Donna Cohen Ross, Outreach Director, Center on Budget and Policy Priorities.

Editor’s Note:  Donna Cohen Ross has been tracking state eligibility rules, enrollment and renewal procedures and cost-sharing practices in Medicaid and CHIP for more than a decade.  Her much anticipated annual survey was released last week by the Kaiser Commission on Medicaid and the Uninsured and the Center on Budget and Policy Priorities.  We asked Donna to give us the highlights in a guest blog entry.

What’s most striking in this year’s 50-state survey on Medicaid and CHIP is that despite the deep, deep “downs” of the economy, many states were reporting impressive “ups” for children’s health coverage.  In fact, a substantial number of states did more than survive in the depressed economic environment — they reached new heights (which is consistent with CCF’s Weathering the Storm findings).

How did they manage to do that?  Flip the pages of the calendar back to February 2009 for the answer.  That month, CHIPRA was signed into law, providing sufficient resources to cover, by 2013, an additional 4.1 million children under Medicaid and CHIP who would otherwise remain uninsured.  In addition, an Executive Order rescinded the August 17th directive, removing the constraints that had hampered states’ ability to expand coverage to children in more moderate-income families.  Later that same month, the American Recovery and Reinvestment Act (ARRA) was enacted, infusing states with fiscal relief by bumping up federal matching funds for Medicaid and prohibiting states from cutting Medicaid eligibility or putting up procedural barriers to enrollment. (These eligibility and enrollment protections did not apply to CHIP, leaving that program vulnerable to cuts.)

It’s now clear these measures were vital in helping health coverage programs rise to the challenge of providing coverage for low-income families as they faced what have been the toughest times many have ever experienced.  Let’s take a look at the specific ups and downs of 2009:

The Ups:

• In 2009, more than half the states (26) took at least one step to advance health coverage for low-income children, parents and pregnant women, with children being the biggest beneficiaries.  Nine states expanded income eligibility for children so that the median income eligibility for children rose to 235 percent of the federal poverty line from 200 percent, and now 24 states (including DC) cover children in families at 250 percent of the federal poverty line or higher.

• Nine states took steps to simplify enrollment and renewal procedures — notably, five adopted 12-month continuous eligibility, which guarantees eligible children a full year of coverage, an important step in fostering retention.

• There is no doubt that the tools and incentives states got from CHIPRA helped push them forward. More than one-third of the states (18) have submitted state plan amendments to cover immigrant children and pregnant women who have been legally residing in the U.S. for less than five years; and more than half the states (27) said they plan to conduct data matches with SSA to meet the citizenship documentation requirement, rather than requiring families to come up with documents like passports, original birth certificates and picture IDs.  State officials also said they were interested in trying out the new Express Lane Eligibility option and a handful said they will provide language and interpreter services (and get enhanced federal administrative match) for enrollment activities.

The Downs:

• To be sure, there also were some “downs,” with 15 states restricting access for children. Increasing CHIP premiums was the action states took most frequently in response to economic pressures. In some states the premium jumps were big, but even after these recent increases, overall, CHIP premiums remain modest with the median charge for two children in a family with income at 200 percent of the federal poverty line is $480 per year ($40 per month), just 1.3 percent of annual income.  Another “down” is that two states — California and Tennessee — froze CHIP enrollment for at least part of the year.  California reopened enrollment, but Tennessee remains closed.  Of greatest concern is that these access-restricting measures mean that eligible children can’t enroll and will remain uninsured.  So, a sick child can’t see a doctor or get the medicine she needs and her family may face compelling financial choices — pay the rent or pay for a prescription — even though the child qualifies for coverage.

Where do we end up as 2009 comes to a close?  The stabilizing effects of ARRA gave states the support they needed to safeguard coverage for low-income families and move forward. But, the federal fiscal relief and enrollment protections are scheduled to expire at the end of 2010.  If that happens, states will no longer have the emergency resources that have been instrumental in keeping their programs intact.  While there are indications that the economy may be beginning to recover, the recession continues to take a toll on families and communities across the nation.  If fiscal relief is not replenished and Medicaid is not protected as under ARRA, many states may buckle under the pressure they are facing to make substantial cuts in programs like Medicaid and CHIP.  Will the “ups” of 2009 turn upside down in 2010?

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.