits through work or have inadequate insurance
. ,overag~ for their children:
.
(more)
�-~-,
U8-l~-ytj
PUj
Ul:joPM
Governor D~an proposed a managed ~are program •• comprehensive pr¢ventativ~ and
acute care services, as well as d~ntar and vi~ion coverage -~ administered by the stines ac; a~
~djunct to their Medicaid programs. The plan would be federally funded and states would
contract with pdvate insurers to provide c:~re.
,
\
,
Families would pay health care premiums on a sliding fee scale up to$240 annually pe.r
houscholll. Norrunal copay~ would 6echarged for some medical visiLs. for a ma).'imumper
houliehold. out-of pocket expense of $750 annually.
It Is estimated the health insurance program would c.:ost $6.5 bIllion. nover~or Dean
propo!'ed increasing the federol excise tax for cigarettes by 24-centsper packand the excise
t.ax on other tobacco products by 7 percent to pay for "Dr. Dynasaur.
all
ft
Immediately following his address. Governor Deanand,coljeagues from several
organizations concernedwilh children'S health care talked with report,ers. Dr. Joseph R. ,
Zanga, Vice Pl"eside[lt~elect of the Amftrican Academy of ~edintrics; Eve Drooks. PresIdent
of the Natlollal Association of f:hild Advocatesi and Howard B. Shapiro, Ph.D.• Director of
Public Policy for the American Colle,ge of Physicians joined ,the Governor in his call r,n
insure AlneriCan children.
' .
,
,
"We have t~ckle.d this p~obIern in Vermorit,~ said Governor Dean. past chair of the
, National Governors', Association. uNow it's time for 'Dr. Dynasaur' to go national. It is
within this nation's menns to insure all children."
,
,
·-30··
Contact; Stepllal;i~ Carter, press secretRTy
American Association of Hecilth Plans annual conference
Septembe"r19, 1996, 10 a.m.
Capital Hilton
1001 NW 16th St.
Washington, D.C.
PRESS AVAILABILI'IY: ImmtUiately following ~peer.h
Ohio Room'
' ,
Capital Hilton
-- ---------------:---'---.
�PU1
nOWARD DEAN.
M.D.
OoVl:lHIUr
State of Vp.rmbnt
.
OFFICE OF THE GOVERNOR .
Montpelier 05609
Tel.. : (H02) ~?J..l.3gg3
1-'",,; (S02) 82.... ·3330
TDD: (S02) 828·33415
Dr. Dynasaur: Ht:alth Insurance forKirl~ .
Governor Huward Dean. M.p.
Dr. DynasauT is a national child health carc prugram proposed by Vermont Governor Howard
Dean, M;D. It wOlJ1d provide health eare cov\;rage to all uninsured. children in families earning.
300 percent of the Federal Poverty Level ollc~~. Modeled after Vermont's program of the same
name, Dr. Dynasau.r hi the nc~ step. after the uew Ktnnedy/Kassebaum I;!w, towards univerrml
health care covernge.
Ver~011t ~ank53eeond in th~ nation in lhepfopuniun of children with health Cine coverage and
first in the nation in childhood immunizations. . :
.
EliGibility
Children up to the age of 18 from families caniing up tu 300 percent of the Fed~r~l Povert), Lev~l
($46,800 for a family offour) would be eligible for Dr. Dynasaur.:
To discourage employers from dropping euiT~ully ill~uredchildrel1 for·cnrollmel1l. in
Dr. Dynasaur, participants must be uninsured for ullca:;t one year.
.Children
who are U.S. citizens or legal residents w()ulJ Gc c1igib16. .
HerMits
Dr. Dynasaur would provide 0. comprchensivc mill1agcd cale jJhlll. including preventive Ilnd ac.ute
c.are.and dental and vision services.
.
"
.
.
The parent~ of nr. DYll3S3ur participants would be required to contribute minilIli11 cupayments
and a monthly premium calculated on a sliding ~;culc based or:t lticolTic.
�UY-1Y-Yb Ui:JoPM
Dr. Dynasa.ur: Health Insurance for Kid"
Page Two
Proaram Cost
The annual,Jrognun cost is estimated to be $900 per Child or $6-.5 billion.
financing
III addition Lo premium revenue, the Dr. Dymt~::\ur program ,irouldbe paid for by increasing the
federal exci:se Uix on cigarerres and other tohacco produCts (li 24 cent inorease on a pack of
cigarettes aud 11 7 percent increase in the tax rate on aU other tobacco products).
-AdministL'alion
Dr. Dynasaw' would be a federallytlihded program administered b:y the states 0:3 an adjwlct to
. state Medic1I.id programs. State administrative costs lire anticjpated to be marginal.
To ensure that states continue their current level of !:lIpport for children, ,9. maintenance ofcffolt
would be required as wellas a continuation of each state's current Medicaid eligibility level for
children.
PUo
�PUti
Cost Estimates: Na.tional Dr.
, J)ynasaur Pogtam '"
.
.
Targeted towliu;sured children
pari.icipation.
~tl00%
Children (<: 18 yrs.):. 68,018,000
.
' "
Children under 300% of poverty:
38,566,206 ....
(-56.7% of above) ,
.
.
.
Proportion of this group who are
untnsured: 13% ("';5,013,607)
Annual per capita cost to insure: $900
Costto insure this group: fully mature'
,
program.
..,
,
$4,512,:l46~300(4.5 billion)
.
,
(5,0 13,601x$900) • Minus $208 millioIl
in premiums to charged households
with income above 185% of poverty""'
or.
approx. $4.3 billion.
Estimated maximum cost $6~5 billion jf the Humber of uninsured
dropped cov~rage.
!:,'TOWS
due to .
Revenue
Current federal excise tax receipts fur tobacco: $5.7 billion (24 cents' per pack of
dgarettes).
.
.
Additional revenues required t~ cQverU.S. uninsured: $6.5 billion.
:..
.
. $
•
,
. Recommend a 24-cent mcrease in taxes per pack of cigarettes with additio1lal 7%
increase of all tobacco products tax rates will produce $6.5 billion.
:t:OfTsets due to copayments are not factored into savil1gs.
�U~-ij-do
PU'I
Ul:j~PM
Data SOurces
E!lt.lmate.d
total Vermont. population under age 18 (1994): 146,000 (Source
R~timat~d Vermo~t population under
v'! DCI)I of llellllh) ,
18 years ofage, ur;dt:r 300% of po~eny: 82,72) (Cun'ent Population Su~c:y data)..
Estimai~d U. S, population under age 18 (1994):68,0 18,000 (:S()llr~c: !Statistical i\[JStract ()flh~ llnited Slates, 1995, T'~blc 22).
, Estimated proportion oftlS, under-IS popula{io~, not currently 'insllr~d, 13%, (Sllurcc
COUIII Dl!labook. StBte P.rolil~s ({I' Chlld Wen.11einc. W~~hjl)glori, DC, 1995,)
"Tmle E. CA~l:y Found~!irin, Kida
Urban Institute March 1994 CPS I1diusted using TRIM2 !'how): 7 4 million uninsured children und~r 300% of
poverty b3.5ed on 1992 data, Howevel, HCFA shows a groWth in children's participation in Medicaid frol11 15.1
'million to lIU'million fromJ992 to 1994 which lends credence to the) million uninsured children used in this
eSfimate, Fully half of ~11 States have used tht: Medicaid options to expllno ('.overage to childr~n beyond mandatoi'y
levels (GAO, 1996), OvcrJO states bave either a supplemental public or a pllhhc/private partnership program for
health coverage for children (NGA, 1995). .
. .
.
j>er capita cost for r~e for-service Medicaid coverage fur AFDC related under-I 8 popl;lation excluding nursing .
home and other LTC seNice5:. $1,000 (Source. VT Oniccufilcailli I\ccc~s projcctc(ll'J'lI). Sinc~the. higher-income
.
Il'ninsured can be presumed to be healthier than the: currelll covered group, we are using $Y()(). assuming managed
care, c.omprehensive coverage ineluditrg dental and vision. (Pi:1l.:ifi<.: Health Policy GroUf>. consulting tirm to VT.,
estimated $900 as an adequate nntional average for the bem~fil package.)
1qq4 federal excise receipt:) for tobncco: $~. 7 billion (S(jurcc SlaiiSlicul A~J~trm;t Olll1c Un;tcd Slates. 199~, TlIhle 518).
.
.
Assume proporticin ofU,S childrenlmder 300QI" ofpovcn:y is the same a.s for Ver~llulll (56.7%).
Assume a one.ye~r waiting period i~posed on anyone who drops ins~rance \;oYci"age.
A'ssume current Meqica.idpmgrllm r~ml\ins in place and states provide their share of state mat~hjllg fUI;d:s for the
existill)l;program under a mairit.enancp.-of-etYort requirement. Inequities rS$ulting from the current coverage:
Medic~id opti9ns selected by a state would h'e ne<\lt with over a phased 3 year period.
.
.
.
As.sumefund6 l1dministered by states as adjunct totheit' Medicaid Programs, but fully federally funded. Services
provided thruugh pre-paid managed care arrangements. Administrative costs \\iould be marginal as a Medicaid
'adjU:ri~t, with Federal rriatchingunder currem.law
Hotiseiioldsb~tw~l!n 1850;~.i25'% ofpovimywoulCl pay a premium of$120/year.Those between 225% - 300%
wOllldpay $240/year. According to Urban lnstitlltf\. March 1994 CPS data adjusted~ there Ilre 2.2 million uhinsur~d
~hildren between 185% - 299% FPL. ,Assuming 1.5 thildrM rer hotlsehold,' 1,466;666 househcld:>,would pay a .
premium, If I million households paid SUO/year and 4Sn.lloo r<lid $240/year, premiums would offset expenditures'
by $208 million.
' .
"
. State:1 wili continue to c0l11ply wilh OBRA 1990 Medicaid mandate
9/30/83 incrementally until 2002,
In
inr,·fp.ilse coverage for children born, after
�UY-\ Y-80
U\ : j~rM
SUMMARY COVERED BENEFITS"
6
NATIONAL DR. DYNASAUR' PROGRAM
Ben"efit Plan' Summary and Cost Sharing
The follo~ing scrvices and cost sharing aft:! included in [he proposed N::ltion"al Dr. Dyn3$OoUr
Program
"
,
•
•
•
•
•
•
•
•
•
•
•
inp'atient hospital Cilrc ~ no capay
outpatient serVices' $2;00 per visit
$2.00,
physician services and well chi'ld carf., incliJding inllllullizatibns
immunizations only - no co pay
trtlnsplantation services - no COpily
vision ~prvjCI?$, including eyeglasses, $2:00 (or professional services; $5.00
" for glasses'
nome healrh carp. $7.00
uulP<lI ient therapy servir.p.~ (hnni~: infusion therapies and occupational,
plw::,icdl, speech a'nd nutrition rhp.ril[iY) • no co'pay
ambulance :it::rvict:!s - no copay
short-term inpatient ft::hduilitation services - no r.oliilY
med)cal equipment ahd :>uJ,Jplies • no capay
"
mental health and chemical dl:!Jenuell<.;Y services - $2.00
•
•
OIJt-oi
prescription drugs· $2.00 per prescription ur refill
dental
care ~ na capay
"
Pocket maximum co-payments' per household:
Armu~l" HQuscholdPremiuh, ,
•
Under 185% of
•
.186%
•
226%
•
rrL - None
225%ofFPL" $120
c
300% FPL - $240
$750 per year
�Uy-\y-yti
PUY
Ul:j~PM
,Table 1
: Expanded Medicaid Coverage of
Pregnant WO.n!!!fl and
Infants ana Chilaren
,
\
'
ChlldffJn Below
,Age Six
Percet1tage of federal
povorty guideline
133%
,133%
133"/0 '
133%
' 1:1~oJ"
133"/0
105%
andlnfant5
Pereontage of federal
pnwmy gLlid~lir.e
Stare
, 33"/0
Alaui;lrflli
Alo.:;l<fl
Ari20na
Arkansas
California,
Coiorado
133%
140%
133%
200"10
133%
195%
185%
"
,
COMAr.lir;ul
Oelaware
Florida
Georgia'
Rl'lwaii'
lOaM
Illinois
Indiana
,
"
pregnsnt W(lme"
Six, snd, Older
Percentage OI,ledl!!ral
poverty guideline '
Age
Limit,
Upp8f
,
100%
100%
"
13'
13"
1<1
100%
100%
13"
19 '/' ,
100%
13--
1000/"
18S"/o
1~'
133% ,
165%
195%
-,
300%
13:W
...
133"/0
100%
19
133%
133"/"
100°/.
20
',100"/0
300%
300%
13,3%
,
'
ClJlldnm Ages
19')' ,
19,
100%
13"
100%
133%
133%
150%
,',"
13'
13"
' "13": ' "
17
1Q
13'
100%
Kansa:;
" 185°)"
1:;0"'/0
Kenlucky
~105%
133%
133%
185%
1::l::l%
'100"/0
1"00%
100"/..
.
100"10,
133%
125%
19
,186%
100%
13"
lo~'a
,,'
,
L(llli~il'l""
Maine,
Maryland~'
133%"
.. '
'::13%
185%
',185°ie
MO:lsacliusetts
165"/"
133%
Michigan
Mir:lOesota
MissiSSiPPi
185'%
150%
275 O
i"
10::l"/0
185%
133%
"
Mk~$oi.;ri
~-.
"
.....
'
18~%
-
\
13~o/"
185%
,165%
,133% "
195%
133"/0
,
133%
133%
133%
133"10
133%
1:1:W
..
133%
~
150%
Gregor.
p~(1,n!:iylvania
Rhode 161iilllUd
SOUlh Carolin~
South LJak(lT~
Tennesse'e'
Texas
$
133%
18::>"/0 '
Z50%
-'.
"
·225"10
133~\'
133°/...
r, !l!)%1l200"/0]"
'50%
1e5%
, :J:JUfo
200°/"
133 /o
Q
185%
.
1:1:;~:"·
195"/"
1000;"
..".
,
' ,
19
19
18,
'-3"
13',
13'
19
100%
'00°/,,'
[250°/,,) P00%]8
1bO"/~
100"/0
100"lor
100%
1:;3%'
133%
133"1,
[200%][225%lg
"
100%
1'33%
' 133%
13'
19
' 13',
100%
10011/0
..,- .... , 133%
'11015%'
'185"/0
, '100"10'
1:1'
13"
1(iO%
250%
185%
133%
"
,-',19
iOO%
18S"!"
, :J'
13'
100%
1:1::1%
~-"'""
Wi5cnMin
'Nyurrling
133,%
-
15"
100%
185%
Nonl'1 DaKota
Virginia
Washington
West Virginia
"',' '
133"10
185%
185"/0
Nevada
New H:lmpsnire
New JerMy
New Mexico
New York
North Carolina
Utah
Vermont
133%
,
133%
150%
Necraska
Ohio
Oklahoma
,
,150%
100%
100%
100%
133%
16G%
MO'!tana ,
13"
100%
225%
1.,.
'"
'
[8J13"
,
,13~
19
13"
1:';"
18
100%
. '11:! . '"
19
2000;.
19
100%
100%
. ,100°/"
19
IJ"
13'
.~
\
�~
, -,;.;. 0 19~ 96 01: 35P
M
Notes for
PlO
Table 1
.
.
'
.
• Under the Omnibus Reconciliation Act of 1990. states are required to provide Medicaid
coverage to children ages six and older born after September 30. f983, Jiving in families with
income below the federal poverty level (FPL), as defined by the poven)' guidelines updated
annually in the Federal Register by the U.S. Department of Health and Human Services,
under authority' of Section 673(2) of the Omnibus Budget Reconciliation Act of 1981.
n. Hawaii's coverage ,of pregnant wqmen and childrenis' through Hawaii QUEST, a Section
1115 wai ver ma'naged care program. Income eligibility is established if income does not
exceed 300 percent of the FPL. However. fully subsidized coverage is provided if in~ome
does not exceed 185 percent of theFPL. For children age one but below age six., fully
subsidized 'coverage is provided jf income does not exceed 133percei"lt of the FPL. For
children ages six or older, fully subsidizedco\'erage is provided if income does not exceed
100 percent of the FPL. When income exceeds the applicable income limits of 185 perceiu,
. 133 percent, or 100 percent of the FPL for the respec!ivegroups. the recipient is eligible to
panicipate in Hawaii QUEST but must cover the full cost of the premium.
'b, Fo~ children age one but below age six, fully subsidized ,Medicaid· coverage is provided in
Maryland if inco,me does not exceed 133, percent of the FPL. Children below age six receive
a primary care benefits package if income is below 185 percentof poveny" For children ages
six and older born after September 30. 1983. fully subsidized Medicaid coverage is provided
if income does not exceed.100 percent of theFPL Children ages six and older born after
, September 30, 1983. and whose income is below 185 percent of poverty, receive a primary
care benefits package.
c. Defined in Michigan as being born after June 30. 1979.
,
d. For individuals in family units with incomes between 1,85 percent ,and 250 percent of the
FfL, cost sharing in Rhode'lsland will be incorporated at the point of serviCe or on a
,
,premium basis.
e. In Rhode Island. ~hildren ag~s 6 or,7are, cO\lered at 250 percent of [he FPL an'dchildren ages
. 8 through 12 are covered at 100 percent ofthe FPL.
".',
,. ,
f. Tennessee~s covenige of pregnant women and chi'ldren is through TennCare, a Section 1115
waiver program.' Pregnant women and infants are automaticany eligible if income is below
185 pert;e~lof the FPL. Children below age six are aUtomatically eligible if income is,bedow
133 pe'rceni of the, FPL; children ages six and o,lder born after September :m. 1983. are
automa'ticallyeligible if income i~ below 100 percent of theFPk, Tennessee also covers
llldividuais above the 'specified income thresholds who were uninsured as of March I, 1993.
When iQcoine e,xceeds the applicable income limits specified ab~ve. the TennCare reCIpient
must P~)', pre~iums the subsidy for which is fully phased ,out at 400 percent of the FPL.
Under certain conditions, Tennessee may suspend enrollment of expanded eligibility groups.
g. In Vermont. pregnant women are covered at 200 percent of theFPL and infants are coveted
up to 225 percent of the, FPL.
~
.
h. In Washington~ pregnanL women are covered at 185 percent of the FPL and infants are
covered up to 200percent of the FPL.
Source: Nation:al Governors' As'sociation. August 1996..
�FAMILY INCOME BASED ON 1996 FEDERAL POVERTY GUIDELINES AND FAMILY SIZE
...
,U
-.
'#
Per additicnal ;JelSOn
Not stats1icatly reliable
Robert Wood Johnson Family Survey. Vermont. 1993 (i 992 fami.y income inflated to 1995 by New England C.:::>,)
Family isa gr9'l..p of tvVo ormoreperslJns rela:e~ by birth. marriage or adoption who live toge~e ....
Source: Poverty Guideli~es published in t"e Federal Register. Mardl4. 1996
::;;;:;
::>....
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::ry
=
=
. POVGUIDE.wk4
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09/17196 11 :03 At...
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Dublin Core
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Chris Jennings - Health Securities Act
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Chris Jennings
Health Securities Act
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<a href="http://clinton.presidentiallibraries.us/items/show/36173" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647904" target="_blank">National Archives Catalog Description</a>
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The Health Security Act (HSA) was an effort by the Clinton Administration to provide universal health care in the form of a comprehensive national health care bill which emphasized managed care and called for the creation of regional health care alliances. This series contains material which provides a detailed analysis of the Health Security Act. A chronological subseries within this file focuses on legislative strategies to enact the HSA, as well as efforts on the part of the Clinton Administration and its supporters to counter intense opposition to the legislation from opponents in Congress and powerful interest groups. This file also contains material which examines in detail the alternatives to the Health Security Act, particularly single-payer plans and a compromise proposal from a bipartisan group of moderates in Congress called the Mainstream Coalition. This series contains memoranda, correspondence, reports, press releases, briefing papers, statistical data, graphs, legislative drafts, publications, and news clippings related to the Health Security Act.
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CHIP 1996 [8]
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Chris Jennings
Health Securities Act
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Box 48
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/JenningsHSA.pdf" target="_blank">Collection Finding Aid</a>
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647904