Health care reform is once again a front and center issue. While the policy debates are just beginning, broad consensus exists that a newly reformed system ought to build on the components of the current system, including the Medicaid program. This means that a central question underlying health care reform is: How can each of those components work together to meet national health care reform goals? This question raises many important issues, including how to best build on and strengthen the Medicaid program.

Overall, more than one-third of the states (19 states) took steps last year to increase access to health coverage for low-income children, pregnant women, and parents –- including 15 states that authorized or implemented coverage expansions. At the same time, 10 states enacted at least one measure to restrict access. The data from this report is also available at Facts and Statistics.

This brief provides an overview of the Medicaid program, its financing, eligibility structure, and spending, the people it covers, and the services it provides. State-level tables, showing variation in program eligibility, enrollment, and spending, are included. 

Medicaid and SCHIP play a key role in covering children in the United States, providing care for more than one in four. This fact sheet summarizes coverage data on the nation's children and examines the key role played by the two programs.

More than 20 million low-income women receive coverage for their health and long-term care through Medicaid. This issue brief describes the wide range of health services that Medicaid covers for women and Medicaid’s eligibility criteria.

As states finalized Medicaid policy decisions for fiscal year 2008, an improved fiscal environment paired with modest spending and enrollment growth allowed states to focus on program restorations, improvements, and expansions for acute and long-term care. This survey of Medicaid officials in all 50 states and the District of Columbia tracks Medicaid spending, enrollment, and policy initiatives.

This report update shows that in December 2006, a total of 42.1 million individuals were enrolled in Medicaid in the 50 states and D.C., a 1.0% decline from the 42.5 million who were enrolled in the previous December, representing the first national decline in Medicaid enrollment in nearly a decade. It also provides state-by-state enrollment variations, as well as trends by eligibility category.

This issue brief examines the relative roles of Medicaid and SCHIP in providing health coverage and reducing the uninsurance rate of low-income children. It also provides evidence of the necessity for additional Medicaid reforms to ensure that Medicaid will continue to meet the needs of low-income children and families.

This report describes the basic elements of Medicaid. It focuses on federal rules governing who is eligible, what services are covered, how the program is financed and how beneficiaries share in the cost, how providers are paid, and the role of special waivers in expanding eligibility and modifying benefits. It also discusses the major changes put in place by the Deficit Reduction Act of 2005.

This data brief explores how Medicaid and SCHIP provided health insurance coverage for low-income children in comparison to low-income adults, finding children were much more likely to have public coverage and much less likely to be uninsured than low-income adults. Additionally, the study found that broader eligibility for public programs among children has not been driving the reduction in employer-sponsored coverage.

After providing a brief background on Medicaid and SCHIP, this issue brief summarizes the available evidence to determine what the effect of the programs has been on the uninsured rate of low-income children. In addition, it examines the extent to which Medicaid and SCHIP provide children with access to needed care and whether the coverage that they provide is cost-effective.

This book serves as a resource for the public and policymakers who wish to understand how the Medicaid program is designed and implemented. It provides detailed information on whom the program covers, what it covers, how it is financed, and how it is administered.

This primer provides an overview of the SCHIP progam. It includes details on eligibility, benefits, cost-sharing, and financing, as well as trends in enrollment and expenditures.

On February 4, 2009, President Obama signed into law the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). The new law (Public Law No. 111-3) is designed to provide coverage to significant numbers of uninsured children and to improve the quality of care that all of America’s children receive. Most notably, it strengthens and extends the Children’s Health Insurance Program (CHIP) over a four and a half year period, covering 4.1 million children who would otherwise be uninsured.

This fact sheet provides an overview of provisions of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which was signed into law in February 2009. The Act extends and expands the State Children's Health Insurance Program that was enacted with bipartisan support a decade ago as part of the Balanced Budget Act of 1997 (BBA).

Overall, more than one-third of the states (19 states) took steps last year to increase access to health coverage for low-income children, pregnant women, and parents –- including 15 states that authorized or implemented coverage expansions. At the same time, 10 states enacted at least one measure to restrict access. The data from this report is also available at Facts and Statistics.

There has been growing interest by states in child buy-in programs, which allow families with incomes in excess of a state's Medicaid/SCHIP eligibility levels to purchase insurance for their children through the public plan. These programs can offer a way for states to provide children in families with moderate incomes with comprehensive coverage. This issue brief provides an overview of the programs and issues to consider.

Medicaid and SCHIP play a key role in covering children in the United States, providing care for more than one in four. This fact sheet summarizes coverage data on the nation's children and examines the key role played by the two programs.

On August 17, 2007, CMS sent a letter, known as the August 17th directive, to state health officials sharply restricting the ability of states to cover uninsured children using SCHIP funds. New data and analyses from state officials, research organizations, and policy experts raise significant questions about the basis for and the potential adverse effects of the August 17th directive, as well as the process by which CMS issued the policy. Drawing on these resourses, this issue brief provides an update on the impact of the directive as of April 2008, reporting that tens of thousands of children have lost out on coverage as a result of the directive.

To help inform the debate over the 2007 reauthorization of SCHIP, this issue brief provides new data on the extent to which low- to moderate-income children are currently enrolled in SCHIP. It shows that children with family income below 300 percent of the federal poverty level presently comprise 99.5 percent of those enrolled in SCHIP.

This issue brief discusses the basic financing for the SCHIP program, including the rules governing how SCHIP funds can be used and the mechanisms used to distribute available SCHIP funds to the states.

Based upon the research and the experience gained since the enactment of SCHIP in 1997, this report describes the important issues at stake for children in the 2007 debate over reauthorization of the program, the progress the country has made in covering children, and the steps that could be taken to move forward.

This report examines the policies and strategies states use to manage their SCHIP programs, drawing on information collected through a series of three surveys conducted between 1998 and 2005.

This data brief explores how Medicaid and SCHIP provided health insurance coverage for low-income children in comparison to low-income adults, finding children were much more likely to have public coverage and much less likely to be uninsured than low-income adults. Additionally, the study found that broader eligibility for public programs among children has not been driving the reduction in employer-sponsored coverage.

Federal rules establish which children states can cover with federal SCHIP funds. This issue brief explains these federal rules, including how they affect the income level, and insurance and citizenship status of children who can be covered under SCHIP.

After providing a brief background on Medicaid and SCHIP, this issue brief summarizes the available evidence to determine what the effect of the programs has been on the uninsured rate of low-income children. In addition, it examines the extent to which Medicaid and SCHIP provide children with access to needed care and whether the coverage that they provide is cost-effective.

A large body of evidence demonstrates that coverage matters and that low-income children enrolled in Medicaid and SCHIP benefit from increased access to needed care. This policy brief reviews the literature and examines the impact of Medicaid and SCHIP on coverage, access to care and health for the nation's low-income children.

In 2005, Missouri adopted sweeping Medicaid cutbacks. More than 100,000 people lost coverage, and many more faced reduced benefits and higher cost sharing. These cutbacks were followed by a major increase in the numbers of uninsured people, greater uncompensated care burden on hospitals, and revenue shortfalls that forced community health centers to obtain larger state grants and charge patients more.

In March of 2003, the Oregon Health Plan made substantial changes in its benefit package, as well as increases in the copayment amounts and the enforcement of premiums. Following implementation, enrollment in the expansion plan decreased from 103,000 in 2002 to 51,000 by late 2003. This study examined the impact of these policy changes on statewide emergency department (ED) use, finding that uninsured ED visits increased 20%. In addition, the proportion of the uninsured visits resulting in hospital admissions also increased.

This evaluation examines SCHIP’s performance in increasing outreach and enrollment, contributing to a decline in the uninsured rate among low-income children, and increasing access to care for enrollees. SCHIP served 6.6 million children in 2006 and has increased access to care, although gaps still remain for children from minority races/ethnicities and those with special health care needs. The report also highlights case studies from 8 states that have tailored their programs to meet the needs of their low-income population.

In this study of 16,700 SCHIP beneficiaries, enrollment was found to improve access to care, particularly relative to those children who were uninsured. Established SCHIP enrollees were more likely to receive office visits, preventive health and dental check-ups, and specialty care. In addition, they were also more likely to have a regular source of care and less likely to have unmet needs.

This study found that the effect of realized access to care (problems getting care and access to need care) on the health-related quality of life of enrollees in the California State Children's Health Insurance Program increased over time. Rates of foregone care decreased substantially, as did the rates of problems in accessing care.

This study interviewed parents of new SCHIP enrollees in New York and followed-up one year later to investigate the impact of SCHIP on access to care and health outcomes for children with asthma. Enrollment in SCHIP was associated with declines in the share of children lacking a usual source of care, having unmet health care needs, and having problems getting to the usual source of care for asthma care. Parents reported less severity in asthma attacks, fewer asthma-related emergency department visits, and better quality of care in general and for asthma-related care. 

This report presents the findings from congressionally-mandated surveys of SCHIP enrollees and disenrollees in 10 states (California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas). SCHIP programs were found to provide health coverage to the population SCHIP was intended to serve, primarily children who would otherwise have been uninsured. The programs availed enrollees of needed primary and other health care services, and were found to have a positive impact on enrollees’ access to health care services, leaving enrollees with fewer unmet needs than they would have had in the absence of SCHIP. Families were satisfied with the ease of enrolling children, many of whom remained enrolled for 12 months.

Congress mandated an independent, comprehensive study of the State Children’s Health Insurance Program (SCHIP). This final report presents findings from the study which focused mainly on SCHIP programs in California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas. The evaluation drew on case studies and surveys of SCHIP enrollees and recent disenrollees in the 10 states and found the program to be successful in nearly all of the areas examined.

This study uses National Health Interview Survey data to examine the effects of SCHIP expansions on the insurance coverage and access to care of children with chronic health conditions. The findings indicate that public insurance increased by almost 10 percentage points, while the share of uninsured children declined by more than 6 percentage points. Improvements in access to care were also found. The study concludes that even greater improvements could be achieved by increased outreach to this population and improvements in the service delivery systems used by Medicaid and SCHIP.

This paper uses data on hospitalizations for ambulatory care sensitive conditions to examine the impact of the implementation of SCHIP in California on primary care access and quality. The authors found that increases in SCHIP enrollment are associated with decreases in these types of hospitalizations, indicating that SCHIP has a strong positive effect on primary care for children enrolled in the program. 

This study uses state data on SCHIP from Florida, Kansas, and New York to examine access to care among vulnerable children, defined as children from an ethnic/racial minority, with a special health care need, or who were uninsured for a full 12 months prior to enrolling in SCHIP. Results show that enrollment in SCHIP increased access to and satisfaction with health care services for these children; however, some disparities remain between vulnerable children and other enrollees that may be due in part to characteristics of vulnerable children, such as coming from poorer, less educated families, that are associated with worse outcomes.

This report contains the results of case studies and qualitative interviews with state and local officials as part of a congressionally mandated evaluation of SCHIP. Over the first three years of the program’s implementation, states experienced rapid growth in enrollment due, in part, to extensive outreach campaigns and a simplified enrollment process. Case study respondents regard SCHIP as a successful program, providing low-cost, comprehensive benefits and improved access to care for enrollees.

In this study, poor children with Medicaid, compared to poor children without health insurance experience superior access across all the measured dimensions of health care, including a usual source of care, the frequency of unmet health needs, and the use of medical services. When compared to nonpoor children with access to private coverage, Medicaid enrollees used similar levels of physician services, but were more likely to have unmet health needs and were less likely to have a usual source of care.

The CHIP law enacted in 2009 includes a number of important program and financing changes that affect both Medicaid and CHIP. Some of the most important changes to CHIP’s financing structure include: significant new federal funding for the CHIP program through September 30, 2013; changes in the formula for distributing CHIP funds among states; and a new option for states to decide whether to use CHIP or Medicaid funding to cover children. Taken together, the financing changes provide states with reliable federal matching funds that should be adequate to both continue and expand their CHIP programs.

This publication describes the basics of the federal medical assistance percentage (FMAP), which is the share of total Medicaid expenditures paid by the federal government. The FMAP formula is defined in the Medicaid statute and is based on per capita income. Determined annually, the FMAP varies from state to state.

This report relays the perspective of leading state Medicaid directors to describe the fiscal strain on Medicaid and other safety-net programs as enrollment swells and state tax revenues shrink, raising the prospect of program cutbacks. It draws on focused interviews with leading Medicaid directors in November 2008.

The authors estimate that there are 4.5 million uninsured children who are eligible but not enrolled in Medicaid or SCHIP. This study estimates how health services utilization and expenditures for the eligible but unenrolled compare with those of children who are already enrolled and finds that the children who are unenrolled would be about 25% less costly than those children currently enrolled.

Combined federal and state spending on the Medicaid program currently exceeds $300 billion each year. It is the largest or second-largest item in state budgets, and is second only to Medicare in terms of federal spending on health care. This CRS report provides background information on Medicaid financing and a discussion of current issues.

When considering Medicaid’s impact on state budgets and other state spending priorities, it is important to distinguish between total spending and spending with state funds. In some states with more favorable federal Medicaid matching rates, the differences between the two can result in dramatically different stories, as federal funds may account for as much as two-thirds to three-quarters of state Medicaid spending. This series of issue briefs examines Medicaid’s role in state budgets and provides details on how much each state spends on Medicaid.

CMS has recently prohibited some states from increasing Medicaid eligibility for low-income children who are currently eligible for SCHIP, stating that this population must first be covered using SCHIP funds if they are available. This decision significantly limits the availability of federal financing for child health insurance and undermines long-standing state flexibility to increase eligibility for children above the mandatory levels if they choose. This brief explores the recent CMS decisions and the implications for states.

Although Congress twice passed SCHIP reauthorization bills with strong, bi-partisan support in 2007, President Bush's decision to veto these bills ultimately led Congress to simply extend the existing SCHIP program with new funding through March 2009. This issue brief provides details on the financing provisions of the extension and state-specific data on the amount of federal SCHIP funding available in fiscal year 2008. It concludes that most states have adequate federal resources with which to pursue planned initiatives to cover more uninsured children.

Maintaining Medicaid coverage during downturns in the economic cycle is a significant policy challenge for states. In recessions, states struggle to finance the cost of Medicaid coverage, which increases as people lose jobs and the health coverage that comes with them, becoming eligible for Medicaid. At the same time, state revenues, mirror¬ing the weak economy, generally become stagnant or decline. This issue brief paper offers four alternative approaches that the federal government could take to strengthen state Medicaid financing programs during periods of economic challenge.


Medicaid spending growth declined for the first time in the program’s 40-plus year history in 2006, falling by 0.2%.
This drop followed several years of very rapid spending growth, as total Medicaid expenditures rose from $205.7 billion in 2000 to $315.0 billion in 2005—an average annual increase of 8.9%. This fact sheet summarizes trends in enrollment and spending in the Medicaid program from 2000 to 2006.

This paper reports new data that shows in recent years, the costs per beneficiary have been rising at a slower pace in Medicaid than in other health care coverage, including both private health insurance and Medicare. It also shows that the increases in Medicaid are not that Medicaid has unusually high or increasing costs, but that the provision of health care in the United States has become very expensive and that health care costs in the private and public sectors alike have been rising rapidly and are expected to continue doing so. 

For many years, Section 1115 waivers have been used in the Medicaid program, and to a lesser degree in CHIP, to provide states an avenue to test and implement coverage approaches that do not meet federal program rules. This brief reviews the experience of Section 1115 Medicaid and CHIP waivers and discusses issues for the Obama administration to consider about the role of future waivers.

In August 2008, Rhode Island applied for federal permission to radically transform its Medicaid program. Rhode Island asked for a fixed amount of federal funds each year along with permission to bypass longstanding federal standards protecting Medicaid beneficiaries. However, the terms and conditions of the waiver fail to take into account the impact of the recession and the five-year cap on federal funds is too low. This makes it likely that the state will have to make cuts in benefits, provider payments, or eligibility to stay under the cap.

Section 1115 of the Social Security Act provides the Secretary of Health and Human Services (HHS) with broad authority to conduct research and demonstration projects under several programs authorized by the Social Security Act, including Medicaid and SCHIP. This report provides background information on this waiver authority.

Currently, 12 states have CMS approval to finance at least some of their adult coverage groups with unspent SCHIP funds.  Recently the Administration has not renewed some waivers that permitted coverage of adults through SCHIP.  This memo provides income eligibility thresholds by adult coverage group and FY2007 adult enrollment counts. In addition, it shows the status of the SCHIP adult coverage waivers, and describes what happened to the adult coverage groups that were previously covered under SCHIP Section 1115 waivers that have expired, as of August 6, 2008.

The use of waivers has become one of the key vehicles for innovation in Medicaid and SCHIP. This background paper examines the use of research, demonstration, and program waiver authorities to test new approaches to the delivery of and payment for health care and long-term care services. The paper reviews the statutory basis and mechanics of demonstrations and program waivers, as well as their history and political context in shaping Medicaid and SCHIP. NHFP also released a fact sheet, The Basics: Medicaid and SCHIP Waivers.

Since 2001, more than half the states have changed their Medicaid programs, through either Medicaid waivers or provisions in the Deficit Reduction Act of 2005. These changes are in benefit flexibility, cost sharing, enrollment expansions and caps, privatization, and program financing. With a few important exceptions, these changes have been fairly circumscribed, but despite their expressed interest, states have not yet fully used this flexibility for their Medicaid programs.

This report examines the experiences of 10 states (Arizona, Idaho, Illinois, Michigan, Minnesota, New Jersey, New Mexico, Oregon, Rhode Island, and Wisconsin) covering adults under SCHIP. GAO finds that the states vary with regard to program structure (covering parents, childless adults, or both; offering direct coverage or premium assistance) as well as enrollment and expenditures. Other issues examined include funding shortfalls, which faced 6 of the ten states, and outreach efforts, which tend to target the whole family.

This report examines 11 states that have been granted waivers to provide health care coverage to parents using SCHIP funds. It shows that while SCHIP parent enrollment nationwide is relatively small, the coverage provided helps fill a major coverage gap for low-income parents and their families.

This issue brief provides an overview of federal Medicaid waiver activity and reviews the implications for coverage and access to care. It explores how waivers give states federal approval to alter the way they provide coverage and/or deliver services to low-income populations.