Testimony by Tricia Brooks of Georgetown University Center for Children and Families before the Medicaid and CHIP Payment and Access Commission (November, 2013)
In 1997, CHIP emerged from the ashes of the prior attempt at health reform. At the time, 5 million uninsured children were eligible but not enrolled in Medicaid, and despite the previous decade’s eligibility expansions, it was evident that effective outreach and simplified procedures were requisites for making further gains.
Thus, CHIP’s enactment fueled a new determination in our country to enroll eligible children by putting out the welcome mat and removing red tape.
We know the basics. CHIP incentivized states to expand coverage with a higher federal match and greater flexibility in program design. But its impact was much broader than creating a new option for more moderate-income uninsured children who were persistently losing access to private insurance. CHIP’s high profile and bipartisan popularity brought about an appraisal of our approach to children’s coverage, spurring 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. But most importantly, CHIP was required to coordinate with Medicaid, resulting in a decisive welcome mat effect. Our success in covering kids through the innovations pioneered by the states inspired the ACA’s vision of streamlined, coordinated enrollment across the continuum of coverage.
Reflecting back as a former CHIP director, I believe at the core of CHIP’s success is its dedicated focus on children while Medicaid’s attention is dispersed across a broader and more diverse set of people, many with complex needs and high costs.
Notably, CHIP’s formative years provided a ripe, pro-child coverage environment for state government and child health policy experts and advocates to collaborate on addressing the barriers that inhibited enrollment and retention. Initiatives such as Covering Kids and Families and the emergence of state-based health-care conversion foundations helped build advocacy capacity and policy expertise among the child health stakeholder community as they partnered with states.
At sweet sixteen, with the exception of enrollment freezes triggered by limited block grant funding that briefly marred its success, CHIP has been a catalyst for advancing coverage in tandem with Medicaid. Our country has achieved historic low rates of uninsured children, with low-income children realizing the largest gains. There is ample evidence that children covered by CHIP, like their peers in Medicaid, have better access to care and less unmet need than uninsured children. Parents are very satisfied with the coverage their children receive through both Medicaid and CHIP, and feel it is more secure than do parents with children insured privately.
There is no question that CHIP and Medicaid are a success. The larger question is, on the eve of health reform with marketplaces in their infancy and a historic transformation of Medicaid and CHIP underway, “where do we go from here”? The ACA clearly anticipated the continuation of CHIP with its maintenance of effort provision through 2019 and by bumping up the CHIP match in 2016. But the lack of funding beyond 2015 is worrisome. Taking an incremental or wait and see approach by extending CHIP funding a year at a time will detract from the thoughtful reflection and planning our nation should engage in as we think holistically and long-term about children’s coverage. The uncertainty of short term funding could stunt the investment of time and resources in continuing to improve children’s coverage and evaluate the adequacy of the marketplace.
To safeguard our progress and ensure children’s coverage remains a priority, funding for CHIP should be extended for the foreseeable future. There are many reasons why.
At the top of the list are child-specific issues in ACA implementation that demand attention. We must fix the family glitch by appropriately basing access to affordable employer insurance on the cost of full-family, not individual, coverage. And although essential health benefits explicitly include pediatric services, the way that dental benefits are being offered in the marketplace, complicated by stand-alone dental plans, is not going to work well. Likewise, it remains to be seen whether state-defined habilitative services will be sufficient, particularly for children with special health needs.
Secondly, the marketplaces need to mature before we can assess how well they are functioning for children. It took many years to align and streamline CHIP with Medicaid, and likewise robust implementation and evaluation of the ACA will be a multi-year effort.
Third, states are stretched beyond capacity. Major IT system overhauls, eligibility and enrollment transformation, delivery system and payment reforms have maxed out state human capital depleted by tight budgets and plentiful opportunities outside government.
As the role of CHIP evolves and broader reforms take hold, we need to keep the spotlight on children.
In the coming year, an estimated 28 percent of the children currently enrolled in separate CHIP programs – over a half million children – will be moving to Medicaid in 17 states with stair-step eligibility. Consolidation of CHIP and Medicaid eligibility systems is occurring in a dozen states. On the other hand, there is this new relationship with the marketplace where coordination with parent coverage is critical. And some states, like Arkansas, are contemplating putting CHIP kids in the marketplace.
Amidst these changes, there are key steps we can take to maintain and advance coverage for children.
# 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 coverage. 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.
Poll after poll show that Americans overwhelmingly believe children should receive the health care they need to maximize their potential in life. We have achieved 99% coverage for our nation’s seniors and should do no less for our kids, who trail with a 92% coverage rate. CHIP has proven that our nation’s leaders can find bipartisan support in making children’s coverage a priority. But there is work to be done.
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. 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 every child has access to continuous, sustainable coverage from birth to adulthood regardless of their coverage source.
Thank you.