At its November meeting, the Medicaid and CHIP Payment and Access Commission (MACPAC) focused much time on CHIP: examining the diversity among CHIP programs, considering the implications of the Affordable Care Act (ACA) on CHIP, and exploring what the future might hold for CHIP. As a former CHIP director and someone who is still involved in the children’s health policy world, I had the privilege of sharing my thoughts with the Commissioners about the role of CHIP in advancing children’s coverage over time, how the ACA is changing CHIP and, most importantly, what we can do to strengthen children’s coverage now and in the future.
Reflecting back, there is clear evidence that CHIP brought about a new determination in our country to enroll eligible children by putting out the welcome mat and removing red tape barriers to coverage. But its impact was much broader than a new path to coverage: CHIP’s high profile and bipartisan popularity spurred states to brand their programs, conduct marketing and outreach, build community partnerships, and test procedural simplifications that improve administrative efficiency while boosting enrollment and retention – all proven ingredients to success in covering children.
It is premature to assume that the marketplaces are a good substitute for CHIP. We must give the marketplaces time to mature and address specific issues that are important to children including the family glitch, access to dental services and the adequacy of habilitative services before we will know how well the marketplaces are functioning for children. In the meantime, there are many opportunities to strengthen and advance kids’ coverage even further.
# 1. Cover parents. When parents are covered, families are healthier and more economically secure and their children are more likely to enroll, retain coverage, and access needed health care services. Expanding Medicaid to parents is vital to covering children, as demonstrated in Massachusetts when the parent expansion nudged the child uninsured rate below two percent. Boosting Medicaid participation in non-expansion states is also a key strategy given that nationwide 46% of uninsured parents are currently eligible but not enrolled.
# 2. Promote continuous eligibility. Gaps in coverage can be harmful to children’s development, particularly at the youngest ages. And it is difficult to adequately measure health care quality and outcomes without continuous coverage. Providing 24 or more, rather than 12, months of continuous eligibility for children and, even better, covering newborns in their first five years of life are ideas worthy of serious consideration.
# 3. Eliminate CHIP waiting periods. In a coverage system intended to create universal access, CHIP waiting periods make no sense and, moreover, are guaranteed to create administrative bottlenecks and coordination challenges in federal marketplace states. Half of the 38 states with CHIP waiting periods have stepped up to eliminate this barrier.
# 4. Invest in community engagement. The enthusiasm of state and national leaders can help or hurt kids’ coverage efforts but a solid community of child health champions from providers, policy experts and advocates to outreach partners and enrollment assisters is also vital. While this point may be a bit outside the purview of this commission, it is critical for policy and administrative efforts to recognize and support this community as has been done by: making outreach grants available to community-based organizations, hosting national children’s coverage summits, and promoting transparency and a collaborative approach to decision-making and problem-solving that involves community stakeholders.
# 5. Use data and incentives to drive program improvement and quality. The initial phase of Medicaid/CHIP performance indicators is a good start but additional metrics and segregation by demographics, including age, are needed to better pinpoint barriers and coordination issues. And while progress is being made on the quality front, the median number of children’s health quality measures last reported by states is 12 of the core set of 24. The CHIPRA performance bonus program could serve as a model to accelerate both the reporting of data and implementation of program improvement strategies.
Our nation’s children deserve no less than a thoughtful process to assure they have a sustainable, continuous path to coverage.
- Americans value children’s coverage; nearly 9 in 10 Americans believe that all children in their state should have health coverage.
- We’ve achieved a 99% coverage rate for seniors; we should do no less for kids trail with a coverage rate of 92.8%.
- Subjecting children to waiting periods, limited enrollment periods or coverage lockouts is costly and creates gaps in coverage that can be harmful to children’s health.
- Scrimping on services places kids at a disadvantage in school and in their development.
- Fixed block grants and short-term funding create uncertainty that can undermine children’s coverage as evidenced by the enrollment freezes that briefly marred CHIP’s success about a decade ago.
CHIP should be reauthorized and funded for the foreseeable future. Smoothing out the rough edges of reform and coordination with the marketplace are important, but without CHIP, we could actually lose ground by eclipsing the spotlight it focuses uniquely on the needs of children. Taking an incremental or wait-and-see approach by extending CHIP funding a year at a time will detract from the thoughtful evaluation and planning our nation should engage in as we think holistically and long-term about children’s coverage. Our longer term challenge is to take the best of Medicaid – its comprehensive benefits, affordability protections and guarantee of coverage – and the best of CHIP – its focus on outreach, program simplifications and bipartisan appeal – to ensure that all children have access to continuous, sustainable coverage from birth to adulthood regardless of their coverage source.
