[Senate Hearing 115-311]
[From the U.S. Government Publishing Office]
S. Hrg. 115-311
THE CHILDREN'S HEALTH INSURANCE PROGRAM: THE PATH FORWARD
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HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 7, 2017
__________
Printed for the use of the Committee on Finance
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COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming BILL NELSON, Florida
JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio
ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana
A. Jay Khosla, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 1
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 3
Burr, Hon. Richard, a U.S. Senator from North Carolina........... 5
Warner, Hon. Mark R., a U.S. Senator from Virginia............... 6
WITNESSES
George, Leanna, mother of a CHIP recipient, Johnston County, NC.. 6
Schwartz, Anne L., Ph.D., Executive Director, Medicaid and CHIP
Payment and Access Commission, Washington, DC.................. 8
Nablo, Linda, Chief Deputy Director, Virginia Department of
Medical Assistance Services, Richmond, VA...................... 10
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bennet, Hon. Michael F.:
Letter submitted by #FundCHIPColorado........................ 39
Brown, Hon. Sherrod:
Letters submitted by the Ohio Department of Medicaid and the
Ohio Children's Hospital Association....................... 42
Burr, Hon. Richard:
Opening statement............................................ 5
George, Leanna:
Testimony.................................................... 6
Prepared statement........................................... 43
Hatch, Hon. Orrin G.:
Opening statement............................................ 1
Prepared statement........................................... 45
Nablo, Linda:
Testimony.................................................... 10
Prepared statement........................................... 46
Schwartz, Anne L.:
Testimony.................................................... 8
Prepared statement........................................... 49
Warner, Hon. Mark R.:
Opening statement............................................ 6
Wyden, Hon. Ron:
Opening statement............................................ 3
Prepared statement........................................... 75
Communications
AASA et al....................................................... 77
American Academy of Family Physicians (AAFP)..................... 79
American College of Physicians (ACP)............................. 81
Asian and Pacific Islander American Health Forum (APIAHF)........ 82
Campaign to End Obesity Action Fund (CEO-AF)..................... 83
Children's Hospital Association.................................. 86
The Fed Is Best Foundation....................................... 87
Healthcare Leadership Council (HLC).............................. 88
National Child Health Organizations.............................. 89
Nemours Children's Health System................................. 91
Oral Health America (OHA)........................................ 93
UnidosUS......................................................... 94
THE CHILDREN'S HEALTH INSURANCE PROGRAM: THE PATH FORWARD
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THURSDAY, SEPTEMBER 7, 2017
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:03
a.m., in room SD-215, Dirksen Senate Office Building, Hon.
Orrin G. Hatch (chairman of the committee) presiding.
Present: Senators Grassley, Cornyn, Thune, Burr, Toomey,
Heller, Scott, Wyden, Stabenow, Cantwell, Carper, Cardin,
Brown, Bennet, Casey, Warner, and McCaskill.
Also present: Republican Staff: Jennifer Kuskowski, Health
Policy Director; and Becky Shipp, Health Policy Advisor.
Democratic Staff: Joshua Sheinkman, Staff Director; Elizabeth
Jurinka, Chief Health Advisor; and Anne Dwyer, Health-care
Counsel.
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. Let us call the meeting to order. But before
we begin, I will take just a moment to say that our thoughts
and prayers go out to those who have been impacted over the
past few days by Hurricane Irma. Of course, we continue to keep
those suffering from the effects of Hurricane Harvey in our
thoughts and prayers as well.
These have truly been horrific events, and I hope and pray
for the safety of everyone involved. I join with my colleagues
in the commitment to doing all we can to assist our citizens
who are in need at this extremely difficult time. And we will
see what we can do to help alleviate some of the pain.
Now the hearing we are having today will come to order.
Twenty years ago, Senator Ted Kennedy and I came together
to create the Children's Health Insurance Program, or CHIP, in
order to provide health coverage for vulnerable children in
families who were too poor to afford private coverage but still
did not qualify for Medicaid. Twenty years ago, we were at
something of a crossroads.
The year before CHIP was signed into law, a Republican
Congress passed and a Democratic President signed a welfare
reform bill which ended the entitlement to cash welfare.
Welfare reform sought to replace a culture of dependency with
an emphasis on work.
The emphasis was to move families off assistance and toward
self-sufficiency. CHIP was needed to help many families make
that transition. So we needed to be forward-thinking, taking
into account the realities at that time with an eye toward
future sustainability of the program.
Senator Kennedy and I worked in good faith for months to
craft CHIP, and while neither of us got everything we wanted,
the result was a dedicated funding stream for the program to
help low-income families get good, reliable health insurance.
CHIP, from the outset, was a bipartisan program that
enjoyed, and continues to enjoy, broad bipartisan support
throughout the country and, I might add, here in Congress.
While it is not perfect, and while, in my view, some of the
subsequent changes to the program have been regrettable, I
believe that, overall, people consider it to be a success.
Current law provides Federal CHIP funding through the end
of fiscal year 2017. According to the Congressional Research
Service, if Congress does not act to provide additional Federal
funding, a number of children who would likely be eligible for
CHIP will go uninsured once Federal funding is exhausted.
Additionally, inaction by Congress with regard to CHIP
would cause another layer of unpredictability and anxiety for
States that have to administer the program. Of course, this
anxiety will pale in comparison to the uncertainty families who
rely on CHIP will be faced with if Congress does not act.
As the committee contemplates the future of the CHIP
program, there are several thresholds we will need to consider.
The basic question is, does the committee want to reauthorize
or merely extend CHIP?
Reauthorization would entail more extensive debate and
consideration of potential policy changes to the underlying
program. And as many of you know, in 2015, Congressman Fred
Upton--who was then chairman of the House Energy and Commerce
Committee--and I put forward a number of substantive policy
recommendations for reforming CHIP, most of which were,
admittedly, met with a mixed reaction from stakeholders.
While some policy changes are certainly in order for the
program, some are justifiably concerned that, given the number
of issues that are already before the committee, there may not
be time to give full and fair consideration to CHIP reforms
prior to the expiration of Federal funding at the end of the
fiscal year. With these concerns in mind, some have suggested
that, instead of reauthorizing the entire program, we simply
act to extend CHIP funding.
Of course, that option comes with its own set of questions.
For example, we will need to determine the appropriate length
for the extension and whether to continue with the 23-percent
increase in Federal matching for CHIP provided under the
Affordable Care Act and extended in 2015.
I know some of our members have strong feelings about both
of these questions. These are not particularly complicated
issues, but they will require some deliberation among members
of the committee.
Long story short, we have some difficult questions ahead of
us. Whether we opt to reopen CHIP for reforms or simply provide
another extension, the committee will need to invest
significant time and effort to find answers to these questions.
Today, we will continue our discussion of these matters as
we hear from witnesses who will testify to the importance of
CHIP and the need for it to continue. I hope members will
listen carefully to these witnesses, confer with their States,
and let me know how they would prefer to proceed with regard to
CHIP.
I look forward to working on a bipartisan basis with
Ranking Member Wyden and all the members of the Senate Finance
Committee to move forward on a bipartisan CHIP bill.
With that, let me now turn to my good friend, Senator
Wyden, for his opening remarks.
[The prepared statement of Chairman Hatch appears in the
appendix.]
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you very much, Mr. Chairman. And I
just want--as we start this extraordinarily important effort,
Mr. Chairman--to note your history with Senator Kennedy. The
fact is, it was that bipartisan partnership that got this
program off the ground and has significantly reduced the number
of uninsured kids in America.
We are very appreciative that you set this in motion. I
know all of the members on our side very much look forward to
working with you to make sure that we get this reauthorized and
done quickly.
The Chairman. Thank you, Senator.
Senator Wyden. Colleagues, the fact is, it would be easy
for those who are casual observers of political news to get
lost right now in what is going on in Washington, DC. And there
is an awful lot of Washington lingo that is just
incomprehensible to people.
There is the continuing resolution, the debt ceiling, CSR
payments, which is cost sharing, NDAA, which is the Defense
Act, and I think all of us could go on and on with others.
Today we are talking about the Children's Health Insurance
Program. It is CHIP, and it is the only health bill with a time
stamp on it. The program is going to expire in a few weeks.
I think our message on this committee needs to be that we
see our job as putting kids first. And that means that we are
going to have to swing into action quickly here, because this
program is a lifeline for almost 9 million vulnerable kids.
It is a source of profound relief for parents in Oregon and
across the country. I want to talk about the kind of person who
really sees this as the lifeline I have described.
We might be talking about a single mom who works multiple
jobs, pays the bills, and handles all of what life throws at
her all by herself. The last thing that single mom needs is a
government letter stamped ``notice of termination'' explaining
that her sick kids are on their own because CHIP funding has
run out.
That single mom is already juggling an awful lot. I think
it is fair to say she does not read page A17 of the morning
newspaper every day, because she has too much going on to be
able to do that and try to decode all of this Washington lingo
to determine if the Congress is going to act.
That single mom sits in her kitchen, and if all she has is
that scary termination letter, we are going to see a lot of
single moms and families in a huge mess very quickly. That is
the prospect families across the country face in a matter of
weeks, and it is what they do not deserve.
Kids who desperately need care might not get it. States are
going to be required to start planning for the worst. That
means enrollment freezes, belt tightening, and emergency steps
to try to preserve care for kids currently in the program.
But a vulnerable child not yet enrolled in CHIP might have
to, in effect, wait until the Congress gets its act together.
At best, that leaves families with a mountain of stress,
anxiety, and heartache. At worst, it is a life-and-death
proposition for a great many of some of the most vulnerable
children in our country.
So today, the Finance Committee is going to discuss the
leading health-care issue Congress has to address this fall.
The Congress created CHIP with one goal in mind: that was to
make sure that no American child falls through the cracks of
our health-care system.
In the coming weeks, we have an opportunity, as Chairman
Hatch just noted, to put together a strong bipartisan agreement
that upholds CHIP's promise to families and gives those kids
security for years to come.
I am beginning this discussion in an optimistic kind of
way, because I have discussed this--as I know many of you
have--with Chairman Hatch, and I know the history. In the
decades since Chairman Hatch and Senator Kennedy led the
Congress to create CHIP, the percentage of kids in America
living without health coverage has fallen from nearly 14
percent to less than 5 percent.
So they gave us concrete proof, again, that you can have
Senators who can have fierce disagreements on a variety of
issues finding common ground when it comes to big challenges.
And I submit--I have heard Senator Casey and others talk about
this--it does not get any bigger than standing up for
vulnerable children.
So it is important for the Congress to act soon. There is
no kicking this can down the road with a short-term bill, and
it cannot wait until December.
The States run their programs differently. Some are going
to run out of funding earlier than others. In that time, no
family ought to face the panic of being unable to get the care
their sick child needs.
As I wrap up, one other point is to note how CHIP and
Medicaid work hand-in-hand for American kids and families,
particularly those families working hard every day to climb
into the middle class. CHIP adds a level of security to the
health care of that single mom and others above and beyond
Medicaid. But CHIP can only work if Medicaid works. So we have
hard work to do, colleagues, now, to uphold the Senate's
promise to kids and families.
We are going to hear from a witness panel that I think it
would be fair to say knows CHIP from A to Z: a mom whose child
counts on this program, an official who assures CHIP runs
smoothly in her State, and an independent expert who knows the
program
inside-out.
So I see this as an opportunity for all Senators on both
sides of the aisle to learn about and discuss this critical
program and set the stage for the work to come. I am confident
that in short order Congress can pass a strong and bipartisan
extension of CHIP that will last for many years. And this is
exactly what the important work of the Finance Committee is all
about.
[The prepared statement of Senator Wyden appears in the
appendix.]
Senator Wyden [presiding]. Now Chairman Hatch is going to
have to do some juggling here. So I am going to call an
audible, and I would like to welcome each of our three
witnesses to our hearing today. Each of your perspectives is
important with respect to CHIP.
First, we are going to hear from Leanna George, who will be
introduced by our friend, Senator Burr.
OPENING STATEMENT OF HON. RICHARD BURR,
A U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Senator Wyden.
Welcome, Leanna. Leanna is a proud parent of two children.
Is that Caleb behind you?
Ms. George. Yes, Sir.
Senator Burr. Caleb, wave at everybody. We are glad to have
you.
Leanna's daughter is eligible for Medicaid because of her
disability. Caleb, her son, is insured by the CHIP program.
Leanna serves as the beneficiary representative on the
Medicaid and CHIP Payment and Access Commission. She is also a
chairperson of the North Carolina Council on Educational
Services for Exceptional Children and is the secretary of the
Consumer Family Advocacy Committee for Johnston County Mental
Health Center, the local management entity that connects
Johnston County citizens with mental health, intellectual
developmental disabilities, and substance abuse services.
She is not only a mom, she is an advocate in every sense of
the word at every level. Leanna, we are just honored to have
you here today. Welcome.
Senator Wyden. Thank you very much, Senator Burr.
Second, we are going to hear from Dr. Anne L. Schwartz, the
Executive Director of the Medicaid and CHIP Payment and Access
Commission, commonly known in Washington lingo as MACPAC.
MACPAC is the nonpartisan legislative branch agency that
provides policy and data analysis and makes recommendations to
Congress, the Secretary of Health and Human Services, and the
States on a wide variety of issues affecting Medicaid and the
State CHIP programs.
Dr. Schwartz previously served as deputy editor of the
journal Health Affairs, vice president at Grant Makers in
Health, and Special Assistant to the Executive Director and
Senior Analyst at the Physician Payment Review Commission--
another mouthful--a precursor to the Medicare Payment Advisory
Commission. Dr. Schwartz has also held positions on committee
and personal staff for the U.S. House of Representatives.
She holds a doctorate in health policy from the School of
Hygiene and Public Health at the Johns Hopkins University.
Finally, we will hear from Ms. Linda Nablo, who is going to
be introduced by our good friend, Senator Warner.
OPENING STATEMENT OF HON. MARK R. WARNER,
A U.S. SENATOR FROM VIRGINIA
Senator Warner. Thank you, Senator Wyden.
I want to echo what both you and Chairman Hatch said about
the importance of CHIP. It is a critically important program.
I would like to present to my colleagues my good friend
Linda Nablo, who is now the Chief Deputy Director for the
Commonwealth's Medicaid agency, the Virginia Department of
Medical Assistance Services, or as we call them, Virginia DMAS.
Linda and I go back to the days when Bob Casey addressed me
as his excellency, the Governor. Linda, at that point, was
Director of the Division of Maternal and Child Health Services.
Our CHIP program back in the early 2000s was, frankly, a
dreadful disaster. We were literally sending tens of millions
of dollars back to the Federal Government because we did not
appropriately sign up enough of our eligible children.
We came in, and with Linda's great help turned that program
around, made it a much easier process to get through the sign-
up process, and turned a multi-page application into a single-
page application process. Linda and I traveled the State at
clinics and other gatherings, and because of her good work and
the work of a lot of folks at DMAS, we went from one of the
bottom of the barrel programs to where we signed up 98 percent
of our eligible children. Kaiser Foundation recognized us as
one of the most effective CHIP programs in the country.
Linda went on to serve at CMS and now has come back to
DMAS. She has a great, great expertise and a great heart for
this program, and she should be a very valuable witness.
Thank you, Senator Wyden.
Senator Wyden. Thank you, Senator Warner. So now we have
gotten to the best part, and that is our witnesses. Why don't
we begin with you, Ms. George? We will go right down the row.
It is a tradition in this committee if you could perhaps
highlight your testimony in 5 minutes. We will make your
prepared remarks a part of the record in full.
Please proceed, Ms. George.
STATEMENT OF LEANNA GEORGE, MOTHER OF A CHIP RECIPIENT,
JOHNSTON COUNTY, NC
Ms. George. Thank you very much.
Good morning. My name is Leanna George, and as Senator Burr
indicated, I am from Johnston County, NC. It is a very small
rural county.
Thank you for the opportunity to be here today to meet with
you and to share my family's experience with the CHIP program
and how it impacts families like mine throughout our great
country.
I am married to a wonderful man named Jim. He is a Marine
Corps vet, and he is in his third year of an electrician's
training program to become a fully licensed electrician. As
mentioned earlier, I have two children: Serenity, who lives in
a group home, and my great son, Caleb, behind me. Both of my
children are on the autism spectrum.
Caleb has ADHD, Attention Deficit Hyperactivity Disorder,
as well as a genetic neurological condition. And as you know,
Serenity has Medicaid, and Caleb is insured by CHIP.
While I am not here to testify on behalf of MACPAC, it was
not until I was appointed to the Commission that I realized
that CHIP's future was so uncertain. As a parent of a child
with extensive needs, my focus had been on advocating for home-
and
community-based service support waivers for children with
developmental disabilities like my daughter. I was not aware
that CHIP was in danger and that the children of working-class
families like mine were in jeopardy of losing their health
insurance.
As the Commission discussed the CHIP program, I began to
wonder just how losing CHIP would impact my family. How would
it affect the monthly premiums we pay for our insurance? Would
Caleb have access to the services he needs? How much would it
cost us?
With the current health insurance plan, there would be no
increase to our premium because my husband's plan only covers
employees or family-only coverage. There is no employee and
spouse-only coverage. However, it has a very high deductible
which already prevents my husband and I from accessing medical
care that we need.
This, in short, means that the services that Caleb needs
would be pretty much out of our financial reach to get for him
without CHIP. These services include occupational therapy,
which addresses fine motor challenges that impact his ability
to write and perform basic self-care tasks like tying his
shoes.
He receives periodic MRIs to mark the progression of his
neurologic condition which allow us to be proactive in
treatment, which results in better outcomes for our children.
My son takes daily medication which helps him be able to focus
in school, which impacts his grades and his ability to learn.
Over the years, the CHIP program has provided all of these
services to us for little to no cost. Even in years when we
have had cost-sharing, CHIP is still a tremendous value for my
family. Without CHIP coverage, his access to services would be
greatly diminished.
CHIP also provides families with financial security and
moms like me with peace of mind. In January, my husband was
laid off of work. That resulted in an insurance lapse for him
and me. We worked hard to ensure that he continued his
medication that he needed, but I was able to feel confident
that Caleb had the services and supports he needed should he
become sick. I am so thankful that I have never had to call his
pediatrician and say, ``I am going to have to cancel our
appointment. We do not have insurance.'' I have never had to
watch him lying in his bed with a fever and not been able to
pursue medical intervention for him.
CHIP has allowed my son to continue to receive the services
he needs without interruption, despite what challenges my
husband and I were facing. If CHIP was to go away, families
like mine would be forced to make many tough decisions for our
children.
Monetary resources are already stretched thin. Families
might have to ration medical care, which could result in
something that appears minor right now progressing into a very
serious condition. Other families may procrastinate on
maintenance services on vehicles and housing, which could lead
to tragic accidents occurring. If we were not able to afford my
son's medication, I know his education would be severely
affected.
Among sacrifices, we have to consider activities that our
kids participate in. Caleb is a Boy Scout. He has been in
scouting since he was in the first grade. He earned his Arrow
of Light last year in Cub Scouts. His uncle and his cousin are
both Eagles, and he is excited about earning his Eagle one day.
And I want to see him grow into a young man who exhibits the 12
principles of the Boy Scout law.
While there is a lot of support for these great programs
that teach leadership and discipline and promote active,
physical, healthy lifestyles, losing CHIP can really put a
hindrance on families being able to continue the support for
these activities for their kids.
Some families would have to sacrifice the care they provide
for others, their children, their parents who live in
situations outside of the home. My daughter lives 4 hours away
from us. I would like to go more often than I can, but without
CHIP, we would be even more limited in our ability to monitor
her needs from where we live.
There are 9 million children who receive CHIP. This program
provides parents and families with peace of mind and financial
security. Without CHIP, life would be a lot harder. I do not
even want to picture or imagine it, but I know the impact is
going to be on our kids for years to come.
I ask you today to continue funding CHIP. And I want to
thank you for your time to determine the future of this great
program. Thank you very much.
Senator Wyden. Thank you, Ms. George. I know you speak for
a lot of parents. We very much appreciate your being here.
[The prepared statement of Ms. George appears in the
appendix.]
Senator Wyden. Dr. Schwartz?
STATEMENT OF ANNE L. SCHWARTZ, Ph.D., EXECUTIVE DIRECTOR,
MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION, WASHINGTON, DC
Dr. Schwartz. Good morning, Senator Wyden and members of
the Finance Committee. I am Anne Schwartz, Executive Director
of MACPAC, the Medicaid and CHIP Payment and Access Commission.
As Senator Wyden noted, MACPAC is a nonpartisan
congressional advisory body charged with analyzing and
reviewing Medicaid and CHIP policies and making recommendations
to Congress, the Secretary of HHS, and the States on issues
affecting these programs. Its 17 members, led by chair Penny
Thompson and vice chair Marsha Gold, are appointed by GAO.
While my statement builds on the analyses conducted by
MACPAC staff, it reflects the views of the Commission itself.
We appreciate the opportunity to share MACPAC's recommendations
at a time when there is a pressing need for congressional
action and the consequences for children and their families are
significant.
Since its enactment with strong bipartisan support in 1997,
CHIP has played an important role in providing insurance
coverage and access to health care for millions of children
with incomes just above Medicaid eligibility levels. Since 1997
to 2015, the share of uninsured children in the typical CHIP
income range has fallen dramatically from 22.8 to 6.7 percent.
CHIP is State-administered within Federal parameters and
jointly financed by the Federal Government and the States.
Flexibility in program design is one of its hallmarks; some
States run CHIP as an expansion of their Medicaid programs, and
others operate entirely separate programs.
As you know, without congressional action, States will not
receive any new Federal funds for CHIP beyond the end of this
month. Our latest projection shows that 3 States and the
District of Columbia will exhaust their CHIP funds by the end
of 2017, and 27 States will do so by the end of the second
quarter of fiscal year 2018.
In the face of uncertainty, many State administrators are
already considering the numerous steps they will have to take
to either freeze enrollment, scale back, or shut down programs.
While they do not wish to alarm beneficiaries, States report
that they cannot continue indefinitely with business as usual.
Mindful of this situation, the Commission issued its
recommendations last January after devoting considerable
attention over several years to CHIP's role in our health-care
system and policy approaches for the future.
We reviewed available evidence about the quality and
affordability of CHIP compared to other alternatives and
focused attention on the implications of various policy
approaches on children and their families, States, providers,
plans, and the Federal Government. Based on this review, and in
light of considerable uncertainty now facing health insurance
markets, MACPAC recommends that Federal funding for CHIP be
extended for 5 years.
If CHIP funding is not renewed, 1.2 million children
covered under separate CHIP will lose their coverage. While
some of these children may be eligible for coverage privately,
they would have to pay considerably more than under CHIP,
creating barriers to needed health and developmental services.
In addition, they would lose access to services covered by CHIP
that are not typically covered by other payers. Those covered
by Medicaid expansion CHIP would not lose coverage, but there
would be a significant shift in the funding obligation to the
States.
The Commission also recommends extension of the current
CHIP maintenance of effort requirement and the 23 percentage
point increase in the Federal CHIP matching rate through fiscal
year 2022.
These linked recommendations reflect the view that
extension of the MOE--which it judged important to retaining
gains in coverage--should be accompanied by an extension in
enhanced funding. The higher CHIP matching rate is also thought
to have influenced decisions in some States, including Florida,
Utah, and Arizona, to expand coverage to previously uninsured
children.
MACPAC's recommendations also look to a future in which a
more seamless system of children's coverage can be created.
Such a system would provide comprehensive and affordable
coverage and remove gaps that occur when children transition
among different sources of publicly and privately financed
coverage.
Recognizing that States will be the drivers of such change,
MACPAC recommends that demonstration grants be made available
to States to develop and test new approaches.
Our other recommendations call for an extension of other
child-focused programs that are typically reauthorized with
CHIP.
CHIP has clearly played an important role in providing
access to health care for millions of America's children. In
addition, CHIP has provided a platform for State innovations to
reach eligible but uninsured children, remove enrollment
barriers, and focus on high-quality pediatric care.
Congress now faces an important decision regarding the
future of CHIP during a period of great uncertainty affecting
other health-care markets, including both Medicaid and the
exchanges. MACPAC's recommendations provide guidance on how to
ensure a stable source of affordable and comprehensive coverage
for low- and moderate-income children amid such uncertainty.
And the Commission urges Congress to act as soon as possible to
extend CHIP, an action necessary to prevent children from
losing coverage and access to care and to ensure that States
have the necessary funds to provide people services.
Senator Wyden. Dr. Schwartz, thank you very much.
[The prepared statement of Dr. Schwartz appears in the
appendix.]
Senator Wyden. Ms. Nablo, welcome.
STATEMENT OF LINDA NABLO, CHIEF DEPUTY DIRECTOR, VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, RICHMOND, VA
Ms. Nablo. Thank you, Senator Wyden, for allowing me to
speak to you today on the importance to States of continued
funding for the Children's Health Insurance Program.
And thank you, Senator Warner. I remember well when you
were Governor and enrolling every eligible child was your top
priority. I particularly remember how you would ask every
Friday--without fail--how many more children we had gotten
covered that week.
So before you ask, let me say that in Virginia today there
are 614,100 children covered through Medicaid and CHIP. These
programs are the health insurance plan for almost one in three
children in the Commonwealth, which is actually slightly below
the national average.
However States have chosen to design their CHIP program, it
plays a vital role for all of us in ensuring children have
access to affordable and appropriate health care by building on
top of the much larger Medicaid program. In fact, CHIP just
turned 20. It is now a mature program that is woven deep into
the fabric of health-care coverage in all States.
There are only two points I want to make with you today in
my few minutes. First is that CHIP is vital to the health of
children. And second is that there are serious consequences
looming if you delay reauthorization even for a few months.
In Virginia, as of September 1st, there are over 58,000
children enrolled in Medicaid, but funded by CHIP. There are
65,000-plus enrolled in our separate program we call ``FAMIS.''
We also have a CHIP waiver to provide prenatal care to pregnant
women, and about 1,100 are currently enrolled.
Virginia receives 88-percent Federal funding for this
program. In the last two State fiscal years, this money has
paid for hundreds of thousands of well-child visits and
immunizations, over 21,000 pairs of glasses, and well over
367,000 visits to the dentist. But we have also paid for 258
heart surgeries, six brain cancer surgeries, two liver
transplants, and one heart transplant. We have provided
services for over 1,100 children diagnosed with cancer, 31
children living with HIV, and 32 babies born with neonatal
abstinence syndrome.
Obviously, CHIP helps children lead healthy and normal
lives. For example, they can play sports. You know you have to
have insurance to play sports. They can control their asthma,
they can see better in school, or get their teeth fixed.
For other children, CHIP has provided lifesaving
treatments. This is true in my State and in yours. But without
congressional action soon--as Senator Wyden clearly explained--
States will be forced to start preparations to shut these
programs down.
You have heard that most States will not actually run out
of CHIP dollars until sometime in the second quarter of 2018.
Some might believe you can safely delay action on CHIP while
you deal with your very full calendar. But let me explain the
reality for States.
According to all estimates, Virginia will run out of
Federal CHIP dollars sometime in March. However, Virginia like
many States, covers these children through managed-care plans.
We pay those health plans a capitated rate retrospectively for
the previous month's coverage. So in March, we will not have
sufficient funds to pay for the month of February. We will,
therefore, need to terminate our separate CHIP program at the
end of January.
In order to give the families of those 65,000 children
adequate notice, we will need to send them letters on or about
December 1st. Before then, we will need to train eligibility
workers, application assisters, call center operators, and
others so they are able to answer questions and provide
whatever assistance they can to these frightened families.
We will also need to inform providers and prepare to deal
with their questions as well. We will need to expend CHIP funds
to reprogram automated eligibility rules and to modify online
and paper applications and notices. Countless other contracts,
from managed care plans, prior authorization reviews, auditors,
et cetera, will all need to be amended.
I suspect for States without a high degree of managed care,
the situation will be even more precarious, as their costs are
less predictable. And remember, Virginia is not one of the
first States to run out of money. Please be aware that your
State will soon be making difficult decisions about if and when
to freeze enrollment so as to preserve current coverage as long
as possible, and what to tell families and when to tell them as
the end of funding approaches.
Because we have come so dangerously close to the wire this
time, States would be grateful for any quick extension of CHIP.
But I do want to make the point that funding this program in
one- or two-year increments can generate instability, dampen
innovation, may limit State investment, and freeze programs
where they are when the future is so uncertain. I hope at some
point you are able to consider the recommendation of MACPAC and
other organizations of reauthorizing and funding the program
for at least 5 years.
Finally, please be aware that, for Virginia alone, if
Congress reauthorizes CHIP by September 30th but reduces the
Federal match rate to previous levels, we will experience over
a $57-million shortfall for the current State fiscal year which
began in July, and an $83-million shortfall in the next.
Senator Wyden and members of the committee, as you know,
CHIP has always had strong bipartisan support. With all of the
very difficult and complex decisions you have to make about
health care in America, surely whether or not to extend CHIP is
not one of the hard ones.
On behalf of States, I am here to ask you to please
continue your support of children's health care by
straightforward reauthorization for continued funding of CHIP
at current levels. And please do it before we have to send
those letters.
Thank you.
Senator Wyden. Thank you, Ms. Nablo.
[The prepared statement of Ms. Nablo appears in the
appendix.]
Senator Wyden. Well said. And I also appreciated hearing
how it was morning in Virginia when Mark Warner was Governor
and everybody got their daily report on how many kids got
covered. [Laughter.]
You all have been an excellent panel. Let me just start
with a couple of questions.
Ms. George, I would like to hear what it really means in a
parent's case, in terms of what they would give up if the
program expires. For example, I think it would be helpful to
know how you would pay for Caleb's medications, because it
sounds like those are pretty pricey. And you talked to us about
a whole variety of circumstances which obviously a parent cares
about, but how would you pay for Caleb's medications?
Ms. George. Right now, I am not really 100-percent sure. I
would probably be asking my mother for a lot more help than we
already get. And right now Caleb and his father take a class
called Tang Soo Do, a martial arts class that helps my husband
with some arthritis challenges and helps Caleb immensely. But
that would be one of the first things we would have to drop.
Right now we put aside money each month so that we can have
money when the Boy Scouts go to summer camp, you know--that is
another area. Because we are looking at $3,600 a year that we
have to find savings for, for his medications, and that is if
they do not go up again.
And that is a third of our--is it a third of our income?
No. It is not a third of our income. It is about a tenth of our
income, actually, though.
And just trying to find that savings would be a challenge,
because we can probably get half of it, as I said, through some
of the martial arts classes that he takes, but the rest of it,
I am not sure where it would come from.
Senator Wyden. That was my sense. And I appreciate that,
because you have described how, basically, every single month
you are trying to watch how you allocate your dollars, and it
is tight, but you get along. And you try to do, obviously,
right by your kids.
I just kept looking at Caleb's medications, and I cannot
figure out how you would be able to pick those up without some
magical approach that we have not talked about. So I probably
want to ask you some more about it.
Ms. Nablo, a question for you. You really gave us a very
concrete and specific case about the kind of bedlam that we
would see in the State of Virginia if this program was delayed.
Can you tell us--because you are an authority on this
subject--what would happen in other States? In other words,
based on your knowledge and your expertise about the program,
tell us a little bit about whether what Virginia does is
representative, and would other States have other problems, and
just walk us through, if you would, some of the other States.
Ms. Nablo. I would say Virginia is probably somewhat
fortunate in this situation in that the Federal funding does
not run out until March, even though the program would have to
close.
Senator Wyden. So the problems you describe would,
essentially, be worse elsewhere?
Ms. Nablo. Absolutely. Obviously, as has already been
stated, there are several States that will run out of funding
before the end of this year. They have really got to be
thinking about notifying those families very soon.
In addition, I believe there are some States that actually
have a State law that says if the funding level from the
Federal Government is reduced or goes away, they have to shut
down their programs. Every State is a little bit different, and
every State program is constructed a little differently. There
are some that I think are really kind of reaching the
desperation point. Now, I suspect if they do not hear something
in the matter of a couple of weeks, several States will be
sending those letters, or being in the paper trying to warn
parents.
Senator Wyden. Your message--and that is particularly
helpful--is that anybody who thinks they can wait around until
December 15th to get serious about this----
Ms. Nablo. Has never shut down a program before.
Senator Wyden. Okay. Well said. You are talking about
people getting a signal in a couple of weeks. And if Congress
plays stall ball on this, there are going to be real
consequences.
Ms. Nablo. Absolutely. There would be very scared families,
and our phones would ring off the hook in State offices and
local offices.
Senator Wyden. Very important to know.
One other really quick question. Dr. Schwartz, we feel very
strongly that this program be multi-year, and we are going to
push for the most generous funding that we can. I mean,
obviously, we are going to have to have discussions back and
forth on that, but that is my objective. That is our objective
here.
What, in your view, is the value of a multi-year extension
and why that is preferable? I mean, my sense is, that gives
some certainty and predictability, but you are the expert on
this.
Dr. Schwartz. Certainly. The last time that MACPAC made a
recommendation in advance of the extension that you passed in
2015--our recommendation was for 2 years. And at that point,
there was some hopefulness that some of the uncertainty in
health-care markets that were a feature in the congressional
debate at that time would be solved. And it is clear that now,
if anything, things are more uncertain. We are not sure about
what sources of coverage would be available to kids going
forward, with the uncertainty affecting Medicaid and the
exchange market as well as privately sponsored coverage.
So it is the Commission's view that it is important to put
kids in a safe space while these other bigger issues are
debated and figured out. And that is why the Commission
recommended a 5-year extension to ensure that families would
have stability in insurance coverage, that States would not be
in a situation where they were constantly having to sort of be
in a groundhog day situation of going through the steps that
they would have to take.
Senator Wyden. Thank you. My time is expired.
Senator Heller?
Senator Heller. I want to thank the ranking member and the
chairman for holding this hearing today. It is a critical
program, and it is a program that helps millions of children.
So I want to thank Ms. George for being here and sharing your
story with us, and the other witnesses for your help and
support of this particular program.
In Nevada, CHIP provides medical coverage for roughly
25,000 children who otherwise might not get care. And over the
years, this program has been responsible for increasing
coverage for low-
income children throughout my home State.
Nevada has made great strides when it comes to improving
our uninsured rate, making sure that our kids have access to
affordable health care. And this is something that both
Governor Sandoval and myself are quite proud of. So it is my
hope that Congress will act swiftly to reauthorize this
program, give families in Nevada and across the Nation the
certainty that they need when it comes to children's health
care.
So with that, I would like to ask a question or two--
specifically to you, Ms. Nablo, because of your background,
expertise, and what you were able to accomplish in Virginia. I
said 25,000 Nevada children now are covered. It is estimated
that probably 9 million--I think, Ms. George, you said that--
children across the country benefit from this program. But they
also estimate that there are roughly 5 million children who
remain uninsured today.
So with your expertise, your background, your knowledge of
this program, can you share what some of the barriers are that
would produce what we have today of 5 million uninsured
children and their inability to get into a program like this?
Ms. Nablo. Certainly. I would say the first barrier is
always awareness. It is amazing how many individuals still do
not understand that this program actually can cover the
children of working families, and there are many families who
never in their life considered that they might be eligible for
a publicly funded health-care program.
And someone loses their job, or their hours get cut back,
and all of a sudden they are eligible. They have never paid
attention to the ads before. So it is a constant need, a
constant drumbeat, because there is always a new population. A
plant closes, whatever, that creates a new population. That is
one.
Plus, there are certain populations that have higher
uninsurance rates that are more difficult to target, but States
really need to make those efforts. Teenagers are much less
insured than young children. Hispanics are classically
underinsured.
So it takes special efforts, special outreach. And quite
honestly, funding for outreach is one of the first things that
goes when States get strapped. So that is a constant campaign
to keep that up.
I think perhaps--and it may be MACPAC that has done some
analysis of those 5 million children still uninsured--a good
percentage of them, I think it is 60-some percent of them,
would be eligible for CHIP or Medicaid if they would apply, if
they were aware and took the action to apply.
Senator Heller. Dr. Schwartz, could you add anything to
that?
Dr. Schwartz. Yes. I do not have those numbers at my
fingertips, although we could get them for you.
I think, also, it is important that that number of children
who remain uninsured includes undocumented children who would
not be eligible for programs in different States.
Senator Heller. Do you anticipate that this number is
climbing, or is it actually getting better at this point?
Ms. Nablo. I think we have seen a consistent drop in the
uninsured number for children going back to 1997, and that was
the primary motivation for the Commission to recommend
extension, wanting to secure those gains in coverage and make
sure that the number of uninsured children does not go back to
where it had been historically.
Senator Heller. Yes.
Ms. Nablo, based on the barriers that you just spoke about,
what can we be doing better here in Congress to address some of
those issues?
Ms. Nablo. I think there is even a recommendation of MACPAC
that money that is set aside, specifically targeted for
outreach--right now States generally take that money out of
their admin dollars that are allowable under the CHIP program.
Those admin dollars get stretched to all kinds of other things.
So having a set-aside, if you will, that is meant to help
States continuously promote this program, I think, would
certainly be helpful.
There are some policy changes that could make it easier for
people. There are some States that still have a required period
of uninsurance before a child can become eligible for CHIP.
That is my least favorite policy in the CHIP program.
Senator Heller. Does the law allow any outreach in the CHIP
program, in the funding the States receive?
Ms. Nablo. Does it allow it?
Senator Heller. Yes.
Ms. Nablo. Yes. You can take it out of your admin dollars.
Every State can spend up to 10 percent on admin of what they
spend on medical care for kids.
So the bigger your program gets, the bigger your admin
budget gets too. But that needs to pay for workers and IT
systems and all of that kind of stuff as well.
But that is where most States are able to find some dollars
for outreach.
Senator Heller. Thank you very much, Mr. Chairman.
Senator Wyden. Thank you, Senator Heller.
Senator Casey?
Senator Casey. Thank you very much. I want to thank the
ranking member for his leadership on this issue over many
years. And of course, I want to thank Chairman Hatch for his
work today as well as his leadership over many years in a
bipartisan fashion.
This is an issue where we are particularly grateful our
witnesses are here, but we are also grateful that you are here
at this time, because we need your voice, we need your
expertise, your advocacy, to inject a sense of urgency into a
place where urgency is often not the order of the day.
I am going to start with Ms. George. We are particularly
grateful that you are here to bring your own, not only
expertise as all three members of the panel bring, but you
bring a personal dimension. Your testimony has--I think in some
ways--added value and significance on a day like today.
I was noting from your testimony all of the, not maybe an
exhaustive list, but some of the services that you testify that
Caleb benefits from. And I am looking at, I guess, the second
page of testimony where you talk about weekly occupational
therapy to address fine motor challenges that affect Caleb,
periodic MRIs and ultrasounds to monitor the progression of his
neurological condition, and daily medication which helps him
stay focused on his schoolwork.
And you say, ``The CHIP program has provided these services
for little or no cost. CHIP is a tremendous value.'' And you
talk about financial security and peace of mind. All of that
testimony is critically important to hear from you as a parent
and hear from you as someone who is deeply concerned about your
son.
I guess my first question would be, if you were to receive
a termination of coverage notification, how would that affect
your family?
Ms. George. Well, the first thing I would be looking for is
a way to appeal the determination as an applicant.
Senator Casey. Right.
Ms. George. But it would just be a challenge. I look at
Caleb and his needs with education. His medication, primarily,
is so important, because without his medication for ADHD, he
could barely complete a half a worksheet in kindergarten.
Within a week or two of having the medication, he is now
completing two worksheets.
This medication allows him to stay focused. Without being
able to focus on what you are doing, you cannot do more complex
math. Right now, we are doing long division. When his meds wear
out, put that aside, because it is too much involved in long
division.
It is just so important that he keeps getting his
medication. So that is the first thing. How are we going to pay
for the medication? How are we going to address his penmanship?
We started occupational therapy over the summer, and he
went from not being able to write legibly at all--I could not
read it. He is homeschooled this year--now he writes fairly
well. As long as we keep that up--and hopefully we can wean him
off of the occupational therapy, but it is just so critical,
that it is going to impact him not just today, but as he goes
into high school, as he goes hopefully into college, into being
an adult, that if he does not have these skills, then he is not
going to be able to achieve as well as he could achieve.
That is why I think it is such a tremendous value,
intervention. But as a family member, it would just be
devastating to find out that all of these things that we have
done to build him up, we are no longer going to have access to.
Senator Casey. We are grateful for that testimony. I know
if you just multiply that in just one State like, in my case,
Pennsylvania--as of August we had over 176,000 children
enrolled. And that number goes up and down depending on what
day of the month it is or what time period, but lots of
children benefit, I am sure, in the same way that Caleb does.
So we are grateful for that testimony.
I am almost out of time, but, Dr. Schwartz, I wanted to ask
you, has the risk to--I am sorry. I was going to ask Director
Nablo this. Has the risk to CHIP funding already impacted your
State in administering the program?
Ms. Nablo. I will say no. We have been very cautiously
optimistic. And so we have not made any cutbacks.
I will say we just recently ended an outreach campaign. It
ended this summer. It was the first media buy we have been able
to do probably since the days when Senator Warner was Governor.
And it did boost our enrollment again, but we have let that
expire, I think, in part, because of funding, but the other
part is, are we driving people to a program that is going to
close soon?
I think there are other States that have had much more
serious consequences. There are States that have prepared those
notices, that are really actively engaged in shutting things
down, are ready to pull the trigger.
Senator Casey. Great. And I will have more.
Dr. Schwartz, I will send you one in writing. Thanks very
much.
Senator Wyden. Thank you, Senator Casey.
Senator Scott?
Senator Scott. Thank you, sir. And thank you to the panel
for being here with us this morning.
Ms. George, thank you and your family for your service to
the country. Your husband's service as a marine is greatly
appreciated.
I will say that, as many of my colleagues know, I have a
passion for helping our most vulnerable, our kids, access
quality education, whether that is through school choice
programs or youth apprenticeships. Anyone who has ever set foot
in a classroom understands and appreciates the importance that
health plays in the success of the child in the classroom and,
by extension, in life.
For almost 9 million children across the country, including
80,000 in South Carolina, the CHIP plays a vital role in
ensuring that our young folks are healthy enough to learn and
thrive in school and in life. In considering the ways in which
CHIP shapes education outcomes for many of our students, we
need to look no further than the issue of asthma.
Asthma is the most common chronic condition among children,
a leading cause of disability, and with bronchitis it is the
leading cause of hospitalization among children in South
Carolina. It is also one of the leading causes of absenteeism
in schools and can increase the risk that that child will not
reach their full potential educationally, and that, in turn,
means in life.
Whether a child is struggling with asthma or another
condition that impacts their ability to succeed at school, CHIP
can help remove some barriers for families who are often up
against a lot of other challenges. By producing healthier
children, we also produce children who can be fully present in
the classroom, fully invested in their studies, and fully
prepared for a fruitful educational journey.
Shortchanging children's health produces a vicious cycle
whereby poor health care leads to lower academic achievement,
and poor academic outcomes, in turn, diminish long-term health.
Ms. George, first off, I want to say thank you again for
the opportunity to listen to your story and to understand and
appreciate that you are here not only as an advocate, but as a
mother. Can you please talk with us as the chairperson of the
Council on Educational Services for Exceptional Children about
how you have seen the connection between health services that
students with exceptional needs receive and the success that
they are able to achieve in the classroom?
Ms. George. Well, as you know, through IDEA, public
students have access through public education and their
Individualized Education Programs for related services such as
occupational therapy, physical therapy, speech therapy--the
list goes on and on. And some of that is funded through public
insurances, CHIP and Medicaid. A lot of students receive these
services. It is very much beneficial to them.
Senator Scott. Excellent--excellent.
My second question for you, ma'am, is, as a mother, you
have come before us, and I wanted to understand and
appreciate--we certainly have heard Senator Warner and others
talk about the importance of CHIP as it relates to your son.
Can you perhaps expound upon the services and the way that they
impact his academic achievements as well?
Ms. George. Well, with the occupational therapy, as I
shared a little bit earlier, with his penmanship--he was
completely illegible. We started homeschooling him in the fifth
grade year, last year. We are in our second year of
homeschooling.
We could not read his handwriting, despite having
occupational therapy in the public school system. So we were
able to get him private therapy, and he has made tremendous
progress between that and constantly redoing it at home.
If you cannot read somebody's handwriting--you cannot write
a letter, you cannot fill out a job application. Even in this
technology-based world, it is still a vital skill. As well as,
with him, when doing multiplication and long division, when he
was trying to line up and add his numbers, if he could not read
the number he wrote, he would come up with the wrong answer.
Senator Scott. Yes, ma'am.
Ms. George. And once again, that impacts his education
there. Yes.
Senator Scott. Thank you very much.
Senator Wyden. Thank you, Senator Scott.
Senator Warner is next.
Senator Warner. Thank you, Senator Wyden. Let me, again,
thank all of our witnesses: Ms. George, Dr. Schwartz; Linda, it
is great to see you again.
I am going to direct most of my questions, I hope
appropriately, to Ms. George and Dr. Schwartz. And I also want
to commend----
Senator Bennet. By the way, when you refer to the days that
Mark Warner was Governor, did you mean the dark days for
Virginia? [Laughter.]
Senator Warner. They were already called the morning in
Virginia, as Senator Wyden mentioned. [Laughter.]
One of the things that I hope, particularly, Ms. George
will take back is, it is rare to have a program where people on
both sides of this dais are all saying good things about the
program. I hope it gives you a little more faith that we can
get our act together and get this done in a timely way.
Dr. Schwartz, we appreciate all of the, kind of broader
policy goals you have looked at, and the extension time you
have set. Again, I think it is a 5-year extension at least.
One of the things I would like you to talk about--I do not
want to be presumptuous and assume we are going to get it done
in a timely way. But one of the things I recall in the past is,
so many of these families, their incomes fluctuate so much
month-to-month, and they may be Medicaid-eligible at one point
and then CHIP-
eligible at another point. On a going forward basis, are there
better ways for us to make sure that people do not have to
constantly reapply, and can we streamline this, so people who
fall within these eligibilities do not have to spend their time
as they bounce from one program qualification to another?
Ms. Nablo. There is an option for States of making the
Medicaid or the CHIP program for children--you would be
continuously eligible for a 12-month period. So even though
your income may fluctuate and you may drop down to Medicaid or
go up to being not eligible for the program, you would not have
to report a constantly changing income and your child would be
covered for 1 year until their annual renewal date.
Not every State by far has adopted that policy. That would
be wonderful if that was part of the law.
Senator Warner. Would you keep that as an optional basis on
reauthorization?
Ms. Nablo. Well, if we really truly wanted to address that
concern, it would not be optional. It would be the way the
program was structured.
In Virginia, we have a version of that. It does say that if
your income goes up, you have to report that.
But you are absolutely right. People's income--there are a
lot of seasonal workers here, there are a lot of people who get
extra jobs over Christmas, and their income changes. You know,
we have school teachers with children on CHIP.
So it is a constantly moving target and fluctuating
environment for families. To realistically expect families,
every time somebody works a few more hours, to report that and
ask an eligibility worker to figure out if that makes a change
or not is really not the smart way to have this coverage.
Senator Warner. Right. There could be a retroactive look-
back after a year or so, but this bouncing between income
levels is really, I think, really important.
Ms. Nablo. Absolutely--absolutely. And in States where the
benefits packages between CHIP and Medicaid are very different,
that alone can cause problems. You may lose a provider. You may
still be eligible for coverage in Medicaid, but perhaps your
provider is not a Medicaid provider.
Senator Warner. And I think we have heard from Senator
Scott and others that, in terms of plain old business ROI,
making sure that child--making sure Caleb--goes to school
healthy and prepared is going to make him a better student.
Ms. Nablo. Sure.
Senator Warner. That pays back enormous benefits.
Ms. Nablo. I think that is what you have to do. Hopefully
you look at the long road, the long picture, and does it make
sense that we have programs where families could potentially
bounce back and forth almost month to month.
Senator Warner. Talk to me a little bit about the
importance of outreach, and particularly rural outreach, since
there are so many communities. I know we have online signups.
But the truth is, many families may not feel comfortable doing
it online or going to a library and putting very personal data
into a computer without an outreach worker. Talk about
outreach, and more specifically, rural outreach.
Ms. Nablo. Certainly. Well, as you know very well, we--the
State--employ a few outreach workers, and we do try to position
them around the Commonwealth, but another thing that we do in
Virginia is, we use some of our CHIP admin dollars to help
support a project through the Virginia Health Care Foundation,
of which you are the founding chairman. And that project--they
also get a Federal grant to do the same. So their reach is more
extensive across the Commonwealth in trying to help families.
And we do still, even in this day and age, we still get a
healthy proportion of our applications on paper, even though
the form is not particularly friendly. Really, it is shorter
than it used to be, but you still have to answer all of those
questions. So we still get a surprising number of people who
submit on paper.
We have working families, working mothers, who cannot take
off during their work hours and go to the local social services
agency and sit across the desk from an eligibility worker to
help complete that form or to follow it through. That is where
the outreach workers come in. They will meet you at McDonalds;
they will meet you at their home; they will meet you at your
home; they will find a way to sit with you in a time and a
place that works for you and help you through that process,
help you understand the questions and get the information in.
Then they will do the all-too-important follow-up on your
behalf, because, as much as we would like to think we are all
about helping people, we are still a bureaucracy, and it is not
easy to deal with the system. So without that handholding,
without that personal touch, especially in rural areas for
families who have limited English capacity, it is absolutely
essential, which is why we have still several million children
who are eligible and not enrolled.
Senator Warner. Thank all of you. Particularly, thank you,
Linda, for your great work in the Commonwealth.
Senator Wyden. Thank you, Senator Warner.
Next, it will be Senator McCaskill, Senator Bennet, and
Senator Grassley. We will have to see what happens if others
come.
Senator McCaskill?
Senator McCaskill. Thank you.
Senator Warner briefly talked about outreach. Ms. George,
how did you find out about CHIP coverage?
Ms. George. When Caleb was born, he was qualified for
Medicaid, and it was pretty much a seamless transfer over from
Medicaid onto the CHIP program in North Carolina----
Senator McCaskill. Executive Director Schwartz, I am not
sure you can talk about this countrywide, but I am really
curious what kind of outreach is going on in these rural
communities. Is there an aggressive outreach? I do not recall
ever seeing anything, but maybe it is more targeted, the
outreach. So in terms of radio or billboards or anything like
that, I do not recall ever seeing anything talking about CHIP
in my State.
Is it more targeted through the Medicaid population? But
there are some children qualified for this in my State who
would not qualify under Medicaid.
Dr. Schwartz. As with all things CHIP and Medicaid, it
definitely varies from State to State. States can use some of
their administrative dollars for outreach and enrollment, as
Linda mentioned. The Federal grants allow States to partner
with community-based organizations, which could be churches, or
a community organization, schools, and so it can range
tremendously across States.
I do want to echo, obviously, the ad buys are the things
that you and I would notice. We have heard quite a bit in
Medicaid about people wanting that personal touch when signing
up. Many people are very nervous in submitting an application,
want to make sure everything is correct, and so that last touch
with an outreach worker, it really gives them peace of mind
that they have done everything properly to ensure that the
enrollment goes through properly.
Senator McCaskill. That would be a role similar to the
navigators in the ACA?
Dr. Schwartz. It is very similar, very.
Senator McCaskill. Which, by the way--I would point out
they have just cut the budget 40 percent for navigators, ACA,
and the advertising budget by 90 percent, which is a real
problem.
Could the two of you address what impact cuts to the
Medicaid program would have on your work, assuming that there
was success, which we hope there will not be, but if there were
success in cutting the Medicaid program as has been proposed a
couple of different times in the context of an ACA replacement.
What impact would that have on the CHIP program?
Dr. Schwartz. Well, CHIP is separately funded from
Medicaid, but in most States, the two programs work hand-in-
hand.
The Medicaid proposals that have been considered over the
past few months would put significant constraints on States,
particularly going forward, on how they use those dollars. And
presumably, if States had to make choices that would reduce
eligibility levels in Medicaid, they would have to also
reassess their CHIP programs.
It is very hard to predict how individual States would make
those choices, but clearly, I think that is very much on the
mind of State administrators.
Ms. Nablo. Absolutely. And I will just add Medicaid,
obviously, takes care of the lower-income children. It also
frequently takes care of the sicker children, waivers,
disability waivers, et cetera. Oftentimes a child may well be
in the CHIP income range or even the private insurance income
range, but given medical expenses and the extent of their
disability, they become eligible for Medicaid.
If Medicaid is curtailed, if enrollment has to be rolled
back because of funding, if those children were to become
eligible for the State's CHIP program, I think you would see us
running through that funding much faster.
Senator McCaskill. So what would happen is, some of the
sickest children potentially would be removed from the Medicaid
rolls and put on the CHIP rolls, which would put incredible
pressure on the funding levels of CHIP, which would squeeze
out, at some point, people from coverage under the CHIP
program?
Ms. Nablo. That would be my assumption, yes.
Senator McCaskill. That is the way that I think it has been
looked at, that you cannot look at Medicaid cuts in isolation
and assume other parts of the system are not going to be put
under pressure, and ultimately folks end up in an emergency
room uninsured, in the most expensive care possible, and all of
those costs are passed on to us.
Thank you very much, Mr. Chairman.
Senator Wyden. Thank you, Senator McCaskill.
The ever-gracious Michael Bennet.
Senator Bennet. Thank you, Mr. Chairman. And to add to
that, let me say words that have not been said in the Senate
before. My questions have been asked. [Laughter.]
Senator Wyden. But not everyone has asked them. [Laughter.]
Senator Bennet. That is true. That is a habit I am trying
to have us break.
But I have spent the morning in the HELP Committee, where
we are trying to work on a bipartisan solution to our health-
care issue. So I apologize to this very able panel. Your
testimony was excellent, and it is really critical that we
reauthorize this program.
CHIP has provided localized health insurance for about
90,000 kids who did not qualify for Medicaid in Colorado but
are still unable to afford private health insurance. Colorado's
working families have benefitted from CHIP by increasing
coverage for kids, driving the percent of uninsured children to
an all-time low now of 2.5 percent.
On both sides of the aisle, everyone in this room certainly
can agree that our children need to be covered and have access
to quality health care, whether it is through CHIP or Medicaid,
which covers over 400,000 children in my State of Colorado.
CHIP also covers about 600 pregnant women in Colorado, and for
these women, they have peace of mind knowing that they will
have a provider to go to for maternity care.
Without reauthorization--as these witnesses have so ably
stated--without reauthorization of the CHIP program this month,
Colorado may stop enrolling new children as of October 1st.
They would have to move forward with an emergency plan, and it
would be a disaster for us.
So, Mr. Chairman, all I would like to do is, with your
permission, submit for the record a letter from the Colorado
CHIP Coalition, which includes over 70 organizations, asking
for reauthorization of the program.
Senator Wyden. Without objection, so ordered.
[The letter appears in the appendix on p. 39.]
Senator Bennet. Thank you, Mr. Chairman. Thank you to the
panel.
Senator Wyden. Thank you, Senator Bennet.
At this point, it is Senator Stabenow and then Senator
Grassley.
Senator Stabenow. Well, thank you very much, Senator Wyden,
for your leadership and for the chairman's leadership. This is
an issue that has traditionally been bipartisan. I am very
hopeful we are going to be able to continue with a long-term
extension in a bipartisan way and do what children and families
across Michigan and across the country are counting on us to
do.
We know that before CHIP was created back in August 1997,
millions of hardworking families could not take their children
to the doctor and give them the care that they needed. Ms.
George, thank you for speaking about your family and your
experiences.
I can tell you in Michigan right now, the good news is that
97 percent of our children can go to the doctor. That is a very
big deal. It is the highest percentage ever because of changes
that we have made through the Affordable Care Act and through
the Childrens' Health Insurance Plan. We want to make that 100
percent, but 97 percent is very good.
Unfortunately, as has been said--and, Ms. Nablo, you have
been talking about the sense of urgency--we are about to see
that health care go away. And we do not need a short-term
extension. What we need is to fully fund the program and give
States, and more importantly, families, the peace of mind of
knowing that they can continue to take their child to the
doctor and give them the certainty that they need.
So we need to act now. We need to act now, and I am hopeful
that we are going to do that and do it in the right way for
families.
I want to just share one story before asking questions. I
have talked to so many people in Michigan, so many families who
are so glad that they have the opportunity to not worry in the
middle of the night what is going to happen if the kids get
sick, but know that they are going to have the confidence to be
able to take them to the doctor and get the care they need.
One of my constituents, Jan, wrote me a letter saying,
``From the time my daughter, Susie, was young, we knew she was
going to need extra help. She was diagnosed in second grade
with ADHD, and we proceeded to try a medical solution to her
attention problems.
``As she got older, she was diagnosed as being bipolar and
required a different approach to control her mood swings.
Without having access to quality health care, we would have
been lost. And thanks to MIChild, the Michigan CHIP program,
with a premium of only $10 a month, we were able to afford the
help she so desperately needed.
``She is now a high school graduate with a goal of
attending community college. And we are so grateful that we
have been able to get the help necessary to help her get to
this point.''
So today's hearing is not about numbers. It is about
people. It is about Susie. And I want to thank you, again, Ms.
George, for coming today.
I want to take a moment--because my questions on the cost
of prescription drugs were ably asked and answered by Senator
Wyden's question, because that is such an important part of
health care today and the drivers of health care.
But there is another piece that Senator Grassley and I have
been working on that I think would be wonderful to add to CHIP
in terms of quality measures for prenatal care and for making
sure that we are providing, through CHIP and Medicaid, a set of
maternity and infant quality measures that have not been there.
And we have been working on this for some time together.
There is a broad coalition of organizations supporting
this. There are so many that it is hard to know who to thank,
but I want to thank the March of Dimes, in particular, for
incredible advocacy on this.
But I want to ask, Dr. Schwartz, if you could speak to the
desire, the need to have a set of measures as it relates to
quality standards. I know that MACPAC recommended a 5-year
extension of the Pediatric Quality Measures Program, which we
are building off of.
So I wonder if you might indicate whether or not you agree
there are gaps in the measures right now for labor and
delivery, and could you discuss some potential quality measures
and how they would benefit moms and babies?
Dr. Schwartz. Certainly. I am not an expert on quality
measurement for maternity. I would note that the Pediatric
Quality Measures Program is intended to help fill gaps, and
also to work with users of measures to make sure that measures
are not some academic exercise but can actually work in terms
of reporting and in their usefulness in providing feedback to
plans and providers about the experience of care.
That work informs the inclusion of measures in the adult
and child core set that CMS uses, and there are measures
related to labor and delivery and prenatal care in both the
adult and child core set. That is, obviously, a dynamic
process, and over time measures have been introduced into the
core set and taken out of the core set as our understanding
increases.
I do think it is important. We talk about value to the
beneficiary and value to the taxpayer of these programs, and
certainly the availability of valid and reliable measures is an
important part of that value equation.
Senator Stabenow. Senator Wyden, I want to thank you and
the chairman for supporting our effort to report out of
committee the Quality Care for Moms and Babies Act last year.
It is strongly bipartisan. It is noncontroversial and would add
to the strength and the quality of what is before us now, and I
am hopeful we can include it in the final bill.
Senator Wyden. I very much appreciate what Senator Stabenow
and Senator Grassley are trying to do here. It has been
supported in the committee, and I look forward to working with
both of my colleagues.
Now at this point, the also-gracious Senator Cardin has
said that, while he is next, it would be fine if Senator
Grassley went. We appreciate Senator Cardin's courtesy, and I
think Senator Grassley has--I think--a relatively short set of
questions. But go ahead.
Senator Grassley. And I appreciate Senator Cardin's----
Senator Wyden. Everybody appreciates everybody. [Laughter.]
Senator Grassley. I think I have a fairly easy question for
Dr. Schwartz, but before I do that, I want to say that we have
this program that is a CHIP program for my State of Iowa. It is
called hawk-i, not exactly spelled the same way as the Hawkeye
football team. It is the Healthy And Well Kids in Iowa program.
We had 83,400 Iowa children covered by hawk-i. It provides
health insurance through commercial health insurance plans to
kids of low-income Iowa households, up to 302 percent of FPL.
Because of this program, children can receive lifesaving
vaccines, medicines, doctor visits. In addition, children are
checked to make sure that they are developing appropriately.
This is a program that I have supported in the past, and I
look forward to its reauthorization.
So to Dr. Schwartz, I want to ask you about children's
access to care. As you may know, I have introduced S. 428, the
Advancing Care for Exceptional Kids Act. We call that the ACE
Kids for short. And I have introduced that with Senator Bennet,
who has already spoken here.
The goal of this legislation is to ensure that sick kids
have access to the very best care. However, there are some
statutory and regulatory barriers which can require children's
hospitals and specialized pediatric doctors additional work in
order to care for these children.
My two questions: has your organization, MACPAC, done work
on this issue, and are there potential solutions that maintain
or even strengthen the program integrity but make caring for
these children more streamlined?
Dr. Schwartz. It is my understanding that the ACE Kids Act
has evolved over a number of months, or perhaps maybe even
longer than a year, in terms of its scope and size. We have not
looked at it recently. It is something that we would be very
willing to do, both at the staff level and the commission
level, and would stand ready to provide any advice and feedback
on that for you.
Senator Grassley. Yes. Well what about just generally? Have
you solutions that would strengthen program integrity and make
caring for these children more streamlined, without looking at
the bill I asked about?
Dr. Schwartz. It is my understanding that the ACE Kids Act
focuses on children who are extremely sick and tend to have
quite a number of hospitalizations. It is a very small
population that needs specialized care and often needs care
outside of their community and maybe even in another State.
So that does create potential challenges for States that
are very scrupulous in program integrity and knowledgeable
about the providers in their State. So certainly that is a
challenge when you have a kid who needs to have care across
State lines. And as I said, we would be happy to look at any
specific provisions and provide any guidance.
Senator Grassley. Okay.
Well, is there any advice you can give about the bill--but
also any consideration you can give, even without the
legislation, would be very much appreciated.
I thank you and thank Senator Cardin.
Senator Wyden. Thank you, Senator Grassley.
And now, the patient Senator Cardin.
Senator Cardin. Thank you, Mr. Chairman. Everybody is
thanking everyone else. I heard your opening statement, and I
just identify with it and thank you for your leadership on the
CHIP program.
Senator Wyden. Thank you.
Senator Cardin. I just really first want to underscore how
important it is for us to timely reauthorize the CHIP program.
There are 143,000 Marylanders who are covered under the CHIP
program.
In this fiscal year, the cost is about $275 million. Now,
$275 million is the total cost of the program. The Federal
share is about $241 million.
The Board of Public Works in Maryland just approved a
budget cut mid-term because of budget deficits in our State.
There is no conceivable, possible way that the State of
Maryland can fill the gap under the CHIP program if it is not
reauthorized in a timely way. So, if we do not reauthorize in a
timely way, there are 143,000 Maryland children who are at
risk. And I just really wanted to underscore that.
I was proud that in the 2009 reauthorization, an amendment
I offered to include mandatory dental coverage was included
under the CHIP program.
Now, Mr. Chairman, many of you have heard me talk about
this before. This was as a result of a tragedy that took place
in Maryland in 2007, 2 years before the reauthorization was
enacted into law. And it occurred about 7 miles from here in
Maryland. Deamonte Driver, a 12-year-old, died because he could
not get access to dental care.
He had an abscessed tooth, needed to find a dentist who
would provide about $80 worth of dental care, and could not be
seen. He ended up becoming abscess-infected in his brain. A
couple of operations later, a quarter of a million dollars, and
he lost his life.
That motivated the Congress to take action, and I was
pleased that we did. And we recognized that tooth decay is the
number one disease affecting children in this country, and it
is preventable.
I went to many schools in Maryland and saw children and
talked to teachers, learned exactly what oral health meant for
the success of students in our schools. You cannot really learn
if you have tooth problems and pain.
So we have made tremendous advancements in dealing with
pediatric dental care as a result of coverage within the
Children's Health Insurance Program. And I am proud of the
progress that we made.
After we included dental under the CHIP program, we also
included pediatric dental under the Affordable Care Act. So one
might think, well, now if CHIP is not reauthorized, will we not
still be protected under the Affordable Care Act? The answer is
``yes,'' but not to the same extent that we have under the
Children's Health Insurance Program because of the match, cost
sharing, and the fact that States can put in caps, et cetera.
So there is a significant difference for oral health for
children if we do not timely reauthorize.
So I would just like to get the view of our distinguished
panel of witnesses as to how important the CHIP program is for
our children's dental care and what changes we have seen occur
nationwide as a result of the coverage for dental care within
the CHIP program.
Dr. Schwartz, would you----
Dr. Schwartz. One of the areas for the Commission's
analysis and consideration in thinking about the future for
children's coverage was the availability of different types of
benefits for children in CHIP versus other sources. And as you
pointed out, pediatric dental is an essential health benefit,
but the way the exchanges cover dental, it is often not
included in a comprehensive package; it can be purchased
separately, but the way the cost sharing works out, it is in
fact more expensive.
So we did not find a tremendous number of differences
between CHIP and exchange coverage, but audiology and dental
were the two benefits that we called out just as you say.
Senator Cardin. I would point out that I was proud of
Maryland in that all of our carriers included pediatric dental
within the prime contracts. We did not have to have a separate
policy. But there are places in the country where you have to
get a separate policy, and then you run into the cost sharings
and the caps that can be different, which causes problems.
Ms. Nablo, would you want to comment?
Ms. Nablo. What occurred to me first, as you were speaking,
was that we are always very cognizant when we do outreach for
the CHIP program of highlighting that it involves dental care.
That is extremely valuable to parents. And it is--I suspect it
is--for parents who do not have a particularly sick child at
this point, it is one of the big drivers that brings them to
our door to apply for CHIP coverage, because it is not common
with private insurance or exchange coverage for those children
to have access to dental care.
Senator Cardin. I would just point out, Mr. Chairman, in
closing that one of the side benefits of the CHIP program and
oral health for children is that we now have dentist access in
communities that did not have that access before. So it is not
just coverage, it is also that providers are now in communities
that they were not in before as a result of the CHIP program.
Thank you, Mr. Chairman.
Senator Wyden. Thank you, Senator Cardin, and thank you for
again highlighting the importance of dental care.
Now here is where we are in the order: Senator Thune, in
order of appearance is next, Senator Cantwell, and then our
friend from Delaware, if that is all right with colleagues.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman, for holding the
hearing on the path forward for the Children's Health Insurance
Program. Of course, I want to thank all of our witnesses for
joining us as well, especially Ms. George, who has shared her
family's personal experience with the CHIP program.
In my home State of South Dakota, CHIP serves more than
50,000 kids in a given month. And like many States, we run a
combination program. And our State projects that if CHIP
expires, nearly 12,000 kids would be shifted to Medicaid and
more than 3,500 could lose coverage altogether.
I think we can all agree that this program has enjoyed
broad bipartisan support over the years, and it is critical
that we work together to ensure that kids across the country
continue to have access to uninterrupted coverage.
And it sounds like this ground has been plowed a little bit
already, but I want to--for purposes of my State's interest--
ask the question of Ms. Nablo.
The administrators of CHIP in South Dakota have talked with
us about the importance of maintaining State flexibility--which
I think you have addressed on some level already--to determine
benefit structure moving forward. You mentioned that in your
testimony as well. From a State perspective, are there other
areas where greater flexibility might be needed so that States
can best meet the needs of their populations?
Ms. Nablo. I would say that the Virginia experience is one
of continual change and continual improvement of the program to
best meet the needs of families in our State. Certainly some
flexibility in the benefit structure is helpful.
For example, Virginia just added a very robust package of
substance use disorder benefits to help address the opioid
epidemic. We added those for children in our CHIP program and
for the pregnant women in our CHIP waiver.
So the ability to be able to do that was very helpful. The
story in Virginia is, we started out with a very restrictive
program. We had some of the most restrictive policies in the
country.
For example, we started out with a 12-month forced period
of uninsurance before a child could be found eligible for CHIP.
That later went to 6 months, then went down to 4 months, and we
have since abolished it. But that is within the ability of the
State, given where the legislature is, what people learn as
they go along with the program about what is needed and as they
become more educated about families' needs. There is a constant
and continual improvement to the program.
I think States probably appreciate the flexibility in CHIP
a great deal. It is one of the most attractive features,
probably originally, for States taking up this offer in the
first place, and I think they would be very concerned if that
flexibility went away.
Senator Thune. Okay.
Dr. Schwartz, South Dakota also raised the importance of
States' continued ability to carry over funds. You raised this
issue in the context of how long States will be able to
continue to run CHIP programs and also raised operational
considerations associated with extending the program.
How quickly can States respond to congressional action? And
I would also, I guess, direct the question to Ms. Nablo, if you
would care to comment on how quickly you would expect Virginia
to be able to respond.
Dr. Schwartz?
Dr. Schwartz. When MACPAC made its recommendations, we set
ourselves a deadline of having our recommendations available at
the beginning of this Congress so that you could act quickly,
to allow States to take the time to plan for the next fiscal
year. Obviously, many months have elapsed since then. States
have held off making changes to their programs, not wanting to
alarm beneficiaries unduly and also to not cause disruption for
the plans and providers.
I think that the clock really is very close to having run
out.
The other point I want to make clear is that, while MACPAC
has put out these figures noting when States will run out of
money, that is not meant to say that Congress can wait until
that deadline to make a decision.
It is really important for States to have the certainty
right now so that they can plan appropriately so that these
programs are run in a deliberate and professional manner.
Senator Thune. Okay. Thank you.
Ms. Nablo, any response in terms of Virginia's----
Ms. Nablo. I would say the challenge is not so much how
fast we can respond to any changes you would choose to make. I
would say the challenge is much more, how long can we wait
until you tell us with certainty that there will be funding for
this program and what level it will be?
I think for some States we are weeks, a few weeks, maybe a
couple of weeks away from having to take proactive measures to
start shutting down. For Virginia, as I said earlier, I have a
long ``to do'' list--I actually have it in my briefcase today--
of things that will need to happen. And that ``to do'' list
starts in October for us, with beginning to do the training,
and the system changes, and all the things that will need to
happen.
If the CHIP is authorized but the funding is reduced, that
causes immediate budgetary problems in the State of Virginia.
We have an immediate $57-million shortfall in this State fiscal
year. Our legislature comes to town on January 10th, and I
guess that would be one of the very first problems they would
have to face, what do we do with that kind of a hole in the
budget, and it grows the next year.
So it is really more a matter of, we are waiting with bated
breath to hear from Congress.
Senator Thune. Okay. Thank you.
Thank you, Mr. Chairman.
Senator Wyden. Thank you, Senator Thune.
We started, actually, a couple of hours ago with that
question. And now as we move towards the end, I am glad you
have highlighted that, because this is not something, where in
the traditional Washington situation, you can have the
amendment, the amendment to the amendment, and maybe it
happens, and maybe it does not. Your question, again--Ms. Nablo
highlighted that this morning--shows this has real consequences
if there is delay. And I appreciate your bringing it up as we
get to wrapping up.
Senator Cantwell?
Senator Cantwell. Well that is definitely the line--thank
you, Mr. Chairman--that I want to follow as well, because I am
from Washington, and we like efficiency in our health-care
delivery system no matter, whether it is talking about CHIP,
adults, or what have you.
I do want to say, Ms. George, I so appreciate your
testimony today. Being here, you really highlighted what this
issue is all about, and it is about giving families the ability
to take care of the needs of their families by making sure that
they have coverage. And I so appreciate that your son, Caleb,
is here as well.
And I wondered if we could just--I was so touched by your
story about his Scouting awards. Is it okay if we give him a
round of applause for his achievements?
[Applause.]
Senator Cantwell. So I do not think we can ever forget the
people who are affected by this program and what it means. And
when I think about Ms. George and her family, what she has been
able to accomplish, I think about the modernization of CHIP.
So in our State, we cover children up to 211 percent of
poverty. And we cover up to 312 percent through CHIP, and yet
we have families at a different level.
One thing that we have seen in New York, with the advent of
the basic health plan, is a front door that allowed families in
CHIP, no matter whatever the entry way was, to then get
coverage. It also has driven down costs. It has driven down
costs for everybody. It has driven down cost for the State. It
has driven down cost for the Federal Government. It has made
the program streamlined and efficient.
Do you think there is more to do, Dr. Schwartz or Ms.
Nablo, in streamlining this program, thinking about both
children and adults, making sure that there is coverage and
cost savings in the administration side of this?
Dr. Schwartz. There is certainly always work to do. One of
the things that the Commission recommended was demonstration
grants to States to try to think about how to better coordinate
different sources of coverage. We know that the answer may be
different in different States and wanted to provide an
opportunity for States to experiment in how to smooth these
transitions across coverage so you do not have situations where
families lose coverage due to change in their life
circumstances and lose continuity of care and have gaps in
coverage.
So there is certainly more work to be done. MACPAC is
meeting next week, and one of the things that we are taking up
is a broader inquiry around Medicaid to assess where we are
with streamlining eligibility, enrollment, and renewal
processes to be able to see what we have accomplished and what
more work needs to be done.
Ms. Nablo. I would agree with Dr. Schwartz. Both within the
health-care arena and also just other Federal programs like
SNAP and TANF, et cetera, there is a great deal of difficulty,
disparity, differences in how those are administered and how
you count income, et cetera, that is extremely confusing for
families and very difficult to administer.
And even if you are successful in, for example, the health-
care arena, moving from CHIP to Medicaid or back or if your
family gets coverage on the exchange or whatever, the benefits
can be very different. The doctors can be very different. The
copayments and deductibles can be extremely different, and it
just creates an extremely confusing atmosphere.
Senator Cantwell. Well, I think it probably creates costs
too.
Ms. Nablo. And costs.
Senator Cantwell. And to me, streamlining that so there is
a front door where families are covered and doing so in the
most cost-effective way, considering they are likely getting
coverage--it is just not in a uniformed way.
I, Mr. Chairman, regret that we--we identified this when we
were doing the Affordable Care Act, but some of our colleagues
were thinking more about CHIP at the time, less about this
confluence that was going to happen. But I wish that then we
would have offered some innovation to streamline, because I
think we could have reduced costs, and I think we could have
given more certainty to those families.
So I certainly hope we will take a look at that now,
because I do think it is one of the keys to making this more
affordable for everybody.
Thank you.
Senator Wyden. Thank you, Senator Cantwell. And Oregon has
always seen itself in a partnership with Washington State on
these efficiencies.
And I think the point you made is extraordinarily
important, because inefficiency wastes money. And if you waste
money, you are not dealing with the scarce services, for
example, that you talked about with respect to Caleb and the
real consequences for people. So I thank my colleague.
Senator Carper?
Senator Carper. I am not sure if Senator Brown was in line
before me.
Senator Wyden. You were here first.
Senator Carper. Okay. Thanks.
To our colleagues here--the four Senators who are here in
the room right now are all Democrats. I would just note that
our chairman, one of his most important--he has a lot of
important accomplishments in the time that he served here, but
maybe none more important than his work, I think, with Senator
Kennedy on the Children's Health Insurance Program.
I look forward to working with my colleagues who are here,
but certainly with Senator Hatch, to extend funding to ensure
that millions of kids, including about 18,000 in Delaware,
continue receiving health insurance coverage under this
program.
I was actually--as chairman of the National Governor's
Association--in the White House with President Clinton and
Hillary Clinton on the day that this was rolled out at the
White House. So this is one that has special meaning for me and
for the people I am privileged to represent.
I have a couple of questions I would like to ask of our
witnesses. Thank you so much for being here. Are you from
Virginia? You work for the Governor there?
Ms. Nablo. Yes, I do.
Senator Carper. Tell him a guy who grew up in Danville and
Roanoke sends his best, please.
And they are building a ship in Newport News, VA today, a
submarine called the U.S.S. Delaware, and we look forward to
being back down there with Terry and to launching that with Joe
Biden in several months.
CHIP serves millions of people in our country, some 18,000
kids in Delaware. Our neighboring State--I think Senator
Cardin, when he was here, just said a few minutes ago about
143,000 kids in Maryland are covered.
But if we allow CHIP to expire at the end of this month,
many of the children in our State, on Delmarva, and across the
country are going to either become uninsured or maybe
underinsured.
I am going to ask Dr. Schwartz, can you speak to whether
other insurance coverage options for kids, including private
insurance, would be able to provide for these children if CHIP
expires, and how do these options compare in terms of cost
sharing protections, in terms of pediatric benefits and
pediatric networks, to CHIP?
Dr. Schwartz. Certainly. Our analysis shows that if CHIP
funding comes to an end, there are two different scenarios
depending upon whether a child is covered under separate CHIP
or a Medicaid expansion CHIP.
Separate CHIP funding programs would end. And we estimate
that 1.2 million of those children would become uninsured.
All of those children would be eligible for either
subsidized exchange coverage or employer-sponsored coverage,
but for most of them, the cost of those, cost sharing, would be
prohibitive, and that is why they would become uninsured.
For those who do enroll in exchange coverage and those who
do enroll in employer-sponsored coverage, they would experience
much higher cost sharing than they currently experience under
CHIP.
And as I noted earlier, there would be some differences in
benefits, most notably audiology and dental were the ones that
we pointed out, and I think it is very likely as well that they
would experience a change in provider in moving to a different
plan.
Senator Carper. Okay. Thanks.
Ms. Nablo, you mentioned the importance of CHIP for access
to mental health services, for substance abuse treatments, for
immunizations, basic health care, to help children be able to
live a normal life. Could you describe for us the role that
CHIP plays in treating mental health conditions as well as
combating the opioid epidemic and the improvements in public
health that Virginia has experienced because of the CHIP
program?
Ms. Nablo. CHIP in Virginia was originally designed based
on the State employee health plan. Over the years, additional
benefits have been added, bringing it much closer to the
Medicaid package of benefits, but not the full range of
Medicaid. For example, we do not cover EPSDT or we do not cover
residential care in CHIP.
But it has become a very robust child-centered benefit
package. So it includes many mental health benefits.
But in reaction to the--I will not say recent, but in the
last several years--awareness of the opioid epidemic, Virginia
has, under the leadership of Governor McAuliffe, taken a very
aggressive stance to try to combat that epidemic. A big part of
that initiative is to add addiction treatments that are
evidence-based and recognized by national associations as being
effective, to both Medicaid and to CHIP and to our pregnant
women coverage in both of those programs as well.
We have just done that. Most of those benefits became
effective April 1st. We just added another one as of July 1st.
So it is, I think, a little too early to talk about the effect
on individuals.
What we have seen--because along with adding those
benefits, we also increased provider rates. So we have seen a
significant growth in providers offering these evidence-based
practices into the southwest of Virginia, Roanoke, and beyond.
We are very excited about the growth in the provider network
and believe that will carry over into improvement in outcomes.
Senator Carper. Thank you.
Thanks so much. Thanks to each of you for the work you do.
God bless.
Senator Wyden. Thank you, Senator Carper.
Senator Brown?
Senator Brown. Thank you, Mr. Chairman.
Today, first a ``thank you'' to the witnesses. I appreciate
your being here and speaking out for one of the most important
things that we should do this fall.
I would like to submit for the record two letters: one from
Ohio's Department of Medicaid Services Director, Barbara Sears;
and one from the Ohio Children's Hospital Association.
Senator Wyden. Without objection, so ordered.
[The letters appear in the appendix beginning on p. 42.]
Senator Brown. Thank you, Mr. Chairman.
I would add that Ohio has, I believe, still more free-
standing children's hospitals than any State in the country. I
know that when my friend, the Senator from Oregon, was in Ohio,
he met some of the people who work in some of these hospitals.
I would like to ask each of you about the importance of
extending CHIP funding for more than 2 years. Dr. Schwartz,
many advocates have written in support of a longer period, as
much as 5 or more years.
When Secretary Price testified--Secretary-Designee Price--I
asked him about the question of longer extension. I suggested 8
years. He concurred and said 8 years could make sense. MACPAC
recommended we extend funding through fiscal year 2022.
Dr. Schwartz, explain briefly--and I need briefly, and I
apologize. And you are probably tired of these questions
anyway. So explain briefly why MACPAC recommends a 5-year
extension?
Dr. Schwartz. Yes, MACPAC's primary reason for the 5-year
extension is the tremendous uncertainty in health insurance
markets generally at this point, whether that relates to
Medicaid or the exchange market, and certainly volatility of
private coverage. And really it is important to secure the
gains in coverage that CHIP has brought and to put kids in a
place that is safe, where coverage is going to be available to
them while all of these other problems are sorted out.
We have had quite long extensions of CHIP in the past. The
first one was for 10 years. CHIPRA was from 2009 to 2013. So
certainly there is a track record in the Congress for long-term
extensions.
Senator Brown. Thank you, Dr. Schwartz.
Ms. George, thank you for coming today. I understand your
son, Caleb, is here, and he is aiming to become an Eagle Scout.
I am an Eagle Scout, and I know the work that he will do to
become an Eagle. I assume that his mother having the peace of
mind knowing that CHIP will be there to raise her healthy young
future Eagle Scout will be important. Talk to me about what
extension means for peace of mind, what that means for a mother
of a young man like Caleb.
Ms. George. Well, probably for me the biggest thing is
knowing that he is covered. Right now, we had an insurance
lapse a couple of months ago because of changing employers. He
was not affected by that because he had CHIP.
Just that peace of mind knowing that no matter what happens
to you, what happens to your loved ones, your child has the
coverage that they need to be healthy, to have everything they
need for school, for developing into the young man that they
can become, is just tremendous. That is why it is so important
for us.
Senator Brown. Good luck.
Let me know when his court of honor is in ``X'' number of
years.
Ms. George. Thank you. I sure will.
Senator Brown. Ms. Nablo, my home State of Ohio has been a
leader in innovating within CHIP and Medicaid. It is to lower
costs and to improve outcomes--we still are embarrassingly
awful in terms of infant mortality and some other indices. But
CHIP has helped us be more than marginally better.
The Kasich administration tells me it is difficult to
innovate when the future of the program is uncertain. Talk
about what certainty means, in terms of stability, in terms of
running a department, in terms of making this all work,
especially in terms of innovation.
Ms. Nablo. Well, when you are looking at--we have come
extremely close to the wire this time. So what does that mean
for the future?
If there is a 1-year extension or a 2-year extension, what
that is saying, I think, to States is, we are going to
potentially be right back here 2 years from now, up against the
wire again.
So the question you have to ask yourself, I think, as a
State is, what kind of an investment are you going to make in
this program? How much outreach are you going to do to drive
children to this program when it may not be there 2 years from
now because it has come so close this time?
There is a feature in CHIP called a Health Services
Initiative, HIS, where States that have sufficient admin
funding can actually help support other programs like poison
control centers. I understand there is one State that is now
using some funding to help supply those kits that help somebody
immediately recover from an overdose, to help pay for some of
that for children.
So do you as a State begin to invest in something like that
when by the time you get all of the paperwork done and the
money flowing----
Senator Brown. So it needs to be at least--it needs to be
more than 2 years?
Ms. Nablo. I will take anything at this point.
Senator Brown. Of course, of course.
Ms. Nablo. But I absolutely----
Senator Brown. But I do not want you to have to come in
here every year or two and say, I will take anything. I want
you to----
Ms. Nablo. But absolutely, 5 years or longer would be a
very welcome thing for States.
Senator Brown. I will continue--and I know the chairman, I
know Senator Wyden agrees with this. We will continue, at least
many of us who care about this program, we will continue to
advocate for at least 5 years.
So thank you all.
Senator Wyden. Thank you, Senator Brown.
I want to just wrap up with a couple of thoughts, picking
up on Senator Brown's really thoughtful case for how important
a long-term extension is. And, Ms. Nablo, you have done an
extraordinary job this morning laying this case out.
I have agreed with every single thought, save that one at
the end about you will take anything. [Laughter.]
I want to leave this hearing saying that I think we all
understand--and you did not mean it that way, of course--that
kids deserve the very best.
I want to kind of recap a little bit on where we are on
this issue. The Children's Health Insurance Program did not
come about by osmosis. It did not just kind of magically show
up in America and everybody said, hey, we are going to cut the
rate of uninsured kids in America.
It happened because two very strong-willed United States
Senators, the late Senator Kennedy and the chairman of this
committee, acknowledged that they had plenty of differences on
plenty of issues, but both said, we have got to do right by
kids. We have got to step up.
And the reality is that without the two of them doing it, I
do not see how it would have happened. So what we are talking
about today is asking United States Senators to pick up on that
extraordinary legacy of Chairman Hatch and Senator Kennedy and
step up.
And you are going to hear a lot this fall about how there
are all kinds of priorities on the Senate calendar. I listed
some of them, and I am sure Caleb was not paying attention to
all of the government lingo and all of the acronyms and all the
initials.
But the real question behind our job going forward is to
make sure that CHIP is way, way, way up that priority list so
it does not get short shrift, it does not put us in a
situation, as Ms. Nablo described very eloquently about this
kind of parade of horribles--I do not know any other way to
describe it--that kicks in if somehow everybody says, oh, we
have other things to do and that sort of thing. And it starts
to happen pretty darn soon if it does not get the attention
that it is deserving.
Now, the last point I want to make is that I am sure we are
going to have a discussion about costs. America has a lot of
challenges in terms of the budget.
But I just hope what we say is, when people say, can we
afford a generous funding package for CHIP, I hope that we
say--on the basis of the really thoughtful comments that you
all have made, and for Caleb sitting behind his mom--I hope we
say America cannot afford not to cover CHIP in a generous kind
of way, because we heard testimony about what it really means
to be able to afford these skyrocketing medication prices.
I noticed your comment was, well, you know, we probably
could figure out a way to do this. You said that as a mom. But
you know, that is not considering all of the prospective price
hikes.
So what we know is that, if you do not get there early for
these children, you end up playing catchup for years and years
to come. So we either get there for kids like Caleb and ensure
that they can afford medications and spend a modest amount of
money in order to get that coverage, or you basically say, oh,
we are not going to do it, and we will pay, and pay, and pay
some more in the years ahead as a result of that short-sighted
thinking.
So we have a lot to do to talk about how we cannot afford
not to do this. We have a lot to do to make sure that this gets
up the priority list. We have a lot to do to show that this did
not just come about by accident. It came about because of the
extraordinary leadership of our chairman and the late Senator
Kennedy.
The three of you have really given us sort of a road map on
how the Congress ought to come together, and why it ought to
come together. Each one of you brought a unique experience.
I have sat in on a fair number of hearings on this
committee and have tried to specialize in health care since the
days when I was director of the Gray Panthers back at home in
Oregon. This has been one of the best health hearings that we
have had in the Finance Committee. It is because the three of
you laid the case out so well.
You could see the great interest among members on both
sides of the aisle, and we are walking out of here today
knowing that the job is going to be tough in the days ahead,
but you have given us a path for the important work that has to
be done.
I have one bit of business on behalf of the chairman. I
wanted to make sure everybody understood he appreciates their
attendance and that he feels that this is a very important
conversation. He wants Senators to meet with him to talk
through their ideas and suggestions. He believes that we are
confident that we can get a meaningful and bipartisan solution.
And the last request of the chairman is that he would like
to make clear that, for any members of the committee who have
written questions for the record, the chairman would request
that those written questions be submitted by the close of
business on September 14th.
With that, the Senate Finance Committee is adjourned.
[Whereupon, at 12 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Letter Submitted by Hon. Michael F. Bennet, a U.S. Senator From
Colorado
#FundCHIPColorado
The Honorable Michael Bennet The Honorable Ken Buck
U.S. Senate U.S. House of Representatives
The Honorable Cory Gardner The Honorable Doug Lamborn
U.S. Senate U.S. House of Representatives
The Honorable Diana DeGette The Honorable Mike Coffman
U.S. House of Representatives U.S. House of Representatives
The Honorable Jared Polis The Honorable Ed Perlmutter
U.S. House of Representatives U.S. House of Representatives
The Honorable Scott Tipton
U.S. House of Representatives
Dear members of the Colorado congressional delegation:
We write to you today with an urgent issue to which we hope you will
give your immediate attention and unwavering support. The Children's
Health Insurance Program (CHIP) funding is set to expire on September
30, 2017. We urge you in the strongest terms to renew funding for this
important program through 2022 at the currently established levels that
enable Colorado to implement a successful program.
Our organizations represent a broad and diverse coalition of child
health advocates, family doctors, pediatricians, community clinics,
large and small hospitals and many others who have seen first-hand that
CHIP, or CHP+ as Colorado's program is called, has made a genuine
impact on thousands of Colorado kids and their families as well as the
pregnant women the program serves. By bridging the gap for working
families who wouldn't otherwise be able to afford private health
insurance for their children, this program represents the difference
between a healthy start and a childhood plagued with no preventive
care, poor health, and poor performance in school.
CHIP has benefited Colorado's working families by ensuring their kids
get the healthy start they need to reach their full potential. A
failure to extend Federal funding for the program would jeopardize
coverage for about 90,000 kids and pregnant women in Colorado.\1\
Nationally, about 8.9 million kids and their families use CHIP for
their health insurance. If financing is not extended, coverage losses
will start in early 2018 according to the Colorado Department of Health
Care Policy and Financing (HCPF). CHIP has been an integral part of
Colorado's efforts to get kids covered, as well as national coverage
gains, since its inception 20 years ago. A loss of the program would
wipe out much of this progress Colorado and other States have achieved.
CHIP, partnered with Medicaid, has given Colorado the two-pronged
approach it needed to help increase coverage for kids, driving the
percent of uninsured Colorado kids to an all-time low of only 2.5
percent.
---------------------------------------------------------------------------
\1\ Roughly 90,000 kids and pregnant women had coverage in
Colorado's CHIP program (CHP+) sometime during the 2015-2016 fiscal
year. This number is slightly higher than HCPF's reported monthly
caseload numbers, which use point-in-time estimates. Since some clients
lose eligibility and others gain eligibility throughout the year, the
number here is higher than the number of children being served during
any one month during the year.
Simply switching to private insurance isn't a solution for families who
use this program. For example, the maximum annual enrollment fee for a
family on CHIP is $75 or about $6.25 per month. The cheapest
catastrophic health plan in Denver for a child is $103 monthly--a 1,500
percent increase. That increase climbs to at least $144 a month--a
2,200 percent jump--if you live in rural Chaffee County. And these
catastrophic health plans would still expose families to very high out-
of-pocket costs including large deductibles. In addition, recent
studies have shown that out-of-pocket maximums for the working families
using the program would skyrocket if the program goes away, jumping
from an average of $789 to as much as $4,500 annually for a family of
---------------------------------------------------------------------------
three living on $32,484 a year.
Like all States that use the program, Colorado has set the rules for
how it operates. Here, families buy into the program through an annual
fee and pay co-pays for services, much like private insurance. Colorado
has worked to ensure that the provider network for the program is
pediatric-focused, which puts kids' health first and provides lower
cost-sharing options than in private plans. The program includes
important benefits, such as dental, that aren't often found in other
plans. This attention to a pediatric-focused benefits package is
particularly important to kids with chronic issues who often require
specialty care. For kids with chronic illnesses and disabilities, CHIP
is critical because it provides more benefits than private insurance.
We know that for all kids, their family's ability to access insurance
for them matters. Kids with CHIP coverage are more likely to have a
doctor that they see for regular care and less likely to be
hospitalized for a condition that could have been treated at a primary
care doctor visit. Kids with health coverage are less likely to drop
out of high school, and more likely to graduate from college and have
higher incomes as adults. An overwhelming amount of research tells us
that healthy kids are better learners in school, have fewer absences
from their educational experience and are better prepared when they
enter adulthood.
From a Colorado budget perspective, our State stands to lose $254
million annually in Federal funding if the program is ended. That's a
hole in the State budget that Colorado won't be able to close due to
constitutionally imposed tax and spending limitations. CHIP funding in
Colorado provides support for both kids and pregnant women in
Colorado's CHP+ program as well as certain kids enrolled in Medicaid.
Colorado's budget for 2017-2018 is already set and includes Federal
CHIP funding at current rates. Abruptly stopping the program does not
allow State lawmakers to appropriately plan for dramatic changes to
anticipated Federal revenue streams, does not give our State government
time to implement thoughtful transitions, and does not give families
the time they need to plan ahead. Extending funding for CHIP through
2022 will provide budget predictability as Colorado plans for the next
fiscal year and beyond.
Across its nearly 20-year history, CHIP has enjoyed bi-partisan support
because it increases health insurance for children and helps working
families while operating more like a private insurance plan through
membership fees and co-pays. Even in our current, deeply divisive
political environment, there is no reason CHIP should not continue to
enjoy this kind of support. It's a strong program with a track record
that has proved its value to our country, our State, Colorado's working
families and, most importantly, the children and pregnant women it
serves. It deserves your attention and support.
Sincerely,
9to5 Colorado
AFT Colorado
All Families Deserve a Chance Coalition
American Academy of Pediatrics--Colorado Chapter
American Heart Association--Colorado
American Liver Foundation, Rocky Mountain Division
Boulder County Commissioners
Boulder County Department of Housing and Human Services
Bruce Doenecke, MD
Center for Health Progress
Children's Hospital Colorado
Chronic Care Collaborative
Colorado Academy of Family Physicians
Colorado Access
Colorado Center on Law and Policy
Colorado Chapter of the National Hemophilia Foundation
Colorado Children's Healthcare Access Program
Colorado Children's Campaign
Colorado Coalition for the Homeless
Colorado Community Health Network
Colorado Consumer Health Initiative
Colorado Covering Kids and Families
Colorado Cross-Disability Coalition
Colorado Dental Association
Colorado Dental Hygienists' Association
Colorado Fiscal Institute
Colorado Gerontological Society
Colorado Hospital Association
Colorado Organization for Latina Opportunity and Reproductive Rights
Colorado Public Health Association
Colorado's Community Safety Net Clinics
Delta Dental of Colorado
Denver Health and Hospital Authority
Early Milestones Colorado
Epilepsy Foundation of Colorado
Family Voices Colorado
Farley Health Policy Center, University of Colorado School of Medicine
Focus Points Family Resource Center
Healthier Colorado
Huerfano-Las Animas Counties Early Childhood Advisory Council
Joanne Sprouse, Director, Division of Human Services, Summit County
La Plata County Board of County Commissioners
La Plata Family Centers Coalition
Larimer County Department of Human Services
Las Animas County Department of Human Services
Leland Johnston, MD
Mara S. Baer, Founder and President, AgoHealth, LLC
Mental Health Colorado
National Association of Social Workers, Colorado Chapter
National Council of Jewish Women, Colorado Section
National Stroke Association
Nurse Advocate
Oral Health Colorado
Parkinson Association of the Rockies
Peak Vista Community Health Centers
Peter Dawson, MD, MPH
Pitkin County Human Services
Planned Parenthood of the Rocky Mountains
ProgressNow Colorado
Pueblo County Department of Social Services
Rocky Mountain Health Plans
Rural Communities Resource Center
Senior Mobile Dental
Stahlman Disability Consulting, LLC
Steve Clifton, Director Fremont County Department of Human Services
Steve Johnson, Larimer County Commissioner
Sunrise Community Health
Support Jeffco Kids
The Arc Arapahoe and Douglas Counties
The Bell Policy Center
The Consortium
Together Colorado
Tri County Health Department
Wendy Zerin, MD, FAAP
Women's Lobby of Colorado
Yondorf and Associates
Young Invincibles
CC: Governor John Hickenlooper
Sue Birch, Executive Director of the Department of Health Care
Policy and
Financing
Gretchen Hammer, Medicaid Director
Senator Kent Lambert
Senator Kevin Lundberg
Senator Dominick Moreno
Representative Bob Rankin
Representative Millie Hamner
Representative Dave Young
______
Letters Submitted by Hon. Sherrod Brown, a U.S. Senator From Ohio
Ohio Department of Medicaid
50 W. Town Street, Suite 400
Columbus, Ohio 43215
http://medicaid.ohio.gov/
John R. Kasich, Governor
Barbara R. Sears, Director
September 6, 2017
The Honorable Rob Portman The Honorable Sherrod Brown
448 Russell Senate Office Building 713 Hart Senate Office Building
Washington, DC 20510 Washington, DC 20510
The Honorable Bob Latta The Honorable Bill Johnson
2448 Rayburn House Office Building 1710 Longworth House Office
Building
Washington, DC 20515 Washington, DC 20515
Re: CHIP Reauthorization
Dear Senators Portman and Brown and Congressmen Latta and Johnson:
I am writing today to urge your support of reauthorizing funding for
the Children's Health Insurance Program (CHIP), which currently
supports coverage for nearly 219,000 Ohio children as part of the Ohio
Medicaid program. Retaining CHIP funding for services at its present
23-point enhanced match rate will provide Ohio with much needed
stability as it faces challenges brought about by an already
challenging State biennial budget.
Unless funding for CHIP is reauthorized, Ohio stands to exhaust CHIP
funding by the close of calendar year 2017. Ohio provides CHIP coverage
as an extension of its Medicaid program. Thus, as required by the
Affordable Care Act's maintenance of effort provisions, Ohio will be
compelled to continue coverage for these children at its regular
Federal match rate, at an estimated cost of more than $200 million over
the next 2 years.
The Ohio Medicaid program is already successfully navigating an
appropriations gap in the State's current budget. However, elimination
of over $200 million in CHIP funding would be a severe additional blow
to the program and would likely require cuts in other services in order
to support continued access to necessary health care for Ohio's
Medicaid-eligible children.
For all of these reasons, I strongly urge your support for a measure
that would reauthorize CHIP for at least the next 2 years. That said, a
longer reauthorization period (5 to 10 years) would provide additional
stability and avoid the cyclical uncertainty that has plagued this
valuable resource over the last several years.
Thank you for your continued support for Ohio's most vulnerable
citizens. If you need further information, please do not hesitate to
contact me.
Sincerely,
Barbara R. Sears
Director
CC: Hon. Orrin G. Hatch, Chairman, Committee on Finance
Hon. Ron Wyden, Ranking Member, Committee on Finance
Hon. Greg Walden, Chairman, Energy and Commerce Committee
Hon. Frank Pallone, Ranking Member, Energy and Commerce
Committee
______
Ohio Children's Hospital Association
September 6, 2017
The Honorable Orrin G. Hatch The Honorable Ron Wyden
Chairman Ranking Member
Committee on Finance Committee on Finance
U.S. Senate U.S. Senate
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: Children's Health Insurance Program
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of the 6 members of the Ohio Children's Hospital Association
and the 1.3 million children who rely on Medicaid and CHIP in Ohio for
their health insurance, we respectfully and strongly urge you to act
quickly to provide a 5-year extension of funding for the Children's
Health Insurance Program (CHIP), at the current enhanced match, to
ensure kids continue to have access to quality health care.
As you know, CHIP provides coverage for children who fall above
Medicaid eligibility levels but lack access to other options. CHIP
covers children whose families earn too much to qualify for Medicaid,
but who do not have access to adequate health insurance options. The
parents of these families have jobs. In fact, 85 percent of the
children in CHIP households have at least one parent working 50 weeks
per year, according to numbers from the Medicaid and CHIP Payment and
Access Commission.
CHIP was designed specifically for children and includes child-
appropriate benefits, access to pediatric providers and cost sharing
limits to protect vulnerable youth. In Ohio, the program extends as a
complement to Medicaid, designed within the State's Department of
Medicaid, and serves on average more than 200,000 children annually.
Many of the children served by CHIP in Ohio also cycle back and forth
between traditional Medicaid and CHIP.
Here in Ohio, Medicaid and CHIP serve the State's most vulnerable
children, including 100% of all youth in foster care--many of whom are
displaced due to the opioid epidemic. These programs also serve more
than half of Ohio's newborns. Children need access to stable and
predictable health care if they are to have an opportunity to grow and
thrive.
With strong bipartisan support, an overwhelming majority of the U.S.
Congress have consistently reauthorized this important program. Current
Federal funding for CHIP expires at the end of Federal FY 2017. Because
this program has not yet been reauthorized, State budgets have now been
built on the assumption that CHIP dollars will be forthcoming. If
Congress does not act before September 30, 2017, States will be forced
to take action to fill those budget gaps by either disenrolling
children, imposing lock-outs and waiting periods, winding down their
programs altogether or cutting providers, in effort to recoup costs not
covered with budgeted Federal dollars.
As always, we appreciate your commitment to support children and
encourage your formal backing of a clean extension of CHIP. We look
forward to working with you to ensure all Ohio children have access to
the health care they need when they need it.
Sincerely,
Nick Lashutka
President and CEO
Ohio Children's Hospital Association
______
Prepared Statement of Leanna George, Mother of a CHIP Recipient
Good morning. My name is Leanna George, and I live in Benson, NC.
Thank you for the opportunity to meet with you and share my family's
experience with the CHIP program and why this program is so important
to working families. My husband and I have been married 16 years. We
met when he was stationed at Marine Corps Base Camp LeJeune. After 7
years of service in the Marines, about a year after our daughter was
born, he was honorably discharged. Currently he has completed 2 years
of a 4 year apprenticeship training program to become a licensed
electrician. Together, we have 2 children: Serenity who is 15 years old
and has severe Autism, Intellectual Disability, and resides in a group
home; and 11-year old Caleb who has Autism, ADHD, and a genetic
neurological condition. While Serenity has Medicaid, Caleb is insured
by CHIP.
Although I'm not here testifying on behalf of MACPAC, it wasn't
until I was appointed to the Commission that I realized that CHIP's
future was so uncertain. As a parent of a child with extensive needs;
the focus of my advocacy had been on increasing the availability of
Medicaid waivers that provide home and community based supports for
people like my daughter. While there is a need for that, I wasn't aware
that basic coverage for children of the working poor was in jeopardy.
As the Commission discussed the CHIP program, I began to wonder just
how much losing CHIP would impact my family. How much would our premium
cost if we added Caleb to our insurance? How would the change impact
the services he's been receiving? How would we pay for it?
With our current health insurance plan, the monthly premiums would
not increase if we added Caleb to our coverage as my husband's company
only offers Employee Only or Family coverage levels. However, our
insurance plan has a high deductible of $6,000 which currently prevents
my husband and me from accessing medical care. This deductible would
put almost all of all of the services Caleb currently receives out of
our financial reach. These services include weekly occupational therapy
to address fine motor challenges that impact Caleb's ability to write
legibly and perform basic self-care tasks such as tying his shoes. He
receives periodic MRIs and ultrasounds to monitor the progression of
his neurologic condition, which allow us to be proactive in treatment
which results in better outcomes. My son also takes daily medication
which helps him stay focused on his schoolwork; this medicine costs in
excess of $300 a month and requires at least biannual office visits for
medication management. Over the years, the CHIP program has provided
these services to us for little to no cost. Even with the cost sharing
we've had in the past, CHIP is a tremendous value. Without CHIP
coverage, Caleb's access to services would be greatly diminished and
that would directly affect his ability to be successful in school. CHIP
supports kids as they learn and grow; enabling them to be healthy and
able to succeed at school which builds them as citizens and leaders for
America's future.
CHIP also provides families with financial security and moms, like
me, with peace of mind. In January of 2017, my husband was laid off.
Thankfully he found employment a few weeks later. However, this short
period of unemployment resulted in an insurance lapse for my husband
and me. While we struggled to pay for my husband's medication, I was
able to live my life with confidence knowing Caleb had access to care
that he may need if he became sick or injured. I have never had to call
the pediatrician and cancel a visit because of lack of insurance. I
have never had to feel helpless and scared while watching him fight off
illness without the benefit of medical intervention. CHIP has meant
that my son has continued to receive the services and medical care he
needs without interruption, despite the uncertainty his father and I
have faced.
If the CHIP program was to go away, many families like mine would
be forced to make tough choices between the immediate health of our
children and the long-term well-being of the family unit. Monetary
resources are already stretched for many families like mine. Families
may have to ration medical care which could result in something that
appears to be a minor medical issue going untreated and progressing
into a more serious condition. Other families may procrastinate
spending on maintenance services for vehicles or houses which can
contribute to a tragic accident or expose the family to environmental
health risks. If we were not able to find a way to afford my son's
medication, his education would be severely impacted and that could
impact his life well into adulthood.
Among the sacrifices families may consider are activities such as
sports leagues, dance classes, and Scouting. These programs teach our
young people so much in terms of teamwork, perseverance, discipline,
and leadership while promoting physical activity and healthy
lifestyles. Caleb has been active in Scouts ever since he was in the
first grade. As a Cub Scout, he earned his Arrow of Light. He recently
made Scout, the first rank in Boy Scouts. His uncle and cousin are both
Eagle Scouts, and he aspires to earn his. I'm looking forward to seeing
him enjoy similar experiences that I saw my brother participate in and
to watch him grow into a young man who exhibits the 12 principles in
the Boy Scout Law. While there is a lot of support for these excellent
youth programs, they still require incredible investment of time and
resources from the families of these youth. Losing CHIP coverage can
affect the availability of these family resources and limit the ability
of children to participate in these life enriching programs.
Some families may even have to sacrifice some of the care and
oversight they provide for loved ones like parents, siblings, or even
their children who, because of their unique needs, may live in group
homes, nursing homes, or are aging in place with support staff. My
daughter lives in a group home that is more than a 4-hour drive from my
home. While I wish I could travel to visit her monthly, the best I have
been able to do is about bimonthly and sometimes it stretches to
quarterly visits. The increased financial burdens my family will
experience if CHIP is not funded will impact our ability to participate
in our daughter's life and insure that her needs are being
appropriately met.
There are approximately 9 million children who receive CHIP. This
program provides parents with the security of knowing their children
have high quality and reliable insurance coverage, no matter what
challenges they face with their own health or employment. Losing CHIP
would jeopardize the health of America's current workforce and the
well-being of its future leaders. I ask you to extend funding for CHIP
with the enhanced match rate for the next 5 years. Funding CHIP will
contribute to the financial security of working middle class families
like mine and ensure our children will continue to have access to
exceptional medical care which impacts their quality of life well into
adulthood. Thank you for the time you are investing in determining the
future of the CHIP program.
______
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing entitled
``The Children's Health Insurance Program: the Path Forward'':
Twenty years ago, Senator Ted Kennedy and I came together to create
the Children's Health Insurance Program, or CHIP, in order to provide
health coverage for vulnerable children in families who were too poor
to afford private coverage but still didn't qualify for Medicaid.
Twenty years ago, we were at something of a crossroads.
The year before CHIP was signed into law, a Republican Congress
passed and a Democratic President signed a welfare reform bill which
ended the entitlement to cash welfare. Welfare reform sought to replace
a culture of dependency with an emphasis on work. The emphasis was to
move families off assistance and toward self-sufficiency. CHIP was
needed to help many families make that transition.
So we needed to be forward-thinking, taking into account the
realities at that time with an eye toward future sustainability of the
program.
Senator Kennedy and I worked in good faith for months to craft
CHIP, and while neither of us got everything we wanted, the result was
a dedicated funding stream for the program to help low-income families
get good, reliable health insurance.
CHIP, from the outset, was a bipartisan program that enjoyed, and
continues to enjoy, broad support throughout the country and here in
Congress. While it isn't perfect, and while, in my view, some of the
subsequent changes to the program have been regrettable, I believe
that, overall, people consider it to be a success.
Current law provides Federal CHIP funding through the end of fiscal
year 2017. According to the Congressional Research Service, if Congress
doesn't act to provide additional Federal funding, a number of children
who would likely be eligible for CHIP will go uninsured once Federal
funding is exhausted.
Additionally, inaction by Congress with regard to CHIP would cause
another layer of unpredictability and anxiety for States that have to
administer the program. Of course, this anxiety will pale in comparison
to the uncertainty families who rely on CHIP will be faced with if
Congress doesn't act.
As the committee contemplates the future of the CHIP program, there
are several thresholds we'll need to consider.
The basic question is, does the committee want to reauthorize or
merely extend CHIP?
Reauthorization would entail more extensive debate and the
consideration of potential policy changes to the underlying program. As
many of you know, in 2015, Congressman Fred Upton--who was then
chairman of the House Energy and Commerce Committee--and I put forward
a number of substantive policy recommendations for reforming CHIP, most
of which were, admittedly, met with a mixed reaction from stakeholders.
While some policy changes are certainly in order for the program,
some are justifiably concerned that, given the number of issues that
are already before the committee, there may not be time to give full
and fair consideration to CHIP reforms prior to the expiration of
Federal funding at the end of the fiscal year. With these concerns in
mind, some have suggested that, instead of reauthorizing the entire
program, we simply act to extend CHIP funding.
Of course, that option comes with its own set of questions.
For example, we'll need to determine the appropriate length for the
extension and whether to continue with the 23-percent increase in
Federal matching for CHIP provided under the Affordable Care Act and
extended in 2015.
I know some of our members have strong feelings about both of these
questions. These are not particularly complicated issues, but they will
require some deliberation among members of the committee.
Long story short, we have some difficult questions ahead of us.
Whether we opt to reopen CHIP for reforms or simply provide another
extension, the committee will need to invest significant time and
effort to find answers to those questions.
Today, we will continue our discussion of these matters as we hear
from witnesses who will testify to the importance of CHIP and the need
for it to continue.
I hope members will listen carefully to these witnesses, confer
with their States, and let me know how they would prefer to proceed
with regard to CHIP. I look forward to working on a bipartisan basis
with Ranking Member Wyden and all the members of the Senate Finance
Committee to move forward on a bipartisan CHIP bill.
______
Prepared Statement of Linda Nablo, Chief Deputy Director,
Virginia Department of Medical Assistance Services
Chairman Hatch, Ranking Member Wyden, and members of the committee,
thank you for allowing me to speak to you today on the importance to
States of continued funding for the Children's Health Insurance
Program.
And thank you, Senator Warner--I remember well when you were
Governor and I was hired as the CHIP Director to help you improve
Virginia's program and enroll every eligible child. I particularly
remember how you would ask every Friday, without fail, how many more
children we had gotten covered that week. So before you go there, I
will say that Virginia currently has 614,100 children covered through
Medicaid and CHIP. These programs are the health insurance plan for
almost one in three children in the Commonwealth, or slightly less than
the national average.
I was invited here today to give the State perspective on the
importance of continued funding for CHIP. As Dr. Schwartz has
explained, the authorizing CHIP legislation provided certain
flexibilities to States in how to design their programs so there are
differences across the country. Virginia, like most States has a
combination program with some children enrolled in Medicaid but
supported by CHIP funding and others covered in a separate program. But
however States have chosen to administer this program, it plays a vital
role for all of us in ensuring children have access to affordable and
appropriate health-care coverage by building on top of the much larger
Medicaid program. In fact, CHIP just turned 20--it is now a mature
program that is woven deep into the fabric of health-care coverage in
all States and is a key program protecting the health of children for
all of us.
There are only two points I want to make in my 5 minutes today.
First, that CHIP is vital to the health of children in Virginia and in
each of the States you represent. By my quick calculation over 4
million children are covered by CHIP in just your States alone. Second,
I want to make sure you understand that there are serious consequences
looming if you delay reauthorization--even for a few months.
In Virginia, as of September 1st, there are 123,256 children
receiving their health care through CHIP. Over 58,000 of them are
enrolled in Medicaid and the other 65,000+ are enrolled in the separate
program initially modeled after the State employee health plan. We call
the separate program ``FAMIS'' and we call the Medicaid program for
children ``FAMIS Plus''; the plus is because Medicaid provides
additional benefits.
In Virginia we cover children up to 200% of the poverty level. We
do not charge premiums but we do charge modest co-payments for services
and children are required to be served through one of our six managed
care plans at an average per child monthly cost of $160.
Virginia also has a CHIP waiver to provide prenatal care to
pregnant women with incomes above the Medicaid limit up to 200% of the
poverty level, and about 1,100 pregnant women are currently enrolled.
We also have a small premium assistance program whereby families can
choose to enroll their child in an employer's health plan and we will
help them cover the cost of the children's coverage, as long as it is
cost-effective to do so and certain benefits are included.
The separate CHIP benefit package is strong, and most recently, we
have added new substance use treatments for CHIP children and pregnant
women as part of Virginia's effort to address the opioid epidemic.
Virginia receives 88% Federal funding for this program and to
emphasize just how important this is to Virginia children, in the last
2 fiscal years this funding has paid for:
218,190 immunizations and 221,309 well-child checkups,
21,430 glasses/contact lenses, and
326,567 dental visits.
In addition to this more routine and preventive care, CHIP has
covered:
258 heart surgeries,
6 brain cancer surgeries,
2 liver transplants, and
1 heart transplant.
We have provided services for:
1,118 children diagnosed with cancer,
31 children living with HIV, and
32 children born with neonatal abstinence syndrome.
You have heard today from Ms. George about the difference CHIP has
made in her child's life. There are thousands of stories in each of
your States that would deliver the same message. In Virginia I could
tell you stories of children who simply get to lead more normal lives
because of CHIP; they can play sports (you know you need to have
insurance to play sports), control their asthma, see better in school,
or get their teeth fixed; and their families breathe easier. Some even
avoid falling into poverty because they have ready access to good
quality health care for their children. Or I could tell you stories of
children with very serious illnesses that have received lifesaving
treatments because of this program. I could talk about James who
learned he needed heart surgery days before he was to turn 18. Everyone
worked together to expedite his eligibility and schedule his surgery so
it would be covered before he aged out of CHIP. We couldn't pay for his
considerable follow-up treatments but we could help fix his heart.
Or Nathan, a 15-year-old without health insurance who showed sudden
symptoms of diabetes and was rushed to the local emergency room. On the
cusp of entering a diabetic coma the staff transferred him to a nearby
hospital better able to treat his health crisis. His mother was
fortunate to connect with a Virginia Health Care Foundation outreach
worker, an organization Senator Warner is very familiar with as he is
the founding chairman, and that we help support with CHIP
administrative dollars. The outreach worker quickly assessed that
Nathan would be eligible for FAMIS and personally engaged the local
department of social services to expedite his application and ensure
receipt of life-saving care without delay. Like so many others,
Nathan's mother was amazed to find out that CHIP is designed to meet
the needs of working families.
I hope you understand that CHIP is vital to the health of our
children and therefore our Nation and it works. But without
congressional action soon we will be forced to start preparations to
shut it down, throwing families of over 60,000 children in Virginia,
and millions across the country into a panic.
You have heard that most States will not actually run out of
Federal CHIP dollars until sometime in the second quarter of FY 2018.
Some might naively believe this means you can safely delay any action
on CHIP while you deal with your very full calendar. But let me explain
how problematic that would be for States and how devastating for
families.
The analysis from CMS and the MACPAC data shows that with some
redistributed funds, Virginia will run out of Federal CHIP dollars
sometime in March--and we agree. However, what that analysis does not
take into account is that Virginia, like many States, covers these
children through managed care plans. We pay those health plans a
capitated rate retrospectively for the previous month's coverage. So in
February 2018 we will pay the six health plans for the month of
January--but in March we will not have sufficient funds to pay for the
month of February. We will therefore need to terminate FAMIS coverage
at the end of January.
In order to give families adequate notice, we will need to send
them letters informing them of this alarming news at the end of
November. To address the inevitable turmoil this will cause, in
Virginia we will first need to train Eligibility Workers, advocates,
application assistors, call center operators, and others before
families receive those letters so they are able to answer questions and
provide whatever assistance they can offer. In essence, we will need to
mount a reverse outreach campaign. We will also need to inform
providers along the same time frame and prepare to deal with their
questions as well.
We will need to expend funds to modify IT systems as eligibility
rules are now embedded into such systems across the country and to
change online and paper applications and notices. Countless other
contracts for managed care, prior authorization reviews, auditors, etc.
will also need to be amended.
I suspect for States without a high degree of managed care the
situation will be even more precarious. They will have to try and
predict what CHIP claims will come in, and when, in order to shut down
the program in time to cover unknown costs. This will be further
complicated as parents who get that letter telling them their child's
coverage will end soon will very likely rush their child to the doctor,
dentist and eye doctor and fill any prescriptions to the maximum; thus
driving up utilization and expending remaining dollars faster than
anticipated.
Even if some States were able to continue a reduced level of
coverage for a time--or move children in a separate program into
Medicaid, it would take months to develop and implement new policies
and change systems. In Virginia our legislators begin their regular
session on January 10th, too late to begin any legislative debate of
how to continue some form of coverage.
If the future of CHIP remains uncertain, States will soon need to
make decisions about policies such as freezing enrollment so as to
preserve current coverage as long as possible, and what to say to
families and when to say it, as the end of funding approaches. I have a
long ``To Do'' list of what will need to happen in Virginia and that
list starts in October if CHIP is not reauthorized by September 30th.
While we have come so close to the wire this time that States would
be grateful for any quick reauthorization, I do want to make the point
that funding this program in 1- or 2-year increments breeds
instability. It dampens innovation and probably limits State investment
when the future is so uncertain. I absolutely endorse the MACPAC
recommendation of reauthorizing and funding the program for 5 years.
Finally, I want to talk about the enhanced Federal match rate for
CHIP. I understand there is some question of whether or not it will
continue at the current rate or be reduced. Please be aware that for
Virginia alone, we know that if Congress reauthorizes CHIP but reduces
the Federal match rate to previous levels (65% for Virginia) we will
experience an immediate $56 million dollar shortfall in the current
State fiscal year (July-June) and an $83 million shortfall in the next.
Virginia, like almost all States, has built the current biennial budget
on current law with the higher CHIP match.
As the chairman knows better than anyone, CHIP has always had
strong bipartisan support, and that is true at the State level as well.
With all the very difficult and complex decisions you have to make
about health care in America, surely whether or not to reauthorize CHIP
is not one of them. On behalf of States I am here to ask you to please
continue your strong support of children's health care with passage of
a straightforward authorization for continued funding of CHIP, at
current levels.
Thank you.
______
Prepared Statement of Anne L. Schwartz, Ph.D., Executive Director,
Medicaid and CHIP Payment and Access Commission
Summary
Since its enactment with strong bipartisan support in 1997, CHIP
has played an important role in providing insurance coverage and access
to health care for tens of millions of low- and moderate-income
children with incomes just above Medicaid eligibility levels. Under
current law, CHIP is funded through fiscal year (FY) 2017. The
Commission urges Congress to act as soon as possible to avoid
disruption for families, plans, providers, and States, and to ensure
that children continue to have access to needed health-care services.
Without congressional action, States will not receive new Federal funds
for CHIP beyond the end of this month, and States will rapidly deplete
available funding. MACPAC projects that four States will exhaust
available Federal funds in the first quarter of FY 2018; another 27
will do so in the second quarter.
In January 2017, MACPAC recommended that Congress extend Federal
CHIP funding for a transition period of 5 years, as well as extend the
CHIP maintenance of effort requirement and 23 percentage point increase
in the CHIP matching rate though FY 2022. The Commission's priority in
making these recommendations was to ensure the stability of children's
health coverage during a period of uncertainty as Congress debates the
future of Medicaid and subsidized exchange markets.
In coming to these recommendations, the Commission considered what
would happen if no CHIP allotments were available to States after FY
2017. Our most recent estimates are that, if CHIP funding is not
renewed, 1.2 million children covered under separate CHIP will become
uninsured. While others may transition to
employer-sponsored or exchange coverage, it would cost considerably
more, potentially creating barriers to obtaining needed health and
developmental services. In addition they could lose access to needed
services that these sources are less likely to cover, such as dental
care or audiology services.
When the Commission made these recommendations, it noted that
coverage under separate CHIP authority should not be maintained
indefinitely but that more time is needed to address concerns related
to the affordability and comprehensiveness of other sources of
children's coverage. Health insurance markets may face substantial
changes over the next few years; unless renewed, Federal funding for
CHIP will be exhausted long before any such changes can be fully
realized.
Although States can continue to use FY 2017 funds into FY 2018,
they cannot do so indefinitely. Moreover, they have legal obligations
to notify families, plans, and providers about future plans, which may
include freezing enrollment, transitioning children to other sources of
coverage, and making eligibility and enrollment systems changes. In
some States (e.g., Arizona and West Virginia), State law requires
termination of CHIP if Federal funding is not available.
In the long term, a more seamless system of children's coverage
needs to be developed. That is why the Commission made a number of
recommendations for a more seamless system of children's coverage to
accompany its recommendations for Federal CHIP funding. Such a system
would provide comprehensive and affordable coverage to low- and
moderate-income children and remove the potential gaps in coverage
children may experience as they transition between publicly and
privately financed health insurance.
______
Good morning, Chairman Hatch, Ranking Member Wyden, and members of
the committee. I am Anne Schwartz, Executive Director of the Medicaid
and CHIP Payment and Access Commission (MACPAC). As you know, MACPAC is
a congressional advisory body charged with analyzing and reviewing
Medicaid and CHIP policies and making recommendations to Congress, the
Secretary of the U.S. Department of Health and Human Services (HHS),
and the States on issues affecting these programs. Its 17 members,
including Chair Penny Thompson and Vice Chair Marsha Gold, are
appointed by the U.S. Government Accountability Office (GAO). While the
insights and information I will share this morning build on the
analyses conducted by MACPAC's staff, they are in fact the views of the
Commission itself. We appreciate the opportunity to share MACPAC's
recommendations and work as this committee considers the future of the
State Children's Health Insurance Program (CHIP).
overview of chip
Since its enactment with strong bipartisan support in 1997, CHIP, a
joint
Federal-State program, has played an important role in providing
insurance coverage and access to health care for millions of low-income
children with incomes just above Medicaid eligibility levels. Over this
period, the share of uninsured children in the typical CHIP income
range (those with family income above 100 percent but below 200 percent
of the Federal poverty level (FPL)) has fallen dramatically--from 22.8
percent in 1997 to 6.7 percent in 2015 (MACPAC 2017a). In contrast,
during the same period, which included two recessions, private coverage
for children in this income range declined substantially--from 55
percent in 1997 to 29.8 percent in 2015 (Martinez et al. 2017).
In fiscal year 2016, 8.9 million children were enrolled in CHIP-
funded coverage (CMS 2017a). States have flexibility in designing CHIP.
States can operate these programs either as an expansion of Medicaid,
an entirely separate program, or a combination of both approaches.
States with Medicaid-expansion CHIP must provide the full Medicaid
benefit package, including early and periodic screening, diagnostic,
and treatment services, and must follow Medicaid cost-sharing rules.
States with separate CHIP provide comprehensive health-care services
subject to the approval of the Secretary of the U.S. Department of
Health and Human Services (the Secretary) or based on a benchmark
benefit package. In separate CHIP, States may require premiums and cost
sharing, such as copayments and deductibles (although not for
preventive services), with a combined limit of 5 percent of income.
States receive an enhanced Federal match for CHIP, subject to the cap
on their allotments, and must contribute a State share to receive their
Federal funding allotments.
basis for macpac recommendations
Under current law, CHIP is funded through FY 2017, and without
congressional action, States will not receive any new Federal funds for
CHIP beyond September 30, 2017. Mindful of this date, the Commission
devoted considerable attention over the past several years to CHIP's
role in our health-care system and policy approaches for the future. We
reviewed available evidence about the quality and affordability of CHIP
compared to other alternatives, and focused attention on the
implications of various policy approaches for children and their
families, States, providers, health plans, and the Federal Government.
Based on this review, the Commission issued a report this past
January recommending that Federal funding for CHIP be extended for 5
years. If CHIP funding is not renewed, many of the children covered
under separate CHIP will lose their health coverage. While some of
these children may be eligible for private coverage, their families
would have to pay considerably more than under CHIP, potentially
creating barriers to needed health and developmental services. In
addition, they would lose access to services covered by CHIP that are
not typically covered by other payers. Those covered by Medicaid-
expansion CHIP would not lose coverage but there would be a significant
shift in the funding obligation for their coverage to the States.
MACPAC has always looked at CHIP in its context, a relatively small
public health coverage program in an evolving array of sources of
coverage for children that includes Medicaid, publicly subsidized
exchange coverage established by the Patient Protection and Affordable
Care Act (ACA, Pub. L. 111-148, as amended), and employer-sponsored
coverage. In the long term, the development of a more seamless system
of children's coverage is needed. Such a system would provide
comprehensive and affordable coverage to low- and moderate-income
children, removing the potential gaps in coverage and care that can
affect children as they transition among different sources of publicly
and privately financed health insurance.
Moreover, the future of publicly financed health coverage markets
currently is uncertain. Over the past few months, Congress has been
debating reforms to both Medicaid and federally subsidized exchange
coverage that would affect the available alternatives for children in
the absence of CHIP. This uncertainty heightens the need for
congressional action to extend CHIP.
In my testimony today, I will present the rationale behind the
Commission's recommendations on the future of CHIP funding and
children's coverage, as well as the evidence it considered in making
its recommendations. I also will address CHIP financing; in particular,
how States will be affected if Federal CHIP funding ends. MACPAC's most
recent analyses focus on when States are projected to run out of CHIP
funds and how the requirement that States maintain coverage for
children through fiscal year (FY) 2019 will affect States
differentially based on their decisions to run CHIP as a Medicaid
expansion or a separate program.
MACPAC's Recommendations on the Future of CHIP and Children's Coverage
In a January 2017 special report (made available in print in our
March 2017 Report to Congress on Medicaid and CHIP), MACPAC made nine
recommendations to Congress to fund and stabilize CHIP, and to move
toward a more seamless system of affordable and comprehensive children
coverage (Box 1).
stabilizing children's health coverage
In making its recommendations for CHIP funding, a key priority for
the Commission was to ensure the stability of children's health
coverage during this period of uncertainty about other sources of
coverage. The Commission recommends that Congress extend Federal CHIP
funding for a transitional period of 5 years through FY 2022. It also
recommends extension of the current CHIP maintenance of effort (MOE)
requirement and the 23 percentage point increase in the Federal CHIP
matching rate through FY 2022.
Rationale. Extending CHIP for a transition period would ensure that
low- and moderate-income children would retain access to affordable
insurance coverage during a time of uncertainty for coverage markets.
The transition period of 5 years would also provide time to address
concerns with affordability and benefits of other coverage sources,
which are described in greater detail below. In addition, this period
would provide Federal and State policymakers time to plan and implement
comprehensive children's coverage demonstrations, which the Commission
also is recommending.
_______________________________________________________________________
BOX 1. MACPAC Recommendations for the Future of CHIP and Children's
Coverage
Recommendation 1.1
Congress should extend Federal CHIP funding for a transition period
that would maintain a stable source of children's coverage and provide
time to develop and test approaches for a more coordinated and seamless
system of comprehensive, affordable coverage for children.
Recommendation 1.2
Congress should extend Federal CHIP funding for 5 years, through
fiscal year 2022, to give Federal and State policymakers time to
develop policies for, and to implement and test coverage approaches
that promote seamlessness of coverage, affordability, and adequacy of
covered benefits for low- and moderate-income children.
Recommendation 1.3
In order to provide a stable source of children's coverage while
approaches and policies for a system of seamless children's coverage
are being developed and tested, and to align key dates in CHIP with the
period of the program's funding, Congress should extend the current
CHIP maintenance of effort and the 23 percentage point increase in the
Federal CHIP matching rate, currently in effect through FY 2019, for 3
additional years, through fiscal year 2022.
Recommendation 1.4
To reduce complexity and to promote continuity of coverage for
children, Congress should eliminate waiting periods for CHIP.
Recommendation 1.5
In order to align premium policies in separate CHIP with premium
policies in Medicaid, Congress should provide that children with family
incomes below 150 percent of the Federal poverty level not be subject
to CHIP premiums.
Recommendation 1.6
Congress should create and fund a children's coverage demonstration
grant program, including planning and implementation grants, to support
State efforts to develop, test, and implement approaches to providing,
for CHIP-eligible children, seamless health coverage that is as
comprehensive and affordable as CHIP.
Recommendation 1.7
Congress should permanently extend the authority for States to use
Express Lane Eligibility for children in Medicaid and CHIP.
Recommendation 1.8
The Secretary of Health and Human Services, in consultation with
the Secretaries of Agriculture and Education, should not later than
September 30, 2018, submit a report to Congress on the legislative and
regulatory modifications needed to permit States to use Medicaid and
CHIP eligibility determination information to determine eligibility for
other designated programs serving children and families.
Recommendation 1.9
Congress should extend funding for 5 years for grants to support
outreach and enrollment of Medicaid- and CHIP-eligible children, the
Childhood Obesity Research Demonstration projects, and the Pediatric
Quality Measures program, through fiscal year 2022.
_______________________________________________________________________
To further stabilize children's coverage and prevent States from
rolling back eligibility, the Commission recommends extending the CHIP
MOE through FY 2022. The current MOE, which requires States to maintain
the CHIP eligibility levels in place on March 23, 2010 through FY 2019,
was established by the ACA (Appendix A). The MOE also prohibits States
from adopting eligibility and enrollment standards or methodologies
that are more restrictive than those in place prior to the enactment of
the ACA (Sec. 2105(d)(3) of the Act).
MACPAC also recommends extending the 23 percentage point increase
to the CHIP enhanced matching rate through FY 2022. This increase was
enacted in the ACA for FYs 2016-2019. In the current fiscal year, 11
States and the District of Columbia have a CHIP matching rate of 100
percent meaning that the Federal Government pays for 100 percent of the
cost of providing CHIP coverage to children (Appendix B). An additional
22 States have CHIP matching rates ranging from 90 percent to 99
percent (MACPAC 2017a).
The Commission's recommendation reflects the view that an extension
to the MOE, which it judged important to retaining gains in coverage,
should be accompanied by an extension of enhanced funding. The increase
to the CHIP matching rate is also thought to have influenced decisions
in 2016 in some States to expand children's coverage, within
permissible limits.\1\ For example, Florida and Utah expanded Medicaid
and CHIP coverage to lawfully residing immigrant children. In July
2016, Arizona reinstated CHIP, which it had previously closed.
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\1\ The definition of targeted low-income child at section 2110(b)
created a CHIP upper income-eligibility limit of no greater than 50
points above the State pre-CHIP Medicaid income levels.
The Commission has long held that coverage under separate CHIP
authority should not be maintained indefinitely (MACPAC 2014a). The
Commission also has stated that children's coverage should be
affordable and comprehensive, and State flexibility in program design
must be maintained. In the Commission's view, other current sources of
coverage do not meet these standards. In addition, over the course of
the Commission's deliberation, two additional facts became clear.
First, more time is needed for assessing, planning, and implementing
changes to address concerns of other coverage sources for children.
Second, given the expectation that health insurance markets may face
substantial changes over the next few years, Federal funding for CHIP
would be exhausted before these changes would be fully realized.
implications if federal chip funding is not renewed
If CHIP funding ends and States exhaust available Federal funds,
the implications for States depend on whether they operate CHIP as a
Medicaid expansion or a separate program. As of January 1, 2016, 10
States (including the District of Columbia) ran CHIP as a Medicaid
expansion, 2 States had separate CHIP, and 39 operated combination
programs (MACPAC 2017a). In the absence of CHIP, children leaving
separate CHIP and gaining other coverage likely would face higher cost
sharing, different benefits, and enrollment in plans with different
provider networks.
Increase in uninsurance. Although the MOE generally requires States
to maintain their children's coverage eligibility levels in place when
the ACA was enacted, States face different scenarios for separate CHIP
and Medicaid-expansion if Federal CHIP funds run out. States with
Medicaid-expansion CHIP must continue that coverage for children, but
instead of receiving the enhanced CHIP match, States will receive the
lower Medicaid matching rate. Of the 8.4 million children enrolled in
CHIP-funded coverage in 2015, 4.7 million were in Medicaid-expansion
CHIP (MACPAC 2017a).
States with separate CHIP are permitted to terminate that coverage
if Federal CHIP funds run out. In this case, the ACA requires States to
develop procedures to automatically transition children from separate
CHIP to exchange coverage that has been certified as ``at least
comparable to'' CHIP programs with respect to benefits and cost sharing
(Sec. 2105(d)(3)(B) of the Social Security Act (the Act)). If the
Secretary finds that no exchange plans are comparable to CHIP, States
are not required to facilitate the transition to exchange coverage,
although families may obtain subsidized exchange coverage on their own.
In November 2015, the Secretary of the U.S. Department of Health and
Human Services (the Secretary) did not certify any exchange plan as
comparable to CHIP coverage (CMS 2015).
We recently updated our analysis of how an end to separate CHIP
would affect children's coverage, finding that in the absence of CHIP,
1.2 million children enrolled in separate CHIP would become uninsured
because the cost of other sources of coverage would be unaffordable.\2\
We estimate that 1.1 million would enroll in employer-sponsored
coverage, and almost 700,000 would enroll in subsidized exchange
coverage.
---------------------------------------------------------------------------
\2\ Urban Institute analysis for MACPAC of Health Insurance Policy
Simulation Model-
American Community Survey (HIPSM-ACS), August 2017.
This analysis also found that of the children losing separate CHIP
---------------------------------------------------------------------------
and who would become uninsured:
Forty-four percent will be eligible for exchange subsidies;
Forty percent are eligible for exchange subsidies because their
parents do not have an offer of employer coverage or the available
employer-sponsored coverage excludes dependent coverage; and
Fifty-six percent will have an offer of employer-sponsored
coverage in the household.
However, the average additional premium to obtain family coverage
would be 8 percent of income, making the total cost of family coverage
equal to 11 percent of family income.
We also previously noted that the majority of separate CHIP-
enrolled children who would become uninsured if CHIP funding is
exhausted have family income below 200 percent FPL (61.3 percent) and
are non-white (53.9 percent). In addition, 89.6 percent have a full-
time worker in the family (MACPAC 2015).
Affordability of coverage. For children in the CHIP income-
eligibility range, CHIP coverage is considerably less costly to
families with respect to both premiums and out-of-pocket cost sharing
than exchange or employer-sponsored coverage (MACPAC 2016, 2015).\3\ In
2015, the combined premiums and cost sharing of separate CHIP in 36
States averaged $158 per year per child, $127 for premium and $31 for
cost sharing. On average in these 36 States, the effective actuarial
value of CHIP coverage was 98 percent. In other words, the plans
covered 98 percent of the cost of covered medical benefits and
enrollees 2 percent.
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\3\ Premiums and cost sharing are permitted for children in
separate CHIP (capped at 5 percent of family income), but they
generally are prohibited for children in Medicaid.
If these same children were enrolled in employer-sponsored
insurance, they would have faced an estimated $891 per year per child
in average annual out-of-pocket spending ($603 for premiums and $288 in
cost sharing), and if enrolled in the second lowest cost silver
exchange plan, they would have faced an estimated $1,073 per year per
child ($806 for premiums and $266 in cost sharing). The effective
actuarial value averaged 81 percent in employer sponsored insurance
plans and 82 percent in second lowest cost silver exchange plans, with
families responsible for the remaining 18 percent to 19 percent through
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cost sharing (MACPAC 2016).
Adequacy of benefits. MACPAC's comparison of benefits in separate
CHIP, Medicaid (including Medicaid-expansion CHIP), exchange plans, and
employer-
sponsored insurance found that covered benefits vary within each
source--between States for Medicaid and CHIP, and among plans for
employer-sponsored insurance and exchange plans (MACPAC 2015). Most
separate CHIP, Medicaid, exchange, and employer-sponsored insurance
plans cover major medical benefits, such as inpatient and outpatient
care, physician services, and prescription drugs. Children enrolled in
Medicaid-expansion CHIP are entitled to all Medicaid services,
including early and periodic screening, diagnostic, and treatment
(EPSDT) services that exchange and employer-sponsored plans often do
not cover.
Differences are pronounced for dental care, an EPSDT service. Like
Medicaid, separate CHIP covers pediatric dental services. However in
most exchanges and employer-sponsored coverage, dental benefits are
offered as a separate, stand-alone insurance product for which families
pay separate premiums and cover cost sharing expenses. More than half
of all employer-sponsored plans (54 percent) do not include pediatric
dental coverage. Of the employers that offer separate dental coverage,
many require an additional premium.
CHIP also covers many services important to children's healthy
development that are not always available in exchange plans. For
example, all separate CHIP and Medicaid programs cover audiology exams,
and 95 percent of separate CHIP programs cover hearing aids. However,
only 37 percent of exchange plan essential health benefit benchmarks
cover audiology exams, and only 54 percent cover hearing aids (MACPAC
2015). Among employer-sponsored health plans, 34 percent cover
pediatric audiology exams and 43 percent cover hearing aids (MACPAC
2015).
Provider networks. The Commission also looked at how CHIP provider
networks compare to those of other sources of coverage. Under Federal
law, CHIP managed care is subject to the same Federal provisions that
establish standards for Medicaid managed care (Sec. 2103(f)(3) of the
Act). These provisions require States to establish ``standards for
access to care so that covered services are available within reasonable
time frames and in a manner that ensures continuity of care and
adequate primary care and specialized services capacity''
(Sec. 1932(c)(1)(A)(i) of the Act). CHIP regulations also specify that
a State must ensure ``access to out-of-network providers when the
network is not adequate for the enrollee's medical condition'' (42 CFR
457.495).
Advocates have suggested that separate CHIP networks are better
than Medicaid or exchange plan networks because they are similar to
private plan networks or because they are designed specifically for
pediatric needs (Hensley-Quinn and Hess 2013, Hoag et al. 2011).
However, we found little empirical evidence to either support or refute
this assertion.
implications for states
MACPAC has also considered the financial and operational
implications for States if CHIP funding were to end, which are
described below. Unless funding for CHIP is renewed, States will begin
running out of available Federal funds during the first quarter of FY
2018, which begins in just a few weeks. All States will exhaust their
funds before the end of fiscal year 2018.
Exhaustion of Federal funds. Federal funding for CHIP is capped and
allotted to States annually. States have 2 years to spend their
allotments, and unspent allotments are available for redistribution to
other States experiencing CHIP funding shortfalls.\4\ Under current
law, new CHIP allotments are not available after FY 2017 and unspent FY
2017 CHIP allotments that remain available for expenditures in FY 2018
are reduced by one-third (Sec. 2104(m)(2)(B)(iv) of the Act).\5\
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\4\ MACPAC projects that the Federal CHIP funding that States have
received through their FY 2017 allotments and the redistribution
funding that is available from prior year allotments will be adequate
to cover projected State spending in FY 2017 (MACPAC 2017b). Four
States and the District of Columbia are projected to have CHIP spending
that exceeds their FY 2017 allotment, but these States are expected to
receive redistribution funds in FY 2017 sufficient to cover their
projected CHIP funding shortfall. Approximately $3 billion in
redistribution funding is available in FY 2017 (MACPAC 2017b).
\5\ States experiencing CHIP funding shortfalls can also receive
contingency fund payments if their CHIP enrollment exceeds target
levels specified in section 2105(n) of the Act. However, contingency
fund payments are not available for FY 2018 and subsequent years.
Under current law, in FY 2018, States may continue to spend unspent
FY 2017 allotments and redistribution funds from prior years (an
estimated $4.2 billion in total), however these funds are expected to
be insufficient to cover expected State CHIP expenses in FY 2018 (an
estimated $17.4 billion).\6\ Based on State spending estimates
submitted to CMS, MACPAC projects that three States and the District of
Columbia will exhaust available Federal CHIP funds sometime in the
first quarter of the fiscal year, and 27 States will do so in the
second quarter (Table 1 and Appendix C).
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\6\ The projected FY 2018 Federal CHIP spending of $17.4 billion
includes States and territories.
Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018
------------------------------------------------------------------------
Number of
Quarter of fiscal year States States
------------------------------------------------------------------------
First quarter 4 Arizona, District of
(October-December 2017) Columbia, Minnesota, and
North Carolina
------------------------------------------------------------------------
Second quarter 27 Alaska, Arkansas, California,
(January-March 2018) Colorado, Connecticut,
Delaware, Florida, Hawaii,
Idaho, Kansas, Kentucky,
Louisiana, Massachusetts,
Mississippi, Missouri,
Montana, Nevada, New York,
Ohio, Oregon, Pennsylvania,
Rhode Island, South Dakota,
Utah, Vermont, Virginia, and
Washington
------------------------------------------------------------------------
Third quarter 19 Alabama, Georgia, Illinois,
(April-June 2018) Indiana, Iowa, Maine,
Maryland, Michigan,
Nebraska, New Hampshire, New
Jersey, New Mexico, North
Dakota, Oklahoma, South
Carolina, Tennessee, Texas,
West Virginia, and Wisconsin
------------------------------------------------------------------------
Fourth quarter 1 Wyoming
(July-September 2018)
------------------------------------------------------------------------
Note: CHIP is the State Children's Health Insurance Program.
Source: MACPAC 2017 analysis using June 2017 Medicaid and CHIP Budget
and Expenditure System data from the Centers for Medicare and Medicaid
Services, including quarterly projections provided by States in May
2017.
State policies may also affect when States exhaust their Federal
CHIP funding. For example, while the ACA's maintenance of effort (MOE)
requirement generally prohibits reducing children's eligibility for
CHIP, States are permitted to impose enrollment limits ``in order to
limit expenditures . . . to those for which Federal financial
participation is available'' (Sec. 2105(d)(3)(A)(iii) of the Act).
States may also take other actions to reduce CHIP spending such as
allowing CHIP waivers to expire and cutting payments to plans and
providers.
State budgets. Most States have fiscal years that begin July 1;
thus they have already set their budgets for the State fiscal year
2018. Despite the uncertainty of Federal CHIP funding, 33 out of 40
States responding to a survey about the future of CHIP funding
indicated that their State budget assumed that CHIP funding would
continue; 21 States have assumed that the 23 percentage point increase
in the CHIP match continues as well (NASHP 2017). Absent congressional
action, these States will likely experience shortfalls and may have to
close their separate CHIP programs or provide coverage to children
enrolled in Medicaid-expansion CHIP with substantially fewer Federal
funds than anticipated.
Operational considerations and timelines. Although States can
continue to use FY 2017 funds into FY 2018, they cannot do so
indefinitely. Moreover, they have legal obligations to notify families,
plans, and providers about future plans, which may include freezing
enrollment, transitioning children to other sources of coverage, and
making eligibility and enrollment systems changes (NASHP 2017). In some
States (e.g., Arizona and West Virginia), State law requires
termination of CHIP if Federal funding is not available.
Although we are hearing from State officials that they do not wish
to unnecessarily alarm beneficiaries and other stakeholders, others are
planning to send notices this month with freezes beginning in October
and November.
Companion Recommendations to Promote Seamless Children's Coverage
In addition to the recommendations pertaining to Federal CHIP
funding, the Commission made a number of companion recommendations for
moving toward a more seamless system of children's coverage. These
recommendations include:
Creating and funding a children's coverage demonstration grant
program to support State efforts to develop, test, and implement
approaches to providing CHIP-eligible children with seamless health
coverage that is as comprehensive and affordable as CHIP;
Eliminating waiting periods in CHIP, aligning separate CHIP
premium policies with those of Medicaid, and permanently extending
authority for States to use Express Lane Eligibility; and
Extending funding to support outreach and enrollment of
Medicaid-and CHIP-eligible children, the Childhood Obesity Research
Demonstration projects, and the Pediatric Quality Measures Program.
Demonstration grants. State innovation will be a key driver in
improving the system of coverage for low- and moderate-income children;
Federal support of such efforts would ease financial barriers to States
that aspire to transform their children's coverage systems.
To encourage and support child-focused efforts, the Commission
recommends providing planning and implementation demonstration grants
to develop and test models for transforming coverage systems for
children. Such models could be developed using existing State plan and
waiver authorities, such as those available under sections 1115 and
1332 of the Act. Developing options for a seamless system of affordable
and comprehensive coverage for children across available coverage
sources will require resources for research and analysis of markets,
needs assessments, stakeholder and expert engagement, as well as legal,
regulatory, policy, and cost analyses. These activities are typically
not eligible for Federal match under State plan authority, and in past
efforts to develop and implement health delivery system changes, States
have used waiver authority or other grant funding such as the Real
Choice Systems Change grant program to finance these planning
activities. Historically, State demonstrations have been an effective
way to gain experience from which learning and strategies can be
gleaned for broader take up by States.
Eliminate CHIP waiting periods and premiums for children under 150
percent FPL. While CHIP has been enormously successful in reducing
uninsurance, steps can be taken to promote greater continuity and
seamlessness of coverage within the existing program. MACPAC initially
recommended such steps relating to CHIP waiting periods and premiums in
order to achieve these goals in March 2014, and continues to recommend
them in 2017. There is little evidence showing that waiting periods
have deterred crowd-out of private coverage; eliminating them would
promote more stable coverage for children, simplify and make CHIP
policy more consistent with Medicaid and other publicly finance
coverage programs, and reduce administrative complexity and burden for
families, States, health plans, and providers (MACPAC 2014b).
Eliminating CHIP premiums for families with incomes under 150 percent
FPL would reduce uninsurance and align CHIP premium policies with
Medicaid policies for lower-income children. Compared to higher-income
enrollees, families with incomes below 150 percent FPL are more price
sensitive and less likely to take up CHIP coverage for their children
when a premium is required (MACPAC 2017).
Express Lane Eligibility. The Commission recommends that Congress
permanently extend Express Lane Eligibility (ELE) authority as an
option States can adopt to simplify enrollment processes and promote
continuity of coverage. ELE, currently authorized through September 30,
2017, permits States to rely on findings from another program
designated as an Express Lane agency (e.g., Supplemental Nutrition
Assistance Program, the National School Lunch Program, and Head Start)
when making Medicaid and CHIP eligibility determinations (including
renewals of eligibility).
ELE processes are associated with positive enrollment gains (both
new enrollment and renewals), and administrative savings in some States
(OIG 2016, Hoag et al. 2013). A Federal evaluation indicated that, as
of December 2013, nearly 1.4 million children enrolled in Medicaid or
CHIP and retained coverage through ELE processes. Federal evaluations
have found that some States reported that implementing ELE resulted in
administrative savings. For example, one State reportedly saved $7.3
million between 2011 and 2014, and another State reported that the
Medicaid agency saved $25.77 per initial enrollment and $5.15 per
renewal (OIG 2016).\7\ Without an extension, States that have
implemented this option would be likely to incur additional costs in
reverting to legacy eligibility processes. Should authority for the ELE
option expire, the States that have implemented this option could only
continue to do so under a section 1115 waiver.\8\
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\7\ Savings were the result of reduced staff time to complete
eligibility determinations due to simplified enrollment processes,
according to State reports (OIG 2016).
\8\ As of January 1, 2016, eight States use ELE for children at
Medicaid enrollment, five States use ELE for CHIP enrollment, seven
States use ELE for children at Medicaid renewal, and three States use
ELE for CHIP renewal (KFF 2016).
The Commission also recommends that the HHS Secretary, in
consultation with the Secretaries of the U.S. Department of Agriculture
and the U.S. Department of Education, assess and report to Congress on
the legislative and regulatory modifications needed to permit States to
use Medicaid and CHIP eligibility determination information to
determine eligibility for other designated programs serving children
and families. Given the efficiencies and favorable enrollment gains
associated with ELE as currently implemented, the Commission seeks
information on changes necessary to modify ELE authority so that
designated programs can use Medicaid or CHIP eligibility determination
information, and the potential for reducing administrative burden for
families and States.\9\
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\9\ Specifically, the report should describe the legislative and
regulatory changes necessary to allow designated programs to use
publicly subsidized health program findings to determine eligibility
for other programs. The report should also assess the operational
challenges and technical feasibility of this policy, and evaluate the
implications of broadening ELE authority.
Renewal of other programs. The Commission recommends extending
funding for three programs that focus on improving aspects of coverage
or care for children enrolled in Medicaid or CHIP for 5 years through
FY 2022: Medicaid and CHIP outreach and enrollment grants, the
Childhood Obesity Research Demonstration (CORD) projects, and the
Pediatric Quality Measures Program. In past years, funding for these
---------------------------------------------------------------------------
programs has been renewed alongside CHIP funding.
Outreach and enrollment grants created in 2009 have helped to
support States, tribes, and community-based organizations in a variety
of proactive outreach and enrollment activities. Funds have also
supported a national outreach and enrollment campaign (CMS 2016). These
grants are needed to maintain the historic successes in finding and
enrolling eligible children and in helping them retain coverage at
renewal. Absent such grants, State spending on outreach and enrollment
would be limited by Federal law to the 10 percent cap on CHIP
administrative spending. CHIPRA established this program, appropriating
$100 million for FYs 2009-2013. Funding was most recently renewed under
the Medicare Access and CHIP Reauthorization Act (MACRA, Pub. L. 114-
10) at $40 million for FYs 2016-2017.
CHIPRA also established the Childhood Obesity Research
Demonstration (CORD) to identify and evaluate health care and community
strategies to combat childhood obesity in children age 2-12 enrolled in
or eligible for Medicaid or CHIP (Dooyema et al. 2013). CORD project
grantees are evaluating whether multi-level, multi-setting approaches
that integrate primary care with public health strategies can improve
health behaviors and reduce childhood obesity. The second phase of CORD
grants focuses on preventive services to individual children and
families in Arizona and Massachusetts. Evaluation results which became
available in July 2017 from some of the Phase I demonstrations, show a
statistically significant reduction in child body mass index and
increase in parent satisfaction with obesity related care. Providers
who participated in one demonstration showed improved confidence in
determining child overweight or obesity status, providing counseling,
and setting behavioral goals with families. Most recently, MACRA
extended funding for this effort, at $10 million for FYs 2016-2017.
Continued Federal funding is important to efforts to develop and test
strategies to reduce childhood obesity, as well as disseminating
results.
In 2009, the Centers for Medicare and Medicaid Services (CMS)
developed a core set of children's health care quality measures for
children in Medicaid and CHIP, the first focused effort to measure the
quality of publicly funded children's health care in a consistent way
on a national level. Since 2010, State participation in reporting the
voluntary core set of child health measures has increased; by FY 2014,
all 50 States and the District of Columbia reported at least one
measure (CMS 2016b, CMS 2011). In its initial phase, the Pediatric
Quality Measures Program (PQMP) worked to improve and strengthen the
initial child core set by bringing together experts, to develop and
improve pediatric quality measures (AHRQ 2016, Sebelius 2014). Current
PQMP grantees are assessing the feasibility and usability of the
measures at the State, health plan, and provider levels (AHRQ 2016).
MACRA extended funding of $20 million over FYs 2016 and 2017.
An extension of PQMP funding will allow the Secretary to continue
to develop, test, validate, and disseminate new child health quality
measures, and to continue revising existing measures for children
enrolled in Medicaid and CHIP. In a November 2014 letter to Congress,
MACPAC stated that the needed investments in quality measurement are
relatively small, but that they are important, not only for those whose
care is financed by Medicaid and CHIP but also for taxpayers (MACPAC
2014b). In the letter, MACPAC noted several key areas in which ongoing
work can build on progress to date, including strengthening CMS's
capacity to calculate quality measures for States, improving quality
measures for individuals with disabilities, and expanding the use of
core quality measures in State quality improvement efforts.
Continuation of the PQMP could also support efforts to measure and
improve care provided to children with special health care needs
enrolled in Medicaid and CHIP coverage.
federal budget implications
The Congressional Budget Office (CBO) estimates that these
recommendations would increase net Federal spending by about $18.7
billion above the agency's current law baseline over a 10-year period
of FYs 2017-2026. CBO's estimate also reflects congressional budget
rules that require the agency to assume in its current law spending
baseline that Federal CHIP funding continues beyond FY 2015 at $5.7
billion each year.\10\
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\10\ The Congressional Budget Office (CBO) makes unique assumptions
regarding the future of CHIP, which will affect the projected Federal
cost of legislative proposals it examines. CBO is required to assume
that CHIP and certain other expiring programs continue in perpetuity at
the last appropriated level (2 U.S.C. 907(b)(2)(A)(i)). However, in
order to reduce the long-term Federal spending projected by CBO under
these assumptions, the Children's Health Insurance Program
Reauthorization Act (CHIPRA) was worded so that the last appropriated
level for CBO's purposes was $5.7 billion in FY 2013 rather than the
$17.4 billion actually appropriated for FY 2013. In extending Federal
CHIP funding by 2 years, the ACA continued the use of this language so
that the last appropriated level for CBO's purposes for CHIP past FY
2015 is $5.7 billion rather than $21.1 billion.
conclusion
CHIP has clearly played an important role in providing access to
health-care coverage to low- to moderate-income children who otherwise
would have been uninsured. In addition, CHIP has provided a platform
for State innovations to improve take-up of public coverage among
eligible but uninsured children, remove enrollment barriers, and focus
on the quality of children's care. For example, outreach and enrollment
techniques that often began as experiments in CHIP in individual States
were subsequently identified as best practices and, in some cases, are
now required in all States for both CHIP and Medicaid.
Congress now faces an important decision regarding the future of
CHIP and its approach to providing a stable, affordable, and adequate
source of coverage to millions of low- and moderate income children.
MACPAC's recommendations provide advice on how to ensure a stable
source of affordable and comprehensive coverage for low- and moderate-
income children during a period of uncertainty affecting other health
care markets.
When the Commission made its recommendations in January, it noted
the urgent need for congressional action. With the end of the fiscal
year in sight, the Commission must underscore the need for Congress to
act as soon as possible to extend CHIP so that States do not respond to
uncertainty around CHIP's future by implementing policies that reduce
children's access to needed health-care services.
The Commission's longer-term vision looks to State innovations that
would create a more seamless system of children's coverage, provide
comprehensive and affordable coverage for low- and moderate-income
children, and remove the potential for gaps in coverage and care as
children transition between different sources of publicly and privately
financed health insurance. Such a system would promote greater
alignment between Medicaid, CHIP, and other insurance sources and would
smooth out transitions between them. The recommendations of the
Commission reflect these goals and take steps to provide States and
their Federal partners the tools to transform children's coverage.
Thank you, members of the committee. I would be happy to answer any
questions you may have.
References
Agency for Healthcare Research and Quality (AHRQ). 2016. Pediatric
Quality Measures Program. Rockville, MD: AHRQ. http://www.ahrq.gov/
policymakers/chipra/pqmp.html.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Human Services. 2017a. 2016 number of children ever
enrolled. 2017. https://www.medicaid.gov/chip/downloads/fy-2016-
childrens-enrollment-report.pdf.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Human Services. 2017b. Key dates for calendar year 2017:
Qualified health plan certification in the federally-facilitated
exchanges; rate review; risk adjustment, reinsurance and risk
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Regulations-and-Guidance/Downloads/Final-Revised-Key-Dates-for-Calend
ar-Year-2017-4-13-17.pdf.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Humans Services. 2016. Connecting kids to coverage outreach
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www.insurekidsnow.gov/initiatives/connecting-kids/funding/history/
index.html.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
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care for Children in Medicaid and CHIP. Baltimore, MD: CMS. https://
www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-
rept.pdf.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Human Services. 2015. Certification of comparability of
pediatric coverage offered by qualified health plans. November 25,
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comparability-of-pediatric-coverage-offered-by-qualified-
health-plans.pdf.
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Human Services. 2011. Children's Health Insurance Program
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children in Medicaid and CHIP. Baltimore, MD: CMS. https://
www.medicaid.gov/medicaid/quality-of-care/downloads/
2011_statereporttocongress.pdf.
Dooyema, C., B. Belay, J. Foltz, et al. 2013. ``The Childhood Obesity
Research Demonstration Project: A comprehensive community approach to
reduce childhood obesity.'' Childhood Obesity 9, no. 5: 454-459.
Hensley-Quinn, M. and C. Hess. 2013. How CHIP can help meet child
specific requirements and needs in the exchange: Considerations for
policymakers. Washington, DC: National Academy for State Health Policy.
https://nashp.org/?s=How+CHIP
+can+help+meet+child+specific+requirements&category_name=.
Hoag, S., M. Harrington, C. Orfield, et al. 2011. Children's Health
Insurance Program: An evaluation (1997-2010). Interim report to
Congress. Ann Arbor, MI: Mathematica Policy Research. http://
aspe.hhs.gov/health/reports/2012/chipra-irtc/index.pdf.
Kaiser Family Foundation (KFF). 2016. State adoption of Express Lane
Eligibility for children's Medicaid and CHIP at enrollment and renewal.
http://kff.org/health-reform/state-indicator/state-adoption-of-express-
lane-eligibility-for-childrens-medicaid-and-chip-at-enrollment-and-
renewal/?currentTimeframe=0&sortModel=%7B
%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
Martinez, M.E, E.P Zammitti, and R.A. Cohen. 2017. Health insurance
coverage: Early release of estimates from the National Health Interview
Survey, January-
September 2016. Hyattsville, MD: National Center for Health Statistics.
https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2017a. Report
to the Congress on Medicaid and CHIP. March 2017. Washington, DC:
MACPAC. https://www.macpac.gov/publication/march-2017-report-to-
congress-on-medicaid-and-chip/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2017b.
Federal CHIP Funding: When Will States Exhaust Allotments? March 2017.
Washington, DC: MACPAC. https://www.macpac.gov/publication/federal-
chip-funding-when-will-states-exhaust-allotments/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2016.
``Chapter 5: Design considerations for the future of children's
coverage: Focus on affordability.'' In Report to Congress on Medicaid
and CHIP. March 2016. Washington, DC: MACPAC. https://www.macpac.gov/
publication/design-considerations-for-the-future-of-childrens-coverage-
focus-on-affordability-2/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2015. Report
to the Congress on Medicaid and CHIP. March 2015. Washington, DC:
MACPAC. https://www.macpac.gov/publication/march-2015-report-to-
congress-on-medicaid-and-chip/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2014a. Report
to the Congress on Medicaid and CHIP. June 2014. Washington, DC:
MACPAC. https://www.macpac.gov/publication/ch-1-chip-and-the-new-
coverage-landscape/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2014b. Report
to the Congress on Medicaid and CHIP. March 2014. Washington, DC:
MACPAC. https://www.macpac.gov/publication/report-to-the-congress-on-
medicaid-and-chip-314/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2014c. Letter
to Secretary of the U.S. Department of Health and Human Services and
Congress regarding ``Adult and Children's Health Care Quality Reports
to the Congress,'' November 2014. Washington, DC: MACPAC. https://
www.macpac.gov/wp-content/uploads/2015/01/MACPAC-comments-on-HHS-
quality-reports-to-Congress.pdf.
National Academy for State Health Policy (NASHP). 2017. 2017 CHIP
directors survey results. February 2017. Washington, DC: NASHP. http://
nashp.org/wp-content/uploads/2017/02/2017-CHIP-Survey-Results.pdf.
Office of the Inspector General (OIG), U.S. Department of Health and
Human Services. 2016. State use of Express Lane Eligibility for
Medicaid and CHIP enrollment. Washington, DC: OIG. https://oig.hhs.gov/
oei/reports/oei-06-15-00410.pdf.
Sebelius, K. 2014. HHS Secretary's efforts to improve children's health
care quality in Medicaid and CHIP. Washington, DC: U.S. Department of
Health and Human Services. https://www.medicaid.gov/medicaid/quality-
of-care/downloads/2014-childrens-report-to-congress.pdf.
APPENDIX A: ELIGIBILITY AND ENROLLMENT
Table A-1. CHIP Eligibility Levels (2016) and Enrollment (FY 2015) by State
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Children in Medicaid-Expansion CHIP \1\ Children in separate CHIP
------------------------------------------------------------------------------------------------------------------------------------------------
Program type \1\ Separate CHIP: Age 0-18 \2\ Separate CHIP: Unborn Total Total CHIP-
State (as of July 1, Infants <1 Age 1-5 (% Age 6-18 --------------------------------------------------------------------------------- separate funded child
2016) (% FPL) FPL) (% FPL) Enrollment Infants <1 Age 1-5 (% Age 6-18 (% CHIP enrollment \4\
(% FPL) FPL) FPL) Enrollment Eligibility \3\ Enrollment enrollment
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Total - - - - 4,702,185 - - - 3,362,642 - 327,175 3,689,817 8,397,651
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama Combination - - 107-141 45,697 142-312 142-312 142-312 87,346 - - 87,346 133,043
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alaska Medicaid 159-203 159-203 124-203 10,182 - - - - - - - 10,182
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Arizona \5\ Combination - - 104-133 37,412 148-200 142-200 134-200 1,399 - - 1,399 38,811
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Arkansas Combination - - 107-142 108,706 143-211 143-211 143-211 - \6\ 209 3,365 3,365 112,071
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
California \7\ Combination 208-261 142-261 108-261 1,787,470 262-317 262-317 262-317 2,461 317 122,197 124,658 1,912,128
, \8\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Colorado Combination - - 108-142 23,687 143-260 143-260 143-260 62,446 - - 62,446 86,133
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Connecticut Separate - - - - 197-318 197-318 197-318 24,884 - - 24,884 24,884
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Delaware Combination 194-212 - 110-133 238 - \9\ 143-212 \9\ 134-212 \9\ 16,141 - - 16,141 16,379
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
District of Medicaid 206-319 146-319 112-319 10,676 - - - - - - - 10,676
Columbia expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Florida Combination 192-206 - 112-133 134,708 - \9\ 141-210 \9\ 134-210 \9\ 293,386 - - 293,386 428,094
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Georgia Combination - - 113-133 53,906 206-247 150-247 134-247 176,909 - - 176,909 230,815
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Hawaii Medicaid 191-308 139-308 105-308 27,239 - - - - - - - 27,239
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Idaho Combination - - 107-133 8,937 143-185 143-185 134-185 25,576 - - 25,576 34,513
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Illinois Combination - - 108-142 113,105 143-313 143-313 143-313 191,328 208 26,138 217,466 330,571
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Indiana Combination 157-208 141-158 106-158 69,462 209-250 159-250 159-250 31,098 - - 31,098 100,560
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Iowa Combination 240-375 - 122-167 21,777 - \9\ 168-302 \9\ 168-302 \9\ 60,880 - - 60,880 82,657
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kansas Combination - - 113-133 54 167-238 150-238 134-238 77,085 - - 77,085 77,139
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kentucky Combination - 142-159 109-159 50,926 196-213 160-213 160-213 36,050 - - 36,050 86,976
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Louisiana Combination 142-212 142-212 108-212 122,878 213-250 213-250 213-250 3,498 209 9,238 12,736 135,614
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Maine Combination - 140-157 132-157 13,440 192-208 158-208 158-208 8,870 - - 8,870 22,310
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Maryland Medicaid 194-317 138-317 109-317 142,327 - - - - - - - 142,327
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Massachusetts Combination 185-200 133-150 114-150 79,299 201-300 151-300 151-300 76,519 200 13,123 89,642 168,941
\10\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Michigan \11\ Combination 195-212 143-212 109-212 29,226 - - - 85,302 195 5,171 90,473 119,699
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Minnesota Combination 275-283 \12 - - 474 - - - - 278 3,361 3,361 3,835
\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mississippi Combination - - 107-133 30,819 205-209 144-209 134-209 56,286 - - 56,286 87,105
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Missouri Combination - 148-150 110-150 38,600 197-300 151-300 151-300 39,744 300 - \13\ 39,744 78,344
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Montana Combination - - 109-143 16,008 144-261 144-261 144-261 29,253 - - 29,253 45,261
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Nebraska Combination 162-213 145-213 109-213 55,515 - - - 4,613 \14\ 197 2,090 6,703 62,218
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Nevada Combination - - 122-133 17,763 161-200 161-200 134-200 44,145 - - 44,145 61,908
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Hampshire Medicaid 196-318 196-318 196-318 16,651 - - - - - - - 16,651
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Jersey Combination - - 107-142 100,826 195-350 143-350 143-350 114,365 - - 114,365 215,191
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New Mexico Medicaid 200-300 200-300 138-240 17,155 - - - 40 \14\ - - 40 17,195
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
New York Combination - - 110-149 235,945 219-400 150-400 150-400 394,787 - - 394,787 630,732
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
North Carolina Combination 194-210 141-210 107-133 134,413 - - 138-211 100,237 - 4 \15\ 100,241 234,654
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
North Dakota Combination - - 111-133 - 148-170 148-170 134-170 4,955 - - 4,955 4,955
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ohio Medicaid 141-206 141-206 107-206 181,100 - - - - - - - 181,100
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Oklahoma Combination 169-205 151-205 115-205 174,167 - - - 208 \16\ 205 16,483 16,691 190,858
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Oregon \17\ Combination 133-185 - 100-133 - 186-300 134-300 134-300 115,726 185 6,143 121,869 121,869
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Pennsylvania Combination - - 119-133 64,638 216-314 158-314 134-314 229,704 - - 229,704 294,342
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Rhode Island Combination 190-261 142-261 109-261 29,948 - - - 1,376 \14\ 253 - \18\ 1,376 31,324
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
South Carolina Medicaid 194-208 143-208 107-208 98,336 - - - - - - - 98,336
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
South Dakota Combination 177-182 177-182 124-182 12,441 183-204 183-204 183-204 3,775 - - 3,775 16,216
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Tennessee \19\ Combination - - 109-133 17,971 196-250 143-250 134-250 78,731 250 9,513 88,244 106,215
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Texas Combination - - 109-133 336,769 199-201 145-201 133-201 614,417 202 98,437 712,854 1,049,623
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Utah Combination - - 105-133 27,762 145-200 145-200 139-200 27,523 - - 27,523 55,285
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Vermont Medicaid 237-312 237-312 237-312 4,766 - - - - - - - 4,766
expansion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Virginia Combination - - 109-143 86,551 144-200 144-200 144-200 102,815 - - 102,815 189,366
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Washington Separate - - - - 211-312 211-312 211-312 37,883 193 8,154 46,037 46,037
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
West Virginia Combination - - 108-133 15,242 159-300 142-300 134-300 33,036 - - 33,036 48,278
\20\
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Wisconsin Combination - - 101-151 96,973 - \9\ 187-301 \9\ 152-301 \9\ 67,845 301 3,758 71,603 168,576
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Wyoming \21\ Combination - - 119-133 - \22\ 155-200 155-200 134-200 - \22\ - - - \22\ 5,649
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Notes: FY is fiscal year. FPL is Federal poverty level. Enrollment numbers generally include individuals ever enrolled during the year, even if for a single month; however, in the event
individuals were in multiple categories during the year (for example, in Medicaid for the first half of the year but separate CHIP for the second half), the individual would only be counted
in the most recent category. Enrollment data shown in the table are as of July 2016, the most current enrollment data available; States may subsequently revise their current or historical
data.
-99Dash indicates that State does not use this eligibility pathway.
\1\ Under CHIP, States have the option to use an expansion of Medicaid, separate CHIP, or a combination of both approaches. Ten States (including the District of Columbia) are Medicaid
expansions and two States are separate CHIP only (Connecticut and Washington). There are combination programs in 39 States; among those, 11 consider themselves to have separate programs but
are technically combinations due to the transition of children below 133 percent FPL from separate CHIP to Medicaid (Alabama, Arizona, Georgia, Kansas, Mississippi, Oregon, Pennsylvania,
Texas, Utah, West Virginia, Wyoming). Medicaid-expansion CHIP eligibility ranges of 5 percentage points attributable to the mandatory 5 percent disregard are not shown. For States that have
different CHIP-funded eligibility levels for children age 6-13 and age 14-18, this table shows only the levels for children age 6-13. For example, Oklahoma offers CHIP-funded Medicaid
coverage to children age 6-14 with family income 115-205 percent FPL, and to 14- to 18-year-olds with family income 65-205 percent FPL. Tennessee offers CHIP-funded Medicaid coverage to
children age 6-14 with family income from 109-133 percent FPL and 14-19 year olds with family income 29-133 percent FPL.
\2\ CHIP eligibility levels as of July 2016.
\3\ Separate CHIP eligibility for children birth through age 18 generally begins where Medicaid coverage ends (as shown in the previous columns). For unborn children, there is no lower bound
for income eligibility if the mother is not eligible for Medicaid.
\4\ Total exceeds the sum of Medicaid expansion and separate CHIP columns due to only total CHIP enrollment being reported for Wyoming.
\5\ Arizona closed separate CHIP (KidsCare) to new enrollment in January 2010. The State reinstated the program on September 1, 2016.
\6\ Although Arkansas transitioned its Medicaid-expansion CHIP to separate CHIP effective January 1, 2015, the State continued to report enrollment for children age 0-18 years under Medicaid-
expansion CHIP.
\7\ California has separate CHIP in three counties only that covers children up to 317 percent FPL.
\8\ Due to reporting system updates, California CHIP enrollment totals are estimates as a result of the exclusion of certain unborn CHIP enrollees in reporting.
\9\ Separate CHIP in Delaware, Florida, Iowa, and Wisconsin covers children age 1-18.
\10\ Certain enrollees who should have been assigned to CHIP were assigned to Medicaid beginning in the second quarter of 2014, making FY 2015 totals artificially low.
\11\ CHIP-funded Medicaid Michigan enrollees are included in Medicaid enrollment counts rather than in CHIP for FY 2015. Therefore, the CHIP enrollment totals are artificially low and the
Medicaid enrollment totals are artificially high. Michigan transitioned its separate CHIP into Medicaid-expansion CHIP effective January 1, 2016.
\12\ In Minnesota, only infants (defined by the State as being under age two) are eligible for Medicaid-expansion CHIP up to 283 percent FPL.
\13\ Missouri began covering unborn children effective January 1, 2016, however the State has not reported enrollment for this coverage group.
\14\ Separate CHIP enrollment figures in Nebraska, New Mexico, and Rhode Island are for the States' Sec. 2101(f) coverage group under the Patient Protection and Affordable Care Act. Section
2101(f) required that States provide separate CHIP coverage to children to who lost Medicaid eligibility (including through Medicaid-expansion CHIP) due to the elimination of income
disregards under the modified adjusted gross income (MAGI) based methodologies. Children covered under Sec. 2101(f) remained eligible for such coverage until their next scheduled renewal or
their 19th birthday, or until they moved out of State, requested removal from the program, or were deceased. Coverage under Sec. 2101(f) has now been phased out.
\15\ North Carolina does not provide unborn children separate CHIP coverage. Errors in enrollment data reported are likely due to data quality issues.
\16\ Separate CHIP enrollment in Oklahoma is for children enrolled in the State's premium assistance program.
\17\ Certain Oregon enrollees who should have been assigned to CHIP were assigned to Medicaid-funded coverage for FY 2014 and FY 2015.
\18\ Lack of enrollment for separate CHIP unborn coverage in Rhode Island is likely due to data quality issues.
\19\ While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for children who roll over from traditional Medicaid.
\20\ West Virginia's enrollment totals are artificially high because children who transitioned between CHIP and Medicaid are reported in both programs, rather than the program they were last
enrolled.
\21\ CMS's FY 2015 children's enrollment report considers these values to be estimates.
\22\ Due to inconsistencies between the Statistical Enrollment Data System data and the Centers for Medicare and Medicaid Services' FY 2015 children's enrollment report, we do not report
enrollment for Medicaid expansion and separate CHIP. We only report total CHIP enrollment as provided in CMS's FY 2015 children's enrollment report.
Sources: Personal communication with CMS staff on December 2, 2016 and December 9, 2016. For numbers of children: MACPAC, 2016, analysis of CHIP Statistical Enrollment Data System from Centers
for Medicare and Medicaid Service as of July 1, 2016; MACPAC, 2016, MACStats: Medicaid and CHIP Data Book, December 2016, Washington, DC: MACPAC, https://www.macpac.gov/publication/child-
enrollment-in-chip-and-medicaid-by-state/. For eligibility levels: MACPAC, 2016, MACStats: Medicaid and CHIP Data Book, December 2016, Washington, DC: MACPAC, https://www.macpac.gov/
publication/medicaid-and-chip-income-eligibility-levels-as-a-percentage-of-the-federal-poverty-level-for-children-and-pregnant-women-by-state/.
APPENDIX B: CHIP ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES
Table B-1. CHIP Enhanced Federal Medical Assistance Percentages by
State, FYs 2013-2017
------------------------------------------------------------------------
E-FMAPs for CHIP
-----------------------------------
State FY 2015 FY 2016 FY 2017
\1\ \2\ \2\
------------------------------------------------------------------------
All States (median) 70.8% 93.8% 94.0%
------------------------------------------------------------------------
Alabama 78.3 100.0 100.0
------------------------------------------------------------------------
Alaska 65.0 88.0 88.0
------------------------------------------------------------------------
Arizona 77.9 100.0 100.0
------------------------------------------------------------------------
Arkansas 79.6 100.0 100.0
------------------------------------------------------------------------
California 65.0 88.0 88.0
------------------------------------------------------------------------
Colorado 65.7 88.5 88.0
------------------------------------------------------------------------
Connecticut 65.0 88.0 88.0
------------------------------------------------------------------------
Delaware 67.5 91.4 90.9
------------------------------------------------------------------------
District of Columbia 79.0 100.0 100.0
------------------------------------------------------------------------
Florida 71.8 95.5 95.8
------------------------------------------------------------------------
Georgia 76.9 100.0 100.0
------------------------------------------------------------------------
Hawaii 66.6 90.8 91.5
------------------------------------------------------------------------
Idaho 80.2 100.0 100.0
------------------------------------------------------------------------
Illinois 65.5 88.6 88.9
------------------------------------------------------------------------
Indiana 76.6 99.6 99.7
------------------------------------------------------------------------
Iowa 68.9 91.4 92.7
------------------------------------------------------------------------
Kansas 69.6 92.2 92.4
------------------------------------------------------------------------
Kentucky 79.0 100.0 100.0
------------------------------------------------------------------------
Louisiana 73.4 96.6 96.6
------------------------------------------------------------------------
Maine 73.3 96.9 98.1
------------------------------------------------------------------------
Maryland 65.0 88.0 88.0
------------------------------------------------------------------------
Massachusetts 65.0 88.0 88.0
------------------------------------------------------------------------
Michigan 75.9 98.9 98.6
------------------------------------------------------------------------
Minnesota 65.0 88.0 88.0
------------------------------------------------------------------------
Mississippi 81.5 100.0 100.0
------------------------------------------------------------------------
Missouri 74.4 97.3 97.3
------------------------------------------------------------------------
Montana 76.1 98.7 98.9
------------------------------------------------------------------------
Nebraska 67.3 88.8 89.3
------------------------------------------------------------------------
Nevada 75.1 98.5 98.3
------------------------------------------------------------------------
New Hampshire 65.0 88.0 88.0
------------------------------------------------------------------------
New Jersey 65.0 88.0 88.0
------------------------------------------------------------------------
New Mexico 78.8 100.0 100.0
------------------------------------------------------------------------
New York 65.0 88.0 88.0
------------------------------------------------------------------------
North Carolina 76.1 99.4 99.8
------------------------------------------------------------------------
North Dakota 65.0 88.0 88.0
------------------------------------------------------------------------
Ohio 73.9 96.7 96.6
------------------------------------------------------------------------
Oklahoma 73.6 95.7 95.0
------------------------------------------------------------------------
Oregon 74.8 98.1 98.1
------------------------------------------------------------------------
Pennsylvania 66.3 89.4 89.3
------------------------------------------------------------------------
Rhode Island 65.0 88.3 88.7
------------------------------------------------------------------------
South Carolina 79.5 100.0 100.0
------------------------------------------------------------------------
South Dakota 66.2 89.1 91.5
------------------------------------------------------------------------
Tennessee 75.5 98.5 98.5
------------------------------------------------------------------------
Texas 70.6 93.0 92.3
------------------------------------------------------------------------
Utah 79.4 100.0 100.0
------------------------------------------------------------------------
Vermont 67.8 90.7 91.1
------------------------------------------------------------------------
Virginia 65.0 88.0 88.0
------------------------------------------------------------------------
Washington 65.0 88.0 88.0
------------------------------------------------------------------------
West Virginia 80.0 100.0 100.0
------------------------------------------------------------------------
Wisconsin 70.8 93.8 94.0
------------------------------------------------------------------------
Wyoming 65.0 88.0 88.0
------------------------------------------------------------------------
Notes: FY is fiscal year. FMAP is Federal medical assistance percentage.
E-FMAP is enhanced FMAP. ACA is the Patient Protection and Affordable
Care Act (ACA, Pub. L. 111-148, as amended). The E-FMAP determines the
Federal share of both service and administrative costs for CHIP,
subject to the availability of funds from a State's Federal allotments
for CHIP.
Enhanced FMAPs for CHIP are calculated by reducing the State share under
regular FMAPs for Medicaid by 30 percent. In FYs 2016 through 2019,
the E-FMAPs are increased by 23 percentage points. For additional
information on Medicaid FMAPs, see https://www.macpac.gov/subtopic/
matching-rates/.
E-FMAPs for the territories are not included. In FY 2015, all
territories had an E-FMAP of 68.5 percent, and in FY 2016 and 2017,
91.5 percent.
\1\ In FY 2015, States received the traditional CHIP E-FMAP.
\2\ Under the ACA, beginning on October 1, 2015, and ending on September
30, 2019, the enhanced FMAPs are increased by 23 percentage points,
not to exceed 100 percent, for all States.
Sources: Assistant Secretary for Planning and Evaluation (ASPE), U.S.
Department of Health and Human Services, ASPE FMAP reports for 2015,
2016, and 2017, https://aspe.hhs.gov/basic-report/fy2017-federal-
medical-assistance-percentages (for FY 2017), http://aspe.hhs.gov/
health/reports/2015/FMAP2016/fmap16.cfm (for FY 2016), http://
aspe.hhs.gov/health/reports/2014/FMAP2015/fmap15.pdf (for FY 2015).
appendix c: federal chip funding: when will states exhaust allotments?
Issue Brief
_______________________________________________________________________
July 2017 Advising Congress on Medicaid and CHIP
Policy
_______________________________________________________________________
federal chip funding: when will states exhaust allotments?
Under current law, Federal funds for the State Children's Health
Insurance Program (CHIP) are only provided through fiscal year (FY)
2017. Unless CHIP funding is extended, all States are expected to
exhaust their Federal CHIP funds during FY 2018; this includes unspent
CHIP funding from prior years. Three States and the District of
Columbia are projected to exhaust their funds by December 2017. Most
States (31 States and the District of Columbia) are projected to
exhaust Federal CHIP funds by March 2018. These estimates are based on
States' projections of their CHIP spending for FYs 2017 and 2018.\1\
How quickly States deplete CHIP funds could change if actual CHIP
spending is above or below projections.
---------------------------------------------------------------------------
\1\ States report their anticipated expenditures for both Medicaid
and CHIP to the Centers for Medicare and Medicaid Services on a
quarterly basis. The data used for this issue brief reflect quarterly
projections provided by States in May 2017. MACPAC previously issued
this data in March 2017 using States' budget projections submitted in
February 2017.
This issue brief updates data on the exhaustion of CHIP funds
presented in a March 2017 issue brief and with MACPAC's January 2017
Recommendations for the Future of CHIP and Children's Coverage. With
the end of FY 2017 approaching, congressional action to renew CHIP
funding is urgent to ensure the stability of children's coverage during
a time in which health insurance markets are expected to face
substantial changes, and to provide budgetary certainty for States. If
CHIP funding is not renewed, States will need to make decisions
including whether to end separate CHIP, how to finance Medicaid-
expansion CHIP with reduced Federal spending, and how to provide
information to families, providers, and plans (Hensley-Quinn and King
2016).
federal chip funding and its exhaustion under current law
Federal CHIP funds are allotted to States annually based on each
State's recent CHIP spending, increased by a growth factor. States have
2 years to spend their allotments, and unspent allotments are available
for redistribution to other States experiencing CHIP funding
shortfalls. Under current law, new CHIP allotments are not available
after FY 2017 and unspent FY 2017 CHIP allotments that remain available
for expenditures in FY 2018 are reduced by one-third
(Sec. 2104(m)(2)(B)(iv) of the Social Security Act (the Act)).
States experiencing CHIP funding shortfalls can also receive
contingency fund payments if their CHIP enrollment exceeds target
levels specified in section 2105(n) of the Act. However, contingency
fund payments are not available for FY 2018 and subsequent years.
CHIP funding in FY 2017
The Federal CHIP funding that States have received for FY 2017 and
the redistribution funding that is available from prior year allotments
is projected to be adequate to cover projected spending in FY 2017. Two
States (Arizona and Minnesota) are projected to have CHIP spending that
exceeds their FY 2017 allotment, but these States are expected to
receive redistribution funds in FY 2017 sufficient to cover their
projected CHIP funding shortfall. Approximately $3 billion in
redistribution funding is available in FY 2017 (CMS 2017).
CHIP funding in FY 2018
Under current law, in FY 2018, States may continue to spend unspent
FY 2017 allotments and redistribution funds from prior years. These
funds will cover some but not all expected State CHIP expenses in FY
2018. By the second quarter of FY 2018, more than half of States are
projected to exhaust all available Federal CHIP funding, including
redistribution funds (Table 1).
Table 1. Projected Exhaustion of Federal CHIP Funds in Fiscal Year 2018
------------------------------------------------------------------------
Quarter of fiscal Number of
year States States
------------------------------------------------------------------------
First quarter 4 Arizona, District of Columbia,
(October-December Minnesota, and North Carolina
2017)
------------------------------------------------------------------------
Second quarter 27 Alaska, Arkansas, California,
(January-March 2018) Colorado, Connecticut, Delaware,
Florida, Hawaii, Idaho, Kansas,
Kentucky, Louisiana, Massachusetts,
Mississippi, Missouri, Montana,
Nevada, New York, Ohio, Oregon,
Pennsylvania, Rhode Island, South
Dakota, Utah, Vermont, Virginia,
and Washington
------------------------------------------------------------------------
Third quarter 19 Alabama, Georgia, Illinois, Indiana,
(April-June 2018) Iowa, Maine, Michigan, Maryland,
Nebraska, New Hampshire, New
Jersey, New Mexico, North Dakota,
Oklahoma, South Carolina,
Tennessee, Texas, West Virginia,
and Wisconsin
------------------------------------------------------------------------
Fourth quarter 1 Wyoming
(July-September
2018)
------------------------------------------------------------------------
Note: CHIP is the State Children's Health Insurance Program.
Source: MACPAC 2017 analysis using June 2017 Medicaid and CHIP Budget
and Expenditure System data from the Centers for Medicare and Medicaid
Services, including quarterly projections provided by States in May
2017.
An estimated $4.2 billion in unspent FY 2017 allotments will be
available for spending in FY 2018. Total projected FY 2018 Federal CHIP
spending for States and territories is $17.4 billion. States will
exhaust their Federal CHIP funds at different points during FY 2018
depending on their rollover balances from prior year allotments and
projected spending (Table 2).
Table 2. Projected Federal CHIP Funding and Spending in FY 2018, by State (millions)
----------------------------------------------------------------------------------------------------------------
Unspent FY FY 2018 Total FY
Estimated 2017 projected 2018 FY 2018
unspent FY allotments redistribution projected projected Month projected to
State 2017 available funding from CHIP Federal exhaust CHIP funding
allotments in FY 2018 prior year funding D = CHIP F
A B = A .67 allotments C B + C spending E
----------------------------------------------------------------------------------------------------------------
Total $6,346.2 $4,230.8 $2,949.4 $7,180.2 $17,372.4 N/A
----------------------------------------------------------------------------------------------------------------
Alabama 176.9 118.0 37.4 155.3 284.4 April 2018
----------------------------------------------------------------------------------------------------------------
Alaska 17.8 11.8 5.4 17.2 35.7 March 2018
----------------------------------------------------------------------------------------------------------------
Arizona 0.0 0.0 60.1 60.1 267.9 December 2017
----------------------------------------------------------------------------------------------------------------
Arkansas 96.3 64.2 28.7 92.9 191.9 March 2018
----------------------------------------------------------------------------------------------------------------
California 192.2 128.1 710.0 838.1 3,291.4 January 2018
----------------------------------------------------------------------------------------------------------------
Colorado 87.5 58.3 55.1 113.4 303.7 February 2018
----------------------------------------------------------------------------------------------------------------
Connecticut 24.3 16.2 14.3 30.5 79.9 February 2018
----------------------------------------------------------------------------------------------------------------
Delaware 10.6 7.1 6.3 13.4 35.2 February 2018
----------------------------------------------------------------------------------------------------------------
District of Columbia 1.6 1.1 10.9 11.9 49.4 December 2017
----------------------------------------------------------------------------------------------------------------
Florida 135.7 90.5 204.6 295.1 1,002.2 January 2018
----------------------------------------------------------------------------------------------------------------
Georgia 220.6 147.1 56.6 203.6 399.1 April 2018
----------------------------------------------------------------------------------------------------------------
Hawaii 17.4 11.6 8.2 19.8 48.1 February 2018
----------------------------------------------------------------------------------------------------------------
Idaho 22.2 14.8 15.4 30.2 83.4 February 2018
----------------------------------------------------------------------------------------------------------------
Illinois 349.1 232.7 36.6 269.3 395.7 June 2018
----------------------------------------------------------------------------------------------------------------
Indiana 144.8 96.5 19.9 116.4 185.2 May 2018
----------------------------------------------------------------------------------------------------------------
Iowa 75.8 50.6 19.4 70.0 137.2 April 2018
----------------------------------------------------------------------------------------------------------------
Kansas 47.7 31.8 15.9 47.7 102.8 March 2018
----------------------------------------------------------------------------------------------------------------
Kentucky 87.7 58.4 40.7 99.2 240.0 February 2018
----------------------------------------------------------------------------------------------------------------
Louisiana 134.1 89.4 58.5 147.9 350.0 March 2018
----------------------------------------------------------------------------------------------------------------
Maine 29.3 19.5 3.3 22.8 34.1 June 2018
----------------------------------------------------------------------------------------------------------------
Maryland 187.6 125.1 35.0 160.1 281.0 April 2018
----------------------------------------------------------------------------------------------------------------
Massachusetts 168.4 112.3 117.0 229.3 633.7 February 2018
----------------------------------------------------------------------------------------------------------------
Michigan 264.8 176.5 31.3 207.9 316.2 May 2018
----------------------------------------------------------------------------------------------------------------
Minnesota 0.0 0.0 38.8 38.8 172.9 December 2017
----------------------------------------------------------------------------------------------------------------
Mississippi 147.7 98.5 41.3 139.8 282.5 March 2018
----------------------------------------------------------------------------------------------------------------
Missouri 118.6 79.1 32.8 111.8 225.0 March 2018
----------------------------------------------------------------------------------------------------------------
Montana 31.8 21.2 18.4 39.6 103.2 February 2018
----------------------------------------------------------------------------------------------------------------
Nebraska 61.1 40.7 6.8 47.5 70.9 June 2018
----------------------------------------------------------------------------------------------------------------
Nevada 16.5 11.0 15.2 26.2 78.6 January 2018
----------------------------------------------------------------------------------------------------------------
New Hampshire 19.9 13.3 4.5 17.8 33.4 April 2018
----------------------------------------------------------------------------------------------------------------
New Jersey 337.1 224.7 59.7 284.4 490.7 April 2018
----------------------------------------------------------------------------------------------------------------
New Mexico 95.7 63.8 10.8 74.6 112.0 May 2018
----------------------------------------------------------------------------------------------------------------
New York 527.3 351.6 197.1 548.6 1,229.8 March 2018
----------------------------------------------------------------------------------------------------------------
North Carolina 12.2 8.2 182.9 191.1 823.2 December 2017
----------------------------------------------------------------------------------------------------------------
North Dakota 16.6 11.1 2.3 13.3 21.2 May 2018
----------------------------------------------------------------------------------------------------------------
Ohio 200.1 133.4 70.1 203.5 445.6 March 2018
----------------------------------------------------------------------------------------------------------------
Oklahoma 127.5 85.0 30.4 115.4 220.6 April 2018
----------------------------------------------------------------------------------------------------------------
Oregon 48.6 32.4 52.5 84.9 266.3 January 2018
----------------------------------------------------------------------------------------------------------------
Pennsylvania 193.6 129.1 114.1 243.2 637.6 February 2018
----------------------------------------------------------------------------------------------------------------
Rhode Island 11.1 7.4 15.4 22.8 76.1 January 2018
----------------------------------------------------------------------------------------------------------------
South Carolina 127.5 85.0 15.5 100.5 154.2 May 2018
----------------------------------------------------------------------------------------------------------------
South Dakota 16.2 10.8 4.5 15.3 30.9 March 2018
----------------------------------------------------------------------------------------------------------------
Tennessee 202.2 134.8 30.1 164.9 268.8 May 2018
----------------------------------------------------------------------------------------------------------------
Texas 1,074.5 716.4 204.6 921.0 1,628.0 April 2018
----------------------------------------------------------------------------------------------------------------
Utah 30.0 20.0 28.2 48.2 145.6 January 2018
----------------------------------------------------------------------------------------------------------------
Vermont 5.6 3.7 5.5 9.2 28.1 January 2018
----------------------------------------------------------------------------------------------------------------
Virginia 127.5 85.0 51.0 136.0 312.3 March 2018
----------------------------------------------------------------------------------------------------------------
Washington 42.1 28.0 49.0 77.1 246.6 January 2018
----------------------------------------------------------------------------------------------------------------
West Virginia 43.8 29.2 8.9 38.0 68.6 April 2018
----------------------------------------------------------------------------------------------------------------
Wisconsin 127.3 84.9 31.8 116.7 226.7 April 2018
----------------------------------------------------------------------------------------------------------------
Wyoming 12.2 8.1 0.8 8.9 11.5 July 2018
----------------------------------------------------------------------------------------------------------------
Notes: FY is fiscal year. CHIP is the State Children's Health Insurance Program. Total dollars include
territories. Under current law, available unspent FY 2017 CHIP allotments are reduced by one-third in FY 2018.
Projected redistribution funding is distributed proportionally among States based on their projected CHIP
funding shortfalls for FY 2018 and the amount of unspent CHIP funding available from prior years.
Source: MACPAC 2017 analysis as of June 2017 of Medicaid and CHIP Budget Expenditure System data from the
Centers for Medicare and Medicaid Services, including quarterly projections provided by States in May 2017.
implications
The exhaustion of CHIP funding in FY 2018 will affect State budgets
and will require States to make decisions about children's coverage
depending on the type of CHIP program States had in place in March
2010.\2\ Under the maintenance of effort requirement in the Patient
Protection and Affordable Care Act (Pub. L. 111-148, as amended),
States must maintain 2010 Medicaid and CHIP eligibility levels for
children through FY 2019.
---------------------------------------------------------------------------
\2\ States have the flexibility to structure CHIP as an expansion
of Medicaid, as a program entirely separate from Medicaid, or as a
combination of both approaches.
States with separate CHIP are permitted to terminate that coverage
if Federal CHIP funding runs out; States with Medicaid-expansion CHIP
must continue that coverage for children at the lower Federal Medicaid
matching rate. As of January 2016, 10 States (including the District of
Columbia) ran CHIP as a Medicaid expansion, 2 States had separate CHIP,
and 39 States operated a combination of both approaches (Table 3,
MACPAC 2017).
separate chip
Of the 8.4 million children enrolled in CHIP-funded coverage during
FY 2015, 43.9 percent (3.7 million) were enrolled in separate CHIP.
Once Federal CHIP funding is exhausted, States are not obligated to
continue covering these children. In the absence of separate CHIP
coverage, some of these children would be eligible for
employer-sponsored insurance or subsidized exchange coverage. MACPAC's
prior estimates indicated that 1.1 million children would become
uninsured (MACPAC 2015).\3\ States that elect to shut down CHIP in the
absence of Federal funding will bear little direct cost for children
they formerly covered whether they move to
employer-sponsored or subsidized exchange coverage, or become
uninsured.
---------------------------------------------------------------------------
\3\ If CHIP funding were exhausted, unborn children enrolled
through separate CHIP in 15 States could not be moved into Medicaid
under current law and regulations.
---------------------------------------------------------------------------
medicaid-expansion chip
In FY 2015, 4.7 million children were enrolled in Medicaid-
expansion CHIP. If CHIP funding is exhausted, the Federal matching rate
for these children falls back from the CHIP enhanced match to the
regular Medicaid matching rate.\4\ Although States are generally
prohibited from reducing eligibility levels in Medicaid-
expansion CHIP through at least FY 2019, the budget consequences
resulting from the higher State share of spending for those children
could lead States to take other steps affecting access, such as
lowering provider payment rates or increasing requirements for prior
authorization.
---------------------------------------------------------------------------
\4\ In FY 2017, the median CHIP matching rate is 94.0 percent and
the median Medicaid matching rate is 58.5 percent (MACPAC 2016).
Table 3. State CHIP Program Type and Enrollment
----------------------------------------------------------------------------------------------------------------
CHIP-funded enrollment (FY 2015) Month and year
----------------------------------------------------------------- of projected
State Program type Medicaid- Separate CHIP CHIP funding
\1\ expansion --------------------------------------- Total \2\ exhaustion (as
CHIP Birth-18 Unborn Total of June 2017)
----------------------------------------------------------------------------------------------------------------
Total 4,702,185 3,362,642 327,175 3,689,817 8,397,651
----------------------------------------------------------------------------------------------------------------
Alabama Combination 45,697 87,346 - 87,346 133,043 April 2018
----------------------------------------------------------------------------------------------------------------
Alaska Medicaid 10,182 - - - 10,182 March 2018
Expansion
----------------------------------------------------------------------------------------------------------------
Arizona \3\ Combination 37,412 1,399 - 1,399 38,811 December 2017
----------------------------------------------------------------------------------------------------------------
Arkansas Combination 108,706 - \4\ 3,365 3,365 112,071 March 2018
----------------------------------------------------------------------------------------------------------------
California \5 Combination 1,787,470 2,461 122,197 124,658 1,912,128 January 2018
\,\6\
----------------------------------------------------------------------------------------------------------------
Colorado Combination 23,687 62,446 - 62,446 86,133 February 2018
----------------------------------------------------------------------------------------------------------------
Connecticut Separate - 24,884 - 24,884 24,884 January 2018
----------------------------------------------------------------------------------------------------------------
Delaware Combination 238 16,141 - 16,141 16,379 February 2018
----------------------------------------------------------------------------------------------------------------
District of Medicaid 10,676 - - - 10,676 December 2017
PColumbia Expansion
----------------------------------------------------------------------------------------------------------------
Florida Combination 134,708 293,386 - 293,386 428,094 January 2018
----------------------------------------------------------------------------------------------------------------
Georgia Combination 53,906 176,909 - 176,909 230,815 April 2018
----------------------------------------------------------------------------------------------------------------
Hawaii Medicaid 27,239 - - - 27,239 March 2018
Expansion
----------------------------------------------------------------------------------------------------------------
Idaho Combination 8,937 25,576 - 25,576 34,513 February 2018
----------------------------------------------------------------------------------------------------------------
Illinois Combination 113,105 191,328 26,138 217,466 330,571 May 2018
----------------------------------------------------------------------------------------------------------------
Indiana Combination 69,462 31,098 - 31,098 100,560 May 2018
----------------------------------------------------------------------------------------------------------------
Iowa Combination 21,777 60,880 - 60,880 82,657 April 2018
----------------------------------------------------------------------------------------------------------------
Kansas Combination 54 77,085 - 77,085 77,139 March 2018
----------------------------------------------------------------------------------------------------------------
Kentucky Combination 50,926 36,050 - 36,050 86,976 February 2018
----------------------------------------------------------------------------------------------------------------
Louisiana Combination 122,878 3,498 9,238 12,736 135,614 March 2018
----------------------------------------------------------------------------------------------------------------
Maine Combination 13,440 8,870 - 8,870 22,310 June 2018
----------------------------------------------------------------------------------------------------------------
Maryland Medicaid 142,327 - - - 142,327 April 2018
Expansion
----------------------------------------------------------------------------------------------------------------
Massachusetts Combination 79,299 76,519 13,123 89,642 168,941 February 2018
\7\
----------------------------------------------------------------------------------------------------------------
Michigan \8\ Combination 29,226 85,302 5,171 90,473 119,699 June 2018
----------------------------------------------------------------------------------------------------------------
Minnesota Combination 474 - 3,361 3,361 3,835 December 2017
----------------------------------------------------------------------------------------------------------------
Mississippi Combination 30,819 56,286 - 56,286 87,105 March 2018
----------------------------------------------------------------------------------------------------------------
Missouri Combination 38,600 39,744 - \9\ 39,744 78,344 March 2018
----------------------------------------------------------------------------------------------------------------
Montana Combination 16,008 29,253 - 29,253 45,261 February 2018
----------------------------------------------------------------------------------------------------------------
Nebraska Combination 55,515 4,613 \10\ 2,090 6,703 62,218 May 2018
----------------------------------------------------------------------------------------------------------------
Nevada Combination 17,763 44,145 - 44,145 61,908 January 2018
----------------------------------------------------------------------------------------------------------------
New Hampshire Medicaid 16,651 - - - 16,651 April 2018
Expansion
----------------------------------------------------------------------------------------------------------------
New Jersey Combination 100,826 114,365 - 114,365 215,191 April 2018
----------------------------------------------------------------------------------------------------------------
New Mexico Medicaid 17,155 40 \10\ - 40 17,195 May 2018
Expansion
----------------------------------------------------------------------------------------------------------------
New York Combination 235,945 394,787 - 394,787 630,732 March 2018
----------------------------------------------------------------------------------------------------------------
North Combination 134,413 100,237 4 \11\ 100,241 234,654 December 2017
Carolina
----------------------------------------------------------------------------------------------------------------
North Dakota Combination - 4,955 - 4,955 4,955 May 2018
----------------------------------------------------------------------------------------------------------------
Ohio Medicaid 181,100 - - - 181,100 March 2018
Expansion
----------------------------------------------------------------------------------------------------------------
Oklahoma Combination 174,167 208 \12\ 16,483 16,691 190,858 April 2018
----------------------------------------------------------------------------------------------------------------
Oregon \13\ Combination - 115,726 6,143 121,869 121,869 February 2018
----------------------------------------------------------------------------------------------------------------
Pennsylvania Combination 64,638 229,704 - 229,704 294,342 February 2018
----------------------------------------------------------------------------------------------------------------
Rhode Island Combination 29,948 1,376 \10\ - \14\ 1,376 31,324 February 2018
----------------------------------------------------------------------------------------------------------------
South Medicaid 98,336 - - - 98,336 June 2018
Carolina Expansion
----------------------------------------------------------------------------------------------------------------
South Dakota Combination 12,441 3,775 - 3,775 16,216 March 2018
----------------------------------------------------------------------------------------------------------------
Tennessee \15 Combination 17,971 78,731 9,513 88,244 106,215 May 2018
\
----------------------------------------------------------------------------------------------------------------
Texas Combination 336,769 614,417 98,437 712,854 1,049,623 April 2018
----------------------------------------------------------------------------------------------------------------
Utah Combination 27,762 27,523 - 27,523 55,285 January 2018
----------------------------------------------------------------------------------------------------------------
Vermont Medicaid 4,766 - - - 4,766 January 2018
Expansion
----------------------------------------------------------------------------------------------------------------
Virginia Combination 86,551 102,815 - 102,815 189,366 February 2018
----------------------------------------------------------------------------------------------------------------
Washington Separate - 37,883 8,154 46,037 46,037 January 2018
----------------------------------------------------------------------------------------------------------------
West Virginia Combination 15,242 33,036 - 33,036 48,278 April 2018
\16\
----------------------------------------------------------------------------------------------------------------
Wisconsin Combination 96,973 67,845 3,758 71,603 168,576 April 2018
----------------------------------------------------------------------------------------------------------------
Wyoming \17\ Combination \18\ \18\ - \18\ 5,649 July 2018
----------------------------------------------------------------------------------------------------------------
Notes: FPL is Federal poverty level. FY is fiscal year. Enrollment numbers generally include individuals ever
enrolled during the year, even if for a single month; however, in the event individuals were in multiple
categories during the year (for example, in Medicaid for the first half of the year but a separate CHIP
program for the second half) the individual would only be counted in the most recent category. Enrollment data
shown in the table are as of July 2016, the most current enrollment data available; States may subsequently
revise their current or historical data.
- Dash indicates zero. State does not use eligibility pathway.
\1\ Under CHIP, States have the option to use an expansion of Medicaid, separate CHIP, or a combination of both
approaches. Eleven States consider their programs to be separate but technically have combination programs due
to the transition of children below 133 percent FPL from separate CHIP to Medicaid (Alabama, Arizona, Georgia,
Kansas, Mississippi, Oregon, Pennsylvania, Texas, Utah, West Virginia, and Wyoming).
\2\ Total exceeds the sum of Medicaid expansion and separate CHIP columns due to Wyoming reporting total CHIP
enrollment only.
\3\ Arizona closed its separate CHIP (KidsCare) to new enrollment in January 2010. The State reinstated the
program on September 1, 2016.
\4\ Although Arkansas transitioned its Medicaid-expansion CHIP to separate CHIP effective January 1, 2015, the
State continued to report enrollment for children age 0-18 years under Medicaid-expansion CHIP.
\5\ California has separate CHIP in three counties only that covers children up to 317 percent FPL.
\6\ Due to reporting system updates, California CHIP enrollment totals are estimates as a result of the
exclusion of certain unborn CHIP enrollees in reporting.
\7\ Certain enrollees who should have been assigned to CHIP were assigned to Medicaid beginning in the second
quarter of 2014, making FY 2015 totals artificially low.
\8\ In Michigan, CHIP-funded Medicaid enrollees are included in Medicaid enrollment counts, rather than in CHIP
for FY 2015. Therefore, the CHIP enrollment totals are artificially low. Michigan transitioned from separate
CHIP to Medicaid-expansion CHIP effective January 1, 2016.
\9\ Missouri began covering unborn children effective January 1, 2016. However, the State has not reported
enrollment for this coverage group.
\10\ Separate CHIP enrollment in Nebraska, New Mexico, and Rhode Island are for the States' section 2101(f)
coverage group under the Patient Protection and Affordable Care Act. Section 2101(f) required that States
provide separate CHIP coverage to children to who lost Medicaid eligibility (including through Medicaid-
expansion CHIP) due to the elimination of income disregards under the modified adjusted gross income-based
methodologies. Children covered under section 2101(f) remained eligible for such coverage until their next
scheduled renewal, their 19th birthday, they moved out of State, they requested removal from the program, or
were deceased. Coverage under section 2101(f) has now been phased out.
\11\ North Carolina does not provide unborn children with separate CHIP coverage. Errors in enrollment data
reported are likely due to data quality issues.
\12\ Separate CHIP enrollment in Oklahoma is for children enrolled in the State's premium assistance program.
\13\ Certain Oregon enrollees who should have been assigned to CHIP were assigned to Medicaid-funded coverage
for FYs 2014 and 2015.
\14\ Lack of enrollment for separate CHIP unborn children coverage in Rhode Island is likely due to data quality
issues.
\15\ While Tennessee covers children with CHIP-funded Medicaid, enrollment is currently capped, except for
children who roll over from traditional Medicaid.
\16\ West Virginia's enrollment totals are artificially high because children who transitioned between CHIP and
Medicaid are reported in both programs, rather than the program they were last enrolled.
\17\ The Centers for Medicare and Medicaid Services (CMS) FY 2015 children's enrollment report considers these
values to be estimates.
\18\ Due to inconsistencies between the Statistical Enrollment Data System (SEDS) data and CMS's FY 2015
children's enrollment report, we do not report enrollment for Medicaid expansion and separate CHIP. We only
report total CHIP enrollment as provided in CMS's FY 2015 children's enrollment report.
Sources: For numbers of children: MACPAC analysis of CMS SEDS data from as of July 1, 2016; MACStats: Medicaid
and CHIP Data Book, December 2016; personal communication with CMS staff on December 2, 2016; and December 9,
2016. For projected exhaustion of CHIP funds: MACPAC 2017 analysis using March June 2017 Medicaid and CHIP
Budget and Expenditure System data from CMS, including quarterly projections provided by States in February-
May 2017.
References
Financial Management Group, Center for Medicaid and CHIP Services,
Centers for Medicare and Medicaid Services (CMS), U.S. Department of
Health and Human Services. 2017. Email to MACPAC staff, March 22.
Hensley-Quinn, M. and A. King. 2016. Looking ahead: A timeline of State
policy and operational considerations if Federal CHIP funding ends for
States. Portland, ME: National Academy for State Health Policy. http://
www.nashp.org/looking-ahead/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2017.
Recommendations for the future of CHIP and children's coverage. January
2017. Washington, DC: MACPAC. https://www.macpac.gov/publication/
recommendations-for-the-future-of-chip-and-childrens-coverage/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2016. Exhibit
6. ``Federal medical assistance percentages (FMAPs) and enhanced FMAPs
(E-FMAPs) by State, FYs 2013-2017.'' In MACStats: Medicaid and CHIP
Data Book. December 2016. Washington, DC: MACPAC. https://
www.macpac.gov/publication/federal-medical-assistance-percentages-
fmaps-and-enhanced-fmaps-e-fmaps-by-state-selected-periods/.
Medicaid and CHIP Payment and Access Commission (MACPAC). 2015. Report
to Congress on Medicaid and CHIP. March 2015. Washington, DC: MACPAC.
https://www.macpac.gov/publication/report-to-the-congress-on-medicaid-
and-chip-314/.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
During this busy month, it would be easy for casual watchers of
political news to get lost in a jumble of Washington lingo and
acronyms. The continuing resolution, the debt ceiling, CSR payments,
the NDAA, and the Children's Health Insurance Program, or CHIP, whose
funding authorization runs out in a matter of weeks.
It is vital that the Congress springs into action in the days ahead
to reauthorize CHIP's funding. This program is a lifeline for nearly 9
million children. It's a source of profound relief for parents in
Oregon and across the country, like the single mom who works multiple
jobs, pays the bills, and handles life's many challenges on her own.
The last thing she needs is a government letter stamped ``NOTICE OF
TERMINATION'' explaining that her sick kids are on their own because
CHIP's funding has run out.
She's already juggling a lot--she's not reading page A17 of the
morning newspaper each day and decoding that Washington lingo to
determine if and when Congress will act. She's sitting in her kitchen,
that scary termination letter is all she has to go by, and she wants to
know how she'll figure a way out of this mess.
That's the prospect families across the country are facing in a
matter of weeks if Congress doesn't act. Kids who desperately need care
might not get it. States will be required to start planning for the
worst. That means enrollment freezes, belt-tightening and emergency
steps to try to preserve care for the kids currently in the program.
But a vulnerable child not yet enrolled in CHIP might have to wait
until Congress gets its act together. At best that will leave families
with a mountain of stress, anxiety, and heartache. At worst, it's a
life and death proposition for some of the most vulnerable kids out
there.
So today the Finance Committee will discuss the leading health-care
issue Congress needs to address this fall. Congress created CHIP with
one goal in mind: to make sure no American child falls through the
cracks of a health-care system with far too many. In the coming weeks,
the Finance Committee has an opportunity to lead the way by creating a
strong, bipartisan agreement that upholds CHIP's promise to families
and gives them security for years to come.
Personally, I'm optimistic about this committee's chances because
of the leadership of our chairman. Chairman Hatch had a foundational
role in the creation of CHIP, working in a bipartisan way with his
late, great friend, Senator Ted Kennedy.
In the decades since they led the Congress to create CHIP, the
percentage of kids in America living without health coverage has fallen
from nearly 14 percent to less than 5 percent. Chairman Hatch and
Senator Kennedy offered proof that leaders with fierce disagreements
can find common ground when it comes to big health-care challenges.
This month the Finance Committee will have an opportunity to show
that's still possible 20 years later.
It's important for Congress to take action soon. There's no kicking
this can down the road with a short-term bill. And this cannot wait
until December. Because States run their programs differently, some
will run out of funding earlier than others. And in that time, no
family should face the panic of being unable to get the care their sick
child needs.
As I wrap up, one point on how important it is to have CHIP and
Medicaid working side-by-side. For American kids and families--
particularly those families working hard every day to climb into the
middle class--CHIP adds a level of security to their health care above
and beyond Medicaid. CHIP can only work if Medicaid works.
So let's do the hard work now, colleagues, and uphold this body's
promise to America's kids and their families. Today this committee is
going to hear from a witness panel that knows CHIP from A to Z--a
mother whose child counts on this program, an official who ensures CHIP
runs smoothly in her State, and an independent expert who knows this
program inside and out.
I hope that this hearing will be an opportunity for Senators on
both sides to learn about and discuss this critical health-care program
and to set the stage for the work to come. I'm confident that in short
order Congress can pass a strong and bipartisan extension of CHIP that
will last for many years--and that the Finance Committee can lead the
way to get the job done.
______
Communications
----------
AASA et al.
September 5, 2017
Re: Extension of Children's Health Insurance Program
The Honorable Greg Walden The Honorable Frank Pallone
Chairman Ranking Member
House Energy and Commerce Committee House Energy and Commerce Committee
U.S. House of Representatives U.S. House of Representatives
Washington, DC 20515 Washington, DC 20515
The Honorable Orrin G. Hatch The Honorable Ron Wyden
Chairman Ranking Member
Senate Finance Committee Senate Finance Committee
U.S. Senate U.S. Senate
Washington, DC 20510 Washington, DC 20510
Dear Chairmen Hatch and Walden and Ranking Members Wyden and Pallone:
The undersigned 39 national organizations of the Save Medicaid in the
Schools Coalition urge you to support a full, clean extension of
funding for the Children's Health Insurance Program (CHIP) for 5 years
at current funding levels. CHIP has benefitted from strong bipartisan
support since its creation in 1997. By providing medical assistance to
children who are not eligible for Medicaid, CHIP provides essential
funding to support states to cover uninsured children. Any delay or a
failure to immediately extend funding for CHIP will jeopardize coverage
for children who are eligible for school-based health-related services
leading to immediate and lasting harmful effects for America's most
vulnerable citizens. A lapse in coverage for children places more
barriers on their ability to come to school ready to learn. During a
time of great uncertainty in the health-care system, children need the
consistent, reliable health coverage CHIP provides today.
A school's primary responsibility is to provide students with a high-
quality education. However, children cannot learn to their fullest
potential with unmet health needs. As such, school district personnel
regularly provide critical health services to ensure that all children
are ready to learn and able to thrive alongside their peers. Schools
deliver health services effectively and efficiently since school is
where children spend most of their days. The access to health care
services that is supported through CHIP improves health care and
educational outcomes for students. Providing health and wellness
services for students ultimately enables more children to become
employable and pursue higher education.
More than half of the nearly 9 million children served by CHIP are
eligible to receive services in school through their state Medicaid
programs. Fifteen states exclusively use CHIP funds to extend their
Medicaid programs, meaning all children who qualify for CHIP receive
identical services and benefits as their traditional Medicaid
counterparts. In most states a substantial portion of children served
by CHIP receive Medicaid services and benefits protections. If Congress
does not act quickly to extend funding for these children's health care
then school districts will lose funding for the critical health
services these children receive that ensure they are healthy enough to
learn. School districts depend on CHIP to finance many of these
services and have already committed to the staff and contractors they
require to provide mandated services for their upcoming 2017-2018
school year.
Without a CHIP extension, every child educated in school districts
across the country will feel the pain. No school district's financial
obligations and mandate to address a child's health needs goes away
simply because CHIP funds disappear. Children with unmet health needs
miss more days of school and can fall behind. The failure to continue
funding CHIP would merely shift the financial burden of providing
services to the schools and the state and local taxpayers who fund
them.
School districts use their Medicaid and CHIP reimbursement funds in a
variety of ways to help support the learning and development of the
children they serve. In a 2017 survey of school districts, district
officials reported that two-thirds of Medicaid dollars are used to
support the work of health professionals and other specialized
instructional support personnel (e.g., speech-language pathologists,
audiologists, occupational therapists, school psychologists, school
social workers, and school nurses) who provide comprehensive health and
mental health services to students. Districts also use these funds to
expand the availability of a wide range of health and mental-health
services available to students in poverty, who are more likely to lack
consistent access to health-care professionals. Further, some districts
depend on Medicaid reimbursements to purchase and update specialized
equipment (e.g., walkers, wheelchairs, exercise equipment, special
playground equipment, and equipment to assist with hearing and seeing)
as well as assistive technology for students with disabilities to help
them learn alongside their peers.
The loss of CHIP funds would also hinder many children's ability to
access basic health screenings for vision, hearing, and mental-health
challenges and access to early identification and treatment. Left
unaddressed, these challenges or delays undermine children's ability to
learn and make any problems more difficult and expensive to treat
later. Loss of CHIP funding would also jeopardize schools' ability to
conduct routine screenings on-site and help to enroll eligible students
in Medicaid or other public coverage programs or connect them with
needed community-based services.
Congress must act expediently to extend CHIP, so states and districts
have the budget certainty necessary to continue to run CHIP programs
and seek necessary reimbursements. We urge you to carefully consider
the important benefits that CHIP provides to our nation's children.
Schools are often the hub of the community, and failing to extend
funding for CHIP could lead to meaningful reductions to comprehensive
health and mental and behavioral health care for children.
If you have questions about the letter or wish to meet to discuss this
issue further, please do not hesitate to reach out to the coalition co-
chair Sasha Pudelski ([email protected]).
Sincerely,
AASA, The School Superintendents Association
Accelify
AESA, Association of Education Service Agencies
American Dance Therapy Association
American Federation of School Administrators (AFSA)
American Federation of Teachers
American Psychological Association
Association of School Business Officials International (ASBO)
Association of University Centers on Disabilities (AUCD)
Coalition for Community Schools
Community Catalyst
Council for Exceptional Children
Council of Administrators of Special Education
Council of Parent Attorneys and Advocates
Division for Early Childhood of the Council for Exceptional Children
(DEC)
Family Voices
First Focus
Healthy Schools Campaign
IDEA Infant Toddlers Coordinators Association (ITCA)
Judge David L. Bazelon Center for Mental Health Law
Learning Disabilities Association of America
National Alliance for Medicaid in Education
National Association of Elementary School Principals
National Association of Pediatric Nurse Practitioners
National Association of Secondary School Principals
National Association of School Nurses
National Association of School Psychologists
National Association of Social Workers
National Association of State Directors of Special Education (NASDSE)
National Black Justice Coalition
National Disability Rights Network
National Education Association
National Health Law Program
National Rural Education Association
School Social Work Association of America
The Arc of the United States
The National Alliance on Mental Illness (NAMI)
Union for Reform Judaism
United Way Worldwide
______
American Academy of Family Physicians (AAFP)
AAFP Headquarters
11400 Tomahawk Creek Pkwy.
Leawood, KS 66211-2680
800-274-2237 913-906-6000
[email protected]
AAFP Washington Office
1133 Connecticut Avenue, NW, Suite 1100
Washington, DC 20036-1011
202-232-9033 Fax: 202-232-9044
[email protected]
On behalf of the American Academy of Family Physicians (AAFP), which
represents over 129,000 family physicians and medical students across
the country, thank you for the opportunity to submit testimony for the
record to the Committee on Finance regarding the continuation of the
Children's Health Insurance Program (CHIP).
Congress Should Swiftly Approve a Long-Term Extension of CHIP Funding
The AAFP urges the Committee to swiftly approve a bipartisan long-term
extension of CHIP, in order to promote stability and health security
for 8.9 million low-income children \1\ and their families. Time is of
the essence in completing this work in order to ensure continuous
access to primary and preventive services for this vulnerable
population, protect progress in public health, and allow States to
adequately plan.
---------------------------------------------------------------------------
\1\ Centers for Medicare and Medicaid Services, 2016 Enrollment
Report, available at https://www.medicaid.gov/chip/downloads/fy-2016-
childrens-enrollment-report.pdf.
The AAFP has supported CHIP since its inception in 1997, and during
each subsequent reauthorization and extension of funding (2007, 2009,
and 2015), as a way to extend health coverage to uninsured children
whose families do not meet eligibility requirements for Medicaid. Since
the enactment of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA), in April 2015, the AAFP has reiterated support for CHIP
funding beyond the current end-date of September 30, 2017--through
letters to this Committee and to Congressional Leadership. As a medical
specialty, family medicine is committed to the success of all of health
insurance programs financed with public dollars, including CHIP. AAFP
member data indicates that over two-thirds of AAFP members accept new
Medicaid patients.\2\ Although the AAFP does not collect member survey
data on CHIP participation, we know (due to the close connection
between Medicaid and CHIP--including the fact that some states operate
combined Medicaid/CHIP programs--and the fact that family physicians
perform so many pediatric services) that family physicians are helping
to carry out Congress's intent behind CHIP: treating low-income
children, many of whom would be uninsured without the program.
---------------------------------------------------------------------------
\2\ AAFP, 2015 Practice Profile Survey (excerpt), available at
http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12.html.
Family physicians play an important role in addressing American
children's health needs. According to the AAFP's latest member census,
published December 31, 2016, over 80 percent of AAFP members care for
adolescents, and 73 percent care for infants and children.\3\ Other
AAFP member survey data reflect that about 20 percent of AAFP's members
deliver babies as part of their practice, with roughly 6 percent
delivering more than 30 babies in a recent calendar year.\4\ Of AAFP
active members with full hospital privileges, 70 percent provide
newborn care in the hospital, and 64 percent provide pediatric care in
the hospital.\5\ This is consistent with family medicine's traditional
role of practicing in the entire scope of the physician license, in
order to meet the needs of the community in which the family physician
practices. A family physician who serves a small rural community
without a pediatrician, for example, will often perform most or all
pediatric care for that community.
---------------------------------------------------------------------------
\3\ AAFP Member Census (Dec. 31, 2016), available at http://
www.aafp.org/about/the-aafp/family-medicine-facts/table-13.html.
\4\ AAFP, 2015 Practice Profile Survey (July 15, 2016).
\5\ Id.
The AAFP also supports health care for all, consistent with the public-
health mission of the specialty of family medicine. The AAFP promotes
universal access to care in the form of ``a primary care benefit design
featuring the patient-centered medical home, and a payment system to
support it,'' for everyone in the United States.\6\ AAFP believes that
all Americans should have access to primary-care services (e.g., in the
case of infants and children, immunizations and other evidence-based
preventive services, prenatal care, and well-child care), without
patient cost sharing. The AAFP believes that universal health care also
should include services outside the medical home (e.g.,
hospitalizations) with reasonable and appropriate cost sharing allowed,
but with protections from financial hardship. Supporting universal
access to care is also consistent with the ``triple aim'' of improving
patient experience, improving population health, and lowering the total
cost of health care in the United States. Research supports the AAFP's
view that having both health insurance and a usual source of care
(e.g., through an ongoing relationship with a family physician)
contributes to better health outcomes, reduced disparities along
socioeconomic lines, and reduced costs.\7\
---------------------------------------------------------------------------
\6\ AAFP, Health Care for All (2014), available at http://
www.aafp.org/about/policies/all/health-care-for-all.html.
\7\ See, e.g., The Robert Graham Center, ``The Importance of Having
Health Insurance and a Usual Source of Care,'' Am. Fam. Physician
(Sept. 15, 2004), available at http://www.aafp.org/afp/2004/0915/
p1035.html.
The AAFP urges Congress to pass a ``clean'' extension of CHIP with a
minimum of unnecessary policy changes. Accordingly, Congress should
extend the current enhanced federal medical assistance percentage
(FMAP), as well as the current maintenance of effort (MOE) provisions,
which are both in effect through September 30, 2019, to align with an
extension of CHIP funding. For example, if Congress extends CHIP
funding for 5 years, then it should extend the enhanced FMAP and MOE
provisions for 3 years. The AAFP also supports maintaining the enhanced
FMAP on policy grounds: Maintaining the enhanced FMAP allows states to
more easily devote scarce resources to their Medicaid programs, which
collectively cover some 70 million low-income Americans. Destabilizing
the enhanced FMAP in CHIP could also discourage the 19 ``non-
expansion'' states from expanding their Medicaid programs and covering
---------------------------------------------------------------------------
yet more uninsured children and adults.
Unlike Medicare and Medicaid, which provide stable and reliable federal
funding under current law, CHIP funding is contingent upon
congressional action at regular intervals. Given the importance of the
program to almost 9 million children from low-income families, the AAFP
urges the Committee to swiftly extend and stabilize the program on a
long-term basis.
Congress Should Also Provide Long-Term Support for the Teaching Health
Center Graduate Medical Education Program
As an additional note, the AAFP would like to emphasize to the
Committee the importance of providing long-term support for the
Teaching Health Center Graduate Medical Education (THCGME) program,
which will also expire on September 30, 2017, absent Congressional
intervention. THCGME is a successful primary-care training program,
currently financing training for 742 medical and dental residents in
community-based ambulatory settings. Residents in the THCGME program
train exclusively in primary-care specialties.
Of relevance to the legislative process surrounding CHIP, two-thirds of
the THCGME residents are training in family medicine and pediatrics.\8\
The THCGME program, administered by the Health Resources and Services
Administration (HRSA), accounts for less than 1 percent of the annual
federal spending devoted to graduate medical education, yet it is the
only GME program that is devoted entirely to training primary-care
physicians and dentists. Residents in the program train in community
health centers (including federally qualified health centers), and tend
to be concentrated in rural and underserved areas that need access to
more providers, particularly primary-care physicians. American Medical
Association Physician Masterfile data confirms that a majority of
family medicine residents practice within 100 miles of their residency
training location.\9\ By comparison, fewer than 5 percent of physicians
who complete training in hospital-based GME programs provide direct
patient care in rural areas.\10\ Thus, the most effective way to get
family and other primary-care physicians into rural and underserved
areas is not to recruit them from remote academic medical centers but
instead to train them in these underserved areas.
---------------------------------------------------------------------------
\8\ Health Resources and Services Administration, Teaching Health
Center Graduate Medical Education Program, Academic Year 2014-2015,
available at https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/
teaching-health-center-graduate-highlights.pdf.
\9\ E. Blake Fagan, M.D., et al., ``Family Medicine Graduate
Proximity to Their Site of Training,'' Family Medicine, Vol. 47, No. 2,
at 126 (Feb. 2015).
\10\ Candice Chen, M.D., MPH, et al., ``Toward Graduate Medical
Education (GME) Accountability: Measuring the Outcomes of GME
Institutions,'' Academic Medicine, Vol. 88, No. 9, p. 1269 (Sept.
2013).
______
American College of Physicians (ACP)
25 Massachusetts Avenue, NW, Suite 700
Washington, DC 20001-7401
202-261-4500, 800-338-2746
190 N. Independence Mall West
Philadelphia, PA 19106-1572
215-351-2400, 800-523-1546
www.acponline.org
The American College of Physicians (ACP) commends the Chairman of the
Senate Finance Committee Senator Orrin Hatch and Ranking Member Ron
Wyden for convening this hearing on the importance of extending the
Children's Health Insurance Program (CHIP) which is set to expire at
the end of the month. We applaud your working together to examine
solutions that will ensure that this program will continue to provide
funding for low income children who depend on it to ensure that they
have health insurance coverage that meets their needs.
ACP is the largest medical specialty organization and the second
largest physician group in the United States, representing 152,000
internal medicine physicians (internists), related subspecialists, and
medical students. Internal medicine physicians are specialists who
apply scientific knowledge and clinical expertise to the diagnosis,
treatment, and compassionate care of adults across the spectrum from
health to complex illness.
ACP Urges Congress to Act Now to Continue CHIP
ACP has been a stalwart supporter of CHIP and we are pleased to know
that an agreement on legislation to extend CHIP funding for 5 years has
been reached between Chairman Hatch and Ranking Member Wyden. We urge
Congress to support and pass this legislation, S. 1827, the Keep Kids
Insurance Dependable and Secure Act of 2017, so that the nearly 9
million children who depend on it will not lose coverage. A 5 year
extension of the program will provide states that administer the CHIP
program with the certainty needed to plan a long-term budget that meets
the needs of their children. It will alleviate the anxiety of many
parents who are now wondering whether or not their children, who
currently receive coverage under CHIP, will continue to have such
coverage if Congress does not act by the end of September. State
officials have warned the Congress that they may have to freeze CHIP
enrollment or terminate coverage if funding is not extended by the end
of the month.
Results of the CHIP Program
CHIP was created to provide health-care coverage for children who did
not qualify for Medicaid but often found it difficult to obtain
affordable health-care coverage in the private market. CHIP builds on
the success of Medicaid and recent estimates determine that in 2016,
CHIP covered 8.9 million children while 37.1 million children were
enrolled in Medicaid coverage. CHIP has been an overwhelming success in
reducing the uninsured rate among our nation's children and reducing
the financial stress of families that must bear the cost of this
coverage. As a result of the passage of CHIP, and Medicaid, new census
data reflects that the uninsured rate among children has reached an
all-time low of 4.5 percent. According to a recent study by the Urban
Institute, ``from 1997 when the CHIP program was enacted, to 2012, the
uninsured rate among all children declined by 6 percentage points and
by even more (12 percentage points) among children with incomes below
200 percent of the federal poverty level.'' The Urban institute also
notes that CHIP and Medicaid have also improved access to care and
reduced the financial burden for families with children enrolled in
these programs. Not only do these programs result in improved access to
health care for our children, but studies also show that Medicaid and
CHIP coverage result in positive outcomes in health, educational
advancement, and financial success.
Conclusion
As evidence has shown, CHIP has been a very successful program and it
is critically important that Congress act now to extend the program for
an additional 5 years. We thank Chairman Hatch and Ranking Member Wyden
for working together, in a bipartisan fashion, on legislation to ensure
the continuation of CHIP funding for the long term. ACP is pleased to
lend its support to S. 1827, the Keep Kids Insurance Dependable and
Secure Act, and help advance it through the legislative process. We
urge Congress to act quickly to approve this legislation as only a few
days remain before the program expires at the end of this month.
______
Asian and Pacific Islander American Health Forum (APIAHF)
1629 K Street, NW, Suite 400
Washington, DC 20006
The Asian and Pacific Islander American Health Forum (APIAHF) submits
this written testimony for the record for the September 7, 2017 hearing
before the Senate Committee on Finance entitled ``The Children's Health
Insurance Program: The Path Forward.''
As the nation's oldest and largest health policy and public health
organization working with Asian American, Native Hawaiian, and Pacific
Islander (AA and NHPI) communities, APIAHF provides a voice in the
nation's capital for AA and NHPI communities. APIAHF works toward
health equity and health justice for all by influencing policy,
mobilizing communities, and strengthening programs and organizations to
improve the health of the over 20 million AAs and nearly 1 million
NHPIs in the United States.
This hearing seeks to address continued funding for the Children's
Health Insurance Program (CHIP). APIAHF strongly urges the Committee to
follow the Medicaid and CHIP Payment and Access Commission (MACPAC)
guidance and extend funding for CHIP for 5 years, through fiscal year
2022.\1\ Over 8.9 million children rely on CHIP, and states need the
security of knowing CHIP funding will be set for the next 5 years.\2\
---------------------------------------------------------------------------
\1\ Recommendations for the Future of CHIP and Children's Coverage,
MACPAC, March 2017, available at: https://www.macpac.gov/publication/
recommendations-for-the-future-of-chip-and-childrens-coverage-2/.
\2\ Children's Health Insurance Program (CHIP): FY 2016 Children's
Enrollment, Medicaid.gov, February 15, 2017, available at: https://
www.medicaid.gov/chip/downloads/fy-2016-childrens-enrollment-
report.pdf.
CHIP funding has dramatically reduced the coverage gap for children of
---------------------------------------------------------------------------
color.
Over the course of 20 years, CHIP, together with Medicaid, has led to
historic coverage rates for children of color. As of 2015, 95.9% of AA
and NHPI children, for example, have coverage thanks to the combined
efforts of CHIP, Medicaid, and the ACA.\3\ Importantly for this
Committee, 28% of AA children and half of NHPI children rely on CHIP
and Medicaid for their coverage.\4\ Similarly, 56% of Latino children,
58% of African American children, and 50% of American Indian Alaska
Native children are covered by CHIP and Medicaid.\5\
---------------------------------------------------------------------------
\3\ Joan Alker and Alisa Chester, Children's Health Coverage Rate
Now at Historic High of 95 Percent, Georgetown University Health Policy
Institute: Center for Children and Families, October 2016, available
at: https://ccf.georgetown.edu/wp-content/uploads/2016/11/Kids-ACS-
update-11-02-1.pdf.
\4\ Samantha Artiga, et al., Key Facts on Health and Health Care by
Race and Ethnicity, Kaiser Family Foundation, June 7, 2016, available
at: http://www.kff.org/report-section/key-facts-on-health-and-health-
care-by-race-and-ethnicity-section-4-health-coverage/.
\5\ Elizabeth Cornachione, et al., Children's Health Coverage: The
Role of Medicaid and CHIP and Issues for the Future, Kaiser Family
Foundation, June 27, 2016, available at: http://kff.org/health-reform/
issue-brief/childrens-health-coverage-the-role-of-medicaid-and-chip-
and-issues-for-the-future/.
Despite these coverage gains, communities of color remain more likely
to be uninsured than whites.\6\ This coverage disparity is due to many
factors, including poverty, health and English literacy and proficiency
and immigration based restrictions. CHIP is vital for continuing to
close this coverage gap because it specifically seeks to cover low-
income working families. The program covers children and pregnant women
that make too much to qualify for Medicaid, but not enough to afford
private insurance. It also includes protections that are designed to
directly serve low-income enrollees, including restrictions on cost-
sharing. This coverage is critical for working families of color, who
comprise 60% of all working families in this country.\7\
---------------------------------------------------------------------------
\6\ Samantha Artiga, et al, Health Coverage by Race and Ethnicity:
Examining Changes Under the ACA and the Remaining Uninsured, Kaiser
Family Foundation, November 4, 2016, available at: http://www.kff.org/
disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-
examining-changes-under-the-aca-and-the-remaining-uninsured/.
\7\ Deborah Povich, et al., Low-Income Working Families: The
Racial/Ethnic Divide, The Working Poor Families Project, 2015,
available at: http://www.workingpoorfamilies.org/wp-content/uploads/
2015/03/WPFP-2015-Report_Racial-Ethnic-Divide.pdf.
Children of color experience higher rates of chronic health conditions,
and CHIP provides access to quality preventive care to prevent and
---------------------------------------------------------------------------
treat those conditions.
Children of color face higher rates of health disparities due to a
multitude of factors including poverty, living in less environmentally
healthy areas, lack of access to fresh healthy food, and lack of health
coverage. CHIP coverage is uniquely situated to address these
disparities because it requires a broad scope of coverage and links
children to continuous preventive care.\8\
---------------------------------------------------------------------------
\8\ CHIP Benefits, Medicaid.gov, available at: https://
www.medicaid.gov/chip/benefits/index.html.
Preventive care is important for AA and NHPI children who suffer from
high rates of diabetes compared to other groups. AA children are 60%
more likely to develop diabetes than white children, and NHPI children
are three times more likely to develop diabetes than white children.\9\
CHIP coverage helps to reduce the burden of expensive and life-changing
chronic conditions for AA and NHPI children by offering access to
routine preventive care to screen early for conditions like diabetes,
obesity, and cancer.
---------------------------------------------------------------------------
\9\ Lenna L. Liu, MD, MPH, et al., ``Type 1 and Type 2 Diabetes in
Asian and Pacific Islander U.S. Youth,'' Diabetes Care, Vol. 32 (Suppl.
2), March 2009, available at: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC2647693/.
Similarly, African American children are four times more likely to die
from asthma than white children, even though this condition is easily
treated with regular care.\10\ By diagnosing conditions early and
keeping children in treatment, CHIP helps to identify health challenges
before they arise, and contributes to better health outcomes across the
child's lifespan.
---------------------------------------------------------------------------
\10\ Children's Environmental Health Disparities: Black and African
American Children with Asthma, Environmental Protection Agency, 2014,
available at: https://www.epa.gov/sites/production/files/2014-05/
documents/hd_aa_asthma.pdf.
In conclusion, 8.9 million children are at risk of losing coverage if
CHIP is not extended. If Congress does not act, children of color will
be particularly impacted given that almost half are enrolled in CHIP or
Medicaid.\11\ States need to know that CHIP will remain as a major
source of coverage with secure funding in order to effectively continue
to plan enrollment and operate their programs. Therefore, APIAHF
strongly urges the adoption of the MACPAC 5 year continued funding plan
for CHIP.
---------------------------------------------------------------------------
\11\ Elizabeth Cornachione, et al., Children's Health Coverage: The
Role of Medicaid and CHIP and Issues for the Future, Kaiser Family
Foundation, June 27, 2016, available at: http://kff.org/health-reform/
issue-brief/childrens-health-coverage-the-role-of-medicaid-and-chip-
and-issues-for-the-future/.
For questions, contact Amina Ferati, Senior Director of Government
---------------------------------------------------------------------------
Relations and Policy at [email protected] (202-466-3550).
______
Campaign to End Obesity Action Fund (CEO-AF)
1341 G Street, NW, 6th Floor
Washington, DC 20005
www.obesityactionfund.org
Who Is the Campaign to End Obesity Action Fund?
The Campaign to End Obesity Action Fund (CEO-AF) is a group of leaders
from industry, academia, public health, and associations dedicated to
reversing one of America's costliest diseases: obesity. Right now, more
than one-third of adults and nearly one in six children have obesity.
Taxpayers, governments and businesses spend billions on obesity-related
conditions each year, including over $300 billion in medical costs.
Ending this epidemic requires change--in individuals, institutions and
communities. CEO-AF advocates for federal policies to reverse the
obesity epidemic and promote healthy weight in children and adults.
Timely Reauthorization of CHIP is Essential.
CHIP provides health-care services to approximately 8.9 million \1\
Americans--many of whom have or are at risk for obesity. Nationwide,
obesity rates continue to trend upward and some projections show that
50 percent of Americans will have obesity by 2030. Low-income children
and families suffer from obesity rates that are 2.7 times higher than
those living above federal poverty guidelines.\2\ As such, it is
imperative that Congress reauthorize CHIP as soon as possible so that
services to these children are not interrupted.
---------------------------------------------------------------------------
\1\ http://www.kff.org/other/state-indicator/annual-chip-
enrollment/?currentTimeframe=O&sor
tModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
\2\ Robert Wood Johnson Foundation and Trust for America's Health.
State of Obesity: Socioeconomics of Obesity, https://
stateofobesity.org/socioeconomics-obesity/.
CHIP reauthorization presents a unique opportunity to set these at-risk
children up for a lifetime of healthy eating and exercise through early
interventions within the health-care system. The continued availability
of CHIP is crucial to improving children's access to obesity prevention
---------------------------------------------------------------------------
and treatment therapies, which can help them become healthy adults.
CEO-AF and 30 Other Groups Urge the Senate Finance Committee to Include
CORD in CHIP Reauthorization.
CHIP, for the last two reauthorization cycles, has contained an
important and ground-breaking pilot program: the Childhood Obesity
Research Demonstration, or CORD.\3\
---------------------------------------------------------------------------
\3\ https://www.congress.gov/bill/111th-congress/house-bill/2;
https://www.congress.gov/bill/114th-congress/house-bill/2.
CORD 1.0 successfully identified childhood obesity intervention models,
which were then tested further in CORD 2.0, with the intention of
eventually expanding these evidence-based programs on a national level.
Specifically through CORD, the Centers for Disease Control and
Prevention (CDC), was able to fund multiple community grantees and
evaluation centers to target children from low-income families at risk
for or suffering from obesity.\4\ Through this funding, CDC was able to
focus on prevention and management of childhood obesity by increasing
obesity screenings and counseling services in the community and
referring overweight and obese children to appropriate and evidence
based lifestyle modification programs.\5\
---------------------------------------------------------------------------
\4\ https://www.cdc.gov/obesity/strategies/healthcare/index.html.
\5\ https://www.cdc.gov/obesity/strategies/healthcare/cord2.html.
A letter from CEO-AF and 30 other groups urging the reauthorization of
---------------------------------------------------------------------------
CORD is attached as part of this statement.
______
Campaign to End Obesity Action Fund (CEO-AF)
September 7, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chair Ranking Member
Senate Finance Committee Senate Finance Committee
U.S. Senate U.S. Senate
Washington, DC 20510 Washington, DC 20510
The Honorable Greg Walden The Honorable Frank Pallone
Chair Ranking Member
Committee on Energy and Commerce Committee on Energy and Commerce
U.S. House of Representatives U.S. House of Representatives
Washington, DC 20515 Washington, DC 20515
Dear Chairman Hatch, Chairman Walden, Senator Wyden, and Representative
Pallone:
The Campaign to End Obesity Action Fund (the CEO Action Fund) is a
coalition of leaders from industry, academia, public health, and
patient and disease communities that advocates before Congress and
federal agencies on needed policy solutions to reverse the U.S. obesity
epidemic. As you may know, childhood obesity in the United States has
reached epic proportions--one in five U.S. children already has
obesity, a fact that also triggers long term health risks and related
expenses to taxpayers--and we believe there are important opportunities
to advance policies that can move the needle on this.
Specifically, as you work to put together the Children's Health
Insurance Program (CHIP) reauthorization package, we request that you
include an extension of the Child hood Obesity Research Demonstration
(CORD). This program--now in its second iteration--has been pivotal in
beginning to identify scalable approaches to addressing childhood
obesity in America.
CORD 1.0 was first authorized in 2009 through the Children's Health
Insurance Program Reauthorization Act (CHIPRA) \1\ and ran from 2011-
2015. The project, as CORD 2.0, was reauthorized in the Medicare Access
and CHIP Reauthorization Act of 2015 for an additional 2 years, and is
set to expire in Fiscal Year 2017.\2\ CORD 1.0 successfully identified
childhood obesity intervention models, which were then tested further
in CORD 2.0, with the intention of eventually expanding these
evidence-based programs on a national level. CORD 2.0 is an ongoing
project--it is essential that CORD continues to receive funding so that
the project can continue to expand incrementally with the goal of
continuing to identify scalable, cost-
effective solutions to combat childhood obesity.
---------------------------------------------------------------------------
\1\ https://www.congress.gov/bill/111th-congress/house-bill/2.
\2\ https://www.congress.gov/bill/114th-congress/house-bill/2.
Through CORD, the Centers for Disease Control and Prevention (CDC), has
funded multiple community grantees and evaluation centers to target
children from low-
income families at risk for or suffering from obesity.\3\ Without this
program, CDC would be without needed, dedicated resources to focus on
the prevention and effective management of childhood obesity. Of
particular importance, CORD funding empowered CDC to increase obesity
screenings and counseling services in the community and refer obese
children to appropriate and evidence based lifestyle modification
programs.\4\
---------------------------------------------------------------------------
\3\ https://www.cdc.gov/obesity/strategies/healthcare/index.html.
\4\ https:// www.cdc.gov/obesity/strategies/healthcare/cord2.html.
Today, some 30 states have childhood obesity rates of 30 percent or
more.\5\ Childhood obesity is a major contributor to other costly
health conditions, such as cancer, cardiovascular disease,
dyslipidemia, Type 2 Diabetes, fatty liver disease, asthma, and
psychological conditions. Because it can negatively impact school
performance and social development,\6\ the toll on families,
communities, the health care system, and the budget of this very
troubling trend is enormous and growing. Congress must continue to fund
the tools, such as CORD, that are making a difference in communities
that are hit hardest by this epidemic.
---------------------------------------------------------------------------
\5\ http://obesityactionfund.org/page.asp?id=28.
\6\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322789/.
Indeed, U.S. taxpayers, businesses, communities, and individuals spend
over $300 billion per year in medical costs due to obesity.\7\
Accordingly, we must continue to invest--as we have with CORD--in
programs that can reduce obesity and, in the long-run, saves lives and
taxpayer money. According to a recent Gallup study, if the 10 cities in
the U.S. with the highest rates of obesity were able to cut their
obesity rates down to the 2009 national average of 26.5%, each city
would save nearly $500 million every year.\8\
---------------------------------------------------------------------------
\7\ https://www.ncbi.nlm.nih.gov/pubmed/25381647.
\8\ http://www.galllup.com/businessjournal/145778/cost-obesity-
cities.aspx.
Today, CORD remains an essential tool in combatting childhood obesity,
---------------------------------------------------------------------------
and we urge the Committee to reauthorize the program in September.
Thank you again for your leadership, and for your consideration of our
request. For any questions you may have, please contact Michelle Seger
at michelle@
obesityactionfund.org or 202-466-8100.
Sincerely,
The Campaign to End Obesity Action Fund
Afterschool Alliance
American College of Sports Medicine
American Council on Exercise
American Heart Association
American Medical Women's Association
American Psychological Association
American Society for Metabolic and Bariatric Surgery
Arkansas Center for Health Improvement
Center for Science in the Public Interest
Consortium to Lower Obesity in Chicago Children
Healthcare Leadership Council
Healthy Schools Campaign
National Association for Health and Fitness
National Association of County and City Health Officials
National Association of School Nurses
National Coalition for Promoting Physical Activity
National Hispanic Medical Association
Nemours Children's Health System
Obesity Action Coalition
Obesity Medicine Association
School Based Health Alliance
The American Cancer Society Cancer Action Network
The Endocrine Society
The Hope Heart Institute
The Obesity Society
Trust for America's Health
United States Bone and Joint Initiative
University of Wisconsin American Family Children's Hospital
Weight Watchers
YMCA of the USA
______
Children's Hospital Association
600 13th St., NW, Suite 500
Washington, DC 20005
202-753-5500
16011 College Blvd., Suite 250
Lenexa, KS 66219
913-262-1436
www.childrenshospitals.org
Contact us: [email protected]
The Children's Hospital Association represents 220 hospitals nationwide
dedicated to the health and well being of our nation's children. On
behalf of our nation's children's hospitals and the patients and
families they serve, we thank the Senate Finance Committee (the
Committee) for its steadfast commitment to the Children's Health
Insurance Program (CHIP). The Committee's support and dedication over
CHIP's long bipartisan history has resulted in improved access to
health care for millions of vulnerable children improving their lives
and the overall health of our nation. We greatly appreciate the joint
statement by Chairman Hatch and Ranking Member Wyden, released on the
20th anniversary of the program, reaffirming their strong support for a
swift and bipartisan CHIP renewal. We share these goals and it is our
hope that, following the Committee's consideration of the program
during its hearing, Congress will take prompt steps to renew funding
for CHIP. We urge Congress to pass a long-term extension of current
policy and funding of CHIP before the end of the fiscal year in order
to give children and families the certainty and stability they need.
CHIP is an important health coverage program for over 6 million low-
income children. Congress created CHIP in 1997, with strong bipartisan
support, to fill a gap in the coverage landscape. CHIP builds off of a
strong Medicaid program by providing coverage for children who fall
above Medicaid eligibility levels, but lack access to other health
coverage options. Congress designed CHIP with children in mind and
included child appropriate benefits, access to pediatric providers, and
cost-sharing limits to protect vulnerable children and families. CHIP,
together with Medicaid, has brought the rate of uninsured U.S. children
to an all-time low, with 95 percent of all children insured. If this
program is not extended beyond 2017, many CHIP-enrolled children will
likely become underinsured or uninsured altogether, threatening our
nation's historic gains in insuring children over the past two decades.
Healthy children grow up to become healthy adults, and CHIP helps
ensure that the children covered by the program are able to reach their
full potential.
Congress must act now to enact a long-term CHIP extension to give
states and families the certainty they need. State budget cycles and
regulations make it difficult for states to maintain their CHIP
programs in the absence of federal funding certainty, and many states
have already planned for the funding to continue. If CHIP funding were
to lapse, states may be forced to make tough choices at the expense of
vulnerable children, including steps to disenroll children, impose
lock-outs and waiting periods, or wind down their CHIP programs
altogether. A clean 5-year extension of CHIP is supported by the
National Governors Association, the Medicaid and CHIP Payment and
Access Commission, and child health advocates because it provides
predictability in the program and encourages states to make
programmatic improvements.
Efforts to extend CHIP should maintain current policy, which includes
the underlying CHIP program along with items like the Pediatric Quality
Measures Program (PQMP), express lane eligibility, and outreach and
enrollment grants--all of which are important components of CHIP. The
PQMP is the only significant federal investment in pediatric health-
care quality. An extension of this program with CHIP is particularly
important in order to continue to improve care and lower costs for
families and purchasers of care, such as state and federal governments.
To ensure maximum stability for children, families and states, we ask
Congress to enact a 5-year extension of current policy.
We thank the Chairman, Ranking Member, and Committee members for their
leadership and resolute support for CHIP. We are thankful for champions
for children like these leaders, and we look forward to working with
the Committee this month to maintain a strong CHIP program and
strengthen health care for children into the future.
______
The Fed Is Best Foundation
Based on June 2017 Medicaid data, there are more than 35 million
Medicaid child and Children's Health Insurance Program (CHIP) enrollees
nationwide whose health needs depend on coverage by these important
health insurance programs. The Fed Is Best Foundation is a non-profit,
public health education organization led by health-care professionals
who believe that (1) babies should never go hungry, and (2) mothers
should be informed of the signs and consequences of preventable hunger
and should be supported in choosing clinically safe feeding options for
their babies. The most recent peer-reviewed clinical data shows
alarming trends in infant feeding, namely a rise in rehospitalizations
for feeding complications in exclusively breastfed newborns who do not
receive enough milk in the first days of life, including increasing
rates of jaundice, hypoglycemia, and dehydration, which threaten a
newborn's brain and can lead to life-long and costly medical needs.
Programs like Medicaid and CHIP are the most significant payors of
infant medical care and are well-positioned to establish infant
nutritional criteria that will protect infants against accidental
starvation and the medical complications that follow while reducing
costs for both one-time and, in many cases, life-long care needs that
infants who suffer from jaundice, hypoglycemia, and dehydration face.
These are costly and avoidable outcomes and could save the health-care
system millions of dollars each year. Clinical data show that
insufficient breast milk production affects at least 1 in 5 women in
the first days of an infant's life. Without enough milk, infants can
starve, and accidental starvation can cause brain injury leading to
preventable cognitive and developmental delays and an increased risk of
seizure disorders.
As reported by the Centers for Medicare and Medicaid Services' (CMS)
Maternal and Infant Health Initiative, Medicaid currently funds about
45% of all births in the U.S. In 2014, an expert panel was convened by
CMS to examine program policies ``that could result in better care,
improve birth outcomes, and reduce the costs of care for mothers and
infants in Medicaid and CHIP.'' There is more work to be done,
including closing the critical gap in public-health education and
protocols for infant nutrition monitoring and support. Such policy
changes can prevent accidental starvation-related care and
hospitalization costs which give rise, in many cases, to life-long
cognitive and developmental medical care needs for both CHIP and
Medicaid beneficiaries.
Contact
Christie del Castillo-Hegyi, M.D., Board Certified Emergency Physician,
Co-Founder, Fed Is Best Foundation at [email protected]/(505) 803-
5304
______
Healthcare Leadership Council (HLC)
September 7, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
Committee on Finance Committee on Finance
U.S. Senate U.S. Senate
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
As the Committee prepares to hold a hearing on the Children's Health
Insurance Program (CHIP), the Healthcare Leadership Council (HLC)
welcomes the opportunity to share our thoughts on this important
program with you.
HLC is a coalition of chief executives from all disciplines within
American health care. It is the exclusive forum for the nation's
health-care leaders to jointly develop policies, plans, and programs to
achieve their vision of a 21st century health system that makes
affordable, high quality care accessible for all Americans. Members of
HLC--hospitals, academic health centers, health plans, pharmaceutical
companies, medical device manufacturers, laboratories, biotech firms,
health product distributors, pharmacies, post-acute care providers, and
information technology companies--advocate for measures to increase the
quality and efficiency of health care through a patient-centered
approach.
CHIP is a critical part of our country's health-care infrastructure.
HLC urges Congress to support some of our most vulnerable citizens--
children from families with low and moderate incomes--by continuing to
fund this program. CHIP has provided coverage and encouraged
participation by simplifying the enrollment and renewal process. Along
with other factors, this has led to a steep decline in the number of
uninsured children, from around 10 million in 1997 (when the program
was enacted) to around 3 million in 2015. Coverage has especially
increased among racial and ethnic minorities. CHIP and Medicaid cover
more than half of Hispanic and African-American children, compared to
about one-quarter of White and Asian children.
HLC strongly believes that keeping children healthy by giving them
access to care is essential to the well-being of our society.
Diagnosing and treating problems at an early age increases the
likelihood that children will grow into healthy adults. This care will
also save costs, as these children will be more able to work and
contribute to our nation's economy in the future.
Without congressional action to extend CHIP beyond September 30th,
states will soon exhaust their CHIP funds. In this time of limited
state resources and tight budgets, a lack of federal assistance means
that states will have to remove children from CHIP. Many of these
children will not be eligible for Medicaid nor will their parents be
able to afford a private insurance plan. They will then become
uninsured and will have to go without necessary doctor visits,
prescriptions, and other health-care services. They will not be able to
access preventive care and will instead likely be treated in emergency
rooms and other high-cost settings.
HLC urges Congress to extend CHIP funding for 5 years. In addition, we
ask the Committee to consider giving states flexibility in
administering this program. For example, states could reduce their
costs by making CHIP a wraparound option for children who are eligible
for the program but who have access to private insurance through their
parents. This option would fill in the gaps in what the private plan
covers and would also cover the cost-sharing expenses of the private
plan. States could also be given incentives for managing CHIP
efficiently and streamlining the enrollment process.
Thank you for your work on this important issue. HLC looks forward to
continuing to collaborate with you. If you have any questions, please
do not hesitate to contact Debbie Witchey at (202) 449-3435.
Sincerely,
Mary R. Grealy
President
______
National Child Health Organizations
Statement for the Record Urging Quick Bipartisan
Action on a Strong, Five-Year Extension of Funding for the
Children's Health Insurance Program
As advocates for children and pregnant women, we call on Congress to
take immediate action to enact a 5-year extension of CHIP funding.
Since its inception in 1997, CHIP, together with Medicaid, has helped
to reduce the numbers of uninsured children by a remarkable 68 percent.
With CHIP funding set to expire on September 30, 2017, now is the time
for Congress to stabilize the CHIP funding stream and protect the gains
in children's health coverage that have resulted in more than 95
percent of all children in America being enrolled in some form of
insurance coverage.
CHIP has a proven track record of providing high-quality, cost-
effective coverage for low-income children and pregnant women in
working families. CHIP was a smart, bipartisan solution to a real
problem facing American children and families when it was adopted in
1997 and its importance and impact in securing a healthy future for
children in low-income families has only increased. Senators,
representatives, and governors all recognize the importance of CHIP in
providing affordable, pediatric-specific coverage to almost 9 million
children who cannot afford private coverage or lack access to employer-
based coverage. CHIP also delivers quality, affordable care to pregnant
women in 19 states, allowing them to obtain the care they need to have
healthy pregnancies and give birth to healthy infants.
With federal CHIP funding set to end on September 30, 2017, states are
facing critical decisions about the future of their CHIP programs. Many
states are just weeks away from setting in motion processes to
establish waiting lists and send out disenrollment notices to families.
Once undertaken, these actions will have an immediate effect, creating
chaos in program administration and confusion for families.
Extending CHIP is particularly important in light of the ongoing debate
on and uncertainty regarding the future of the Affordable Care Act
(ACA), Medicaid, and the stability of the individual insurance markets.
With state budgets already set for the coming year, states are counting
on CHIP to continue in its current form. Changes to CHIP's structure--
including changes to the Maintenance of Effort or the enhanced CHIP
matching rate--would cause significant disruption in children's
coverage and leave states with critical shortfalls in their budgets.
Given CHIP's track record of success, changes to CHIP that would cause
harm to children must not be made.
Today, we stand united in urging Congress to honor CHIP's 20 years of
success by securing this critical source of coverage for children and
pregnant women into the future. As Congress continues to work on larger
health system reforms, a primary goal should be to improve health
coverage for children, but at a minimum, no child should be left worse
off. We urge our nation's leaders to work together to enact a 5-year
extension of CHIP funding as an important opportunity for meaningful,
bipartisan action.
Contact: Ari Goldberg, VP Communications, First Focus, 240-678-9102;
agoldberg@
firstfocus.org.
#KeepKidsCovered
#CHIPworks
Endorsing Organizations
1,000 Days
Academic Pediatric Association
ADAP Advocacy Association (aaa+)
AFSCME
AIDS Alliance for Women, Infants, Children, Youth, and Families
Alliance for Strong Families and Communities
America's Essential Hospitals
American Academy of Family Physicians
American Academy of Nursing
American Academy of Ophthalmology
American Academy of Pediatrics
American Association for Pediatric Ophthalmology and Strabismus
American Association of Child and Adolescent Psychiatry
American Congress of Obstetricians and Gynecologists
American Dental Education Association
American Heart Association
American Lung Association
American Muslim Health Professionals
American Network of Oral Health Coalitions
American Pediatric Society
American Public Health Association
American Society for Radiation Oncology
American Society of Pediatric Hematology/Oncology
Asian and Pacific Islander American Health Forum
Association for Community Affiliated Plans
Association of Asian Pacific Community Health Organizations (AAPCHO)
Association of Maternal and Child Health Programs
Association of Medical School Pediatric Department Chairs
Association of Pediatric Hematology/Oncology Nurses
Association of School Business Officials International (ASBO)
Association of University Centers on Disabilities (AUCD)
Autism Speaks
Cancer Support Community
Center for Law and Social Policy (CLASP)
Center for Popular Democracy
Child Care Aware of America
Child Welfare League of America
Children and Family Futures
Children's Brain Tumor Foundation
Children's Cause for Cancer Advocacy
Children's Defense Fund
Children's Dental Health Project
Children's Health Fund
Children's Hospital Association
Children's Leadership Council
Children's Mental Health Network
Clearinghouse on Women's Issues
Coalition on Human Needs
Community Access National Network (CANN)
Community Catalyst
Cystic Fibrosis Foundation
Division for Early Childhood of the Council for Exceptional Children
(DEC)
Doctors for America
Easterseals
Every Child Matters
Families USA
Family Focused Treatment Association
Family Voices
First Focus
First Star Institute
Forum for Youth Investment
Generations United
Health Care for America Now
Healthy Schools Campaign
Healthy Teen Network
Heart Rhythm Society
HIV Medicine Association
IDEA Infant Toddler Coordinators Association (ITCA)
Judge David L. Bazelon Center for Mental Health Law
Justice in Aging
League of Women Voters of the United States
Leukemia and Lymphoma Society
Make Some Noise: Cure Kids Cancer Foundation, Inc.
March of Dimes
Mental Health America
NAACP
National Alliance on Mental Illness (NAMI)
National Alliance of State and Territorial AIDS Directors (NASTAD)
National Alliance of Children's Trust and Prevention Funds
National Association for Children's Behavioral Health
National Association of Community Health Centers
National Association of Councils on Developmental Disabilities
National Association of County Human Services Administrators
National Association of Pediatric Nurse Practitioners
National Association of Perinatal Social Workers
National Association of Social Workers
National Black Women's HIV/AIDS Network
National Center for Transgender Equality
National Consumers League
National Council of Jewish Women
National Crittenton Foundation
National Health Law Program
National Immigration Law Center
National Partnership for Women and Families
National Patient Advocate Foundation
National Respite Coalition
National Women's Health Network
Nemours Children's Health System
NETWORK Lobby for Catholic Social Justice
National Minority AIDS Council (NMAC)
Nurse-Family Partnership
Oral Health America
Out2Enroll
Partnership for America's Children
Pediatric Infectious Diseases Society
Pediatric Policy Council
Physicians for Reproductive Health
Raising Women's Voices for the Health Care We Need
Religious Institute
RESULTS
School-Based Health Alliance
Society for Pediatric Research
Solving Kids' Cancer
The Children's Partnership
The Jewish Federations of North America
The United Methodist Church--General Board of Church and Society
Trust for America's Health
United Way Worldwide
Universal Health Care Action Network
Voices for Progress
Young Invincibles
ZERO TO THREE
For more information, please contact:
Lisa Shapiro Kathleen King
Vice President, Health Policy Deputy Director, Child Health
First Focus Children's Defense Fund
1400 Eye Street, NW, Suite 650 25 E Street, NW
Washington, DC 20005 Washington, DC 20001
Office: (202) 657-0675 Office: (202) 662-3576
Email: [email protected] Email: [email protected]
______
Nemours Children's Health System
1201 15th Street, NW, Suite 520
Washington, DC 20005
www.nemours.org
Contact: Daniella Gratale
Email: [email protected]
Nemours Children's Health System owns and operates freestanding
children's hospitals in Wilmington, DE and Orlando, FL, as well as
primary and specialty practices and urgent care clinics throughout the
Delaware Valley and Florida. As one of the nation's largest pediatric-
focused health systems specializing in serving the needs of children,
including medically complex children, our 7,000 associates provide
direct care and services to more than 350,000 children, with over 1.3
million unique patient encounters annually.
We join with our nation's children's hospitals and the patients and
families they serve, in thanking the Senate Finance Committee (the
Committee) for its steadfast commitment to the Children's Health
Insurance Program (CHIP). The Committee's bipartisan support over
CHIP's long history has resulted in improved access to health care for
millions of vulnerable children--improving their lives and the overall
health of our nation. We greatly appreciate the joint statement by
Chairman Hatch and Ranking Member Wyden, released on the 20th
anniversary of the program, reaffirming their strong support for a
swift and bipartisan CHIP renewal. Particularly, Nemours would be
remiss not to recognize and thank Chairman Hatch for working hand in
hand with former Senators Kennedy, Rockefeller and Chafee to pass the
original CHIP program. It is our hope that, following the Committee's
consideration of the program during its hearing, Congress will take
prompt steps to renew funding for CHIP before the current authorization
expires on September 30, 2017.
CHIP is an important health coverage program for over 6 million low-
income children. Congress created CHIP in 1997, with strong bipartisan
support, to fill a gap in the coverage landscape. CHIP builds off a
strong Medicaid program by providing coverage for children who fall
above Medicaid eligibility levels but lack access to other health
coverage options. Congress designed CHIP with children in mind and
included child appropriate benefits, access to pediatric providers, and
cost-sharing limits to protect vulnerable children and families. CHIP,
together with Medicaid, has brought the rate of uninsured U.S. children
to an all-time low, with 95 percent of all children insured.
At Nemours, in 2016 nearly 15,000 CHIP-enrolled children sought care
within our system across the Delaware Valley and Florida (a total of
35,000 visits and discharges). Healthy children are more likely to grow
up to become healthy adults with a greater chance of success in life,
and CHIP helps ensure that the children covered by it have greater
opportunity to reach their full potential. If this program is not
reauthorized, many CHIP-enrolled children will likely become
underinsured or uninsured, threatening our nation's historic gains in
insuring children over the past two decades.
Nemours joins the National Governors Association, the Children's
Hospital Association, the Medicaid and CHIP Payment and Access
Commission (MACPAC), and many other child health advocates in
supporting a clean, 5-year reauthorization of CHIP in order to provide
certainty, stability and predictability in the program for states and
families and enable states to make programmatic improvements.
Time is of the essence for Congress to act. State budget cycles and
regulations make it difficult for states to maintain their CHIP
programs in the absence of federal funding certainty, and many states
have already planned for the funding to continue. If CHIP funding were
to lapse, states may be forced to make tough choices at the expense of
vulnerable children, including steps to disenroll children, impose
lock-outs and waiting periods, or wind down their CHIP programs
altogether.
Efforts to reauthorize CHIP should maintain current policy, which
includes the underlying CHIP program along with items like the
Pediatric Quality Measures Program (PQMP), express lane eligibility,
Childhood Obesity Research Demonstration Projects (CORD) and outreach
and enrollment grants--all of which are important components of CHIP.
The PQMP is the only significant federal investment in pediatric
health-care quality. An extension of this program with CHIP is
particularly important in order to continue to improve care and lower
costs for families and purchasers of care, such as state and federal
governments. Similarly, CORD supports promising health care and
community strategies to combat childhood obesity in children age 2-12,
who are enrolled in or eligible for Medicaid or CHIP. An extension of
CORD (as well as PQMP) is recommended by MACPAC and dovetails with
Nemours' longstanding priority to focus on preventive services to
reduce childhood obesity across the nation.
We thank the Chairman, Ranking Member, and Committee members for their
leadership and resolute support for CHIP. We are thankful for these
champions for children, and we look forward to working with the
Committee this month to maintain a strong CHIP program and strengthen
health care for children into the future.
______
Oral Health America (OHA)
180 N. Michigan Ave., Ste. 1150
Chicago, IL 60601
phone (312) 836-9900
fax (312) 836-9986
www.oralhealthamerica.org
September 5, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
Senate Committee on Finance Senate Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: CHIP Reauthorization is Essential to Children's Oral Health and
Well-being
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of Oral Health America (OHA), a leading nationwide
organization dedicated to changing the lives by connecting communities
with resources to increase access to care, education, and advocacy for
all, especially those most vulnerable, I write to submit a statement
for the record following the Senate Committee on Finance's September 7,
2017 hearing on ``The Children's Health Insurance Program: The Path
Forward.'' OHA requests the importance of extending funding for the
Children's Health Insurance Program (CHIP) be taken into strong
consideration by the Committee as the September 30th deadline
approaches. Specifically, OHA urges Congress to support a 5-year
extension through to fiscal year 2022 as has been widely-recommended.
OHA is deeply concerned the President's FY 2018 budget cuts CHIP by an
estimated $6 billion, or a 20% cut, despite the program being extended
through to 2019.
Since 1997, CHIP has helped children whose families have incomes too
high to qualify for Medicaid, but too low to afford private health
insurance. CHIP has reduced the number of uninsured children by more
than 50% while improving health outcomes and access to care for
children and pregnant women across the nation. Of direct interest to
the oral health community is the fact CHIP is the only insurance that
guarantees 8 million children a dental health benefit that includes
coverage for screenings and exams, cleanings, fluoride, and sealants.
Untreated tooth decay can cause pain that may lead to difficulty
eating, sleeping, and concentrating in school, leading to poor school
attendance, and academic performance. Without CHIP, these children
would lose much needed medical and dental coverage. According to the
Medicaid and CHIP Payment and Access Commission (MACPAC), without CHIP
some families would be susceptible to additional premiums and cost
sharing to access dental services in marketplace plans and/or employer-
sponsored insurance. This is particularly concerning for low-income
families and children. Furthermore, CHIP contributes to overall cost-
savings to the system by decreasing the number of emergency room visits
that are 10-times more expensive than routine, preventative care.\1\
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\1\ Health Policy Institute, American Dental Association. Thomas
Wall, Marko Vujicic. ``Emergency Department Use for Dental Conditions
Continues to Increase.'' April 2015.
Historically, CHIP has had bipartisan support. It gives states
flexibility in designing their programs, allowing them to implement the
program by expanding Medicaid, creating a separate program, or a
combination of both approaches.\2\ With that flexibility, states can
design a program that works best for their state and its children.
Simply stated, CHIP provides states needed ``certainty'' in planning
their budgets. MACPAC estimates all states would exhaust federal CHIP
funding at some point in FY18, with four states and the District of
Columbia running out of federal funds as early as December 2017.\3\
Therefore, time is of the essence. OHA urges Congress to act soon with
a 5-year CHIP funding extension.
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\2\ https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/
chip/index.html.
\3\ https://www.macpac.gov/topics/chip/.
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Respectfully submitted,
Beth Truett
CEO and President
______
UnidosUS
1126 16th Street, NW, Suite 600
Washington, DC 20036-4845
Submitted by Eric Rodriguez, Vice President
Office of Research, Advocacy, and Legislation
Introduction
UnidosUS, formerly the National Council of La Raza, is the largest
national Hispanic civil rights and advocacy organization in the United
States. We have a long history of advancing opportunities for middle-
and working-class Latino children and families, including immigrant and
mixed-status households, to achieve the highest level of health
possible.
In this capacity, UnidosUS and its Affiliate network of over 260 local,
community based organizations in 41 states, the District of Columbia,
and Puerto Rico, work diligently to ensure that the needs of our
community are met. Through our work with these affiliates we help
ensure that all individuals--regardless of who they are or where they
are from--have access to affordable, quality health coverage and care.
Advancing health equity is crucial for all Americans, including Latino
children who are more likely to be uninsured than their peers. Our
children are the future of this nation, and it is important that every
child has the opportunity and ability to grow up healthy.
As evidence of our commitment to improving access to health coverage
and care, UnidosUS has published several reports on policies and
programs, like the Children's Health Insurance Program (CHIP),
demonstrated to have had a positive impact on the health and well-being
of Latino children, including:
Latino Children's Coverage Reaches Historic High, But Too Many
Remain Uninsured, published by UnidosUS and the Georgetown Center for
Children and Families (December 2016)
Toward a More Equitable Future: The Trends and Challenges Facing
America's Latino Children, published by UnidosUS and the Population
Reference Bureau (September 2016)
Historic Gains in Health Coverage for Hispanic Children in the
Affordable Care Act's First Year, published by UnidosUS and the
Georgetown Center for Children and Families (January 2016)
The Children's Health Insurance Program (CHIP), has proven to be
essential to keeping millions of children and families, including
Latinos, healthy and financially secure. Since 1997, CHIP has provided
no-cost and low-cost health insurance for children of working families
who earn too much to qualify for Medicaid, but not enough to afford
private insurance. This program has enjoyed bipartisan support
throughout its 20-year history. Chief among these champions has been
Chairman Hatch, along with Democratic counterparts, including the late
Senator Edward Kennedy and Senator Jay Rockefeller.
CHIP's impact on our children has only grown during this time. In 2016,
there were nearly 9 million children enrolled in the CHIP program. Most
of these children (89 percent) are in working families earning between
$24,600 and $49,200 for a family of four, or between 100 percent and
200 percent of the Federal Poverty Level (FPL).\1\ The increase in
coverage for children in working families has precipitated a dramatic
decline in the number of all uninsured children. Since 1997, the
overall child uninsured rate has declined by two-thirds, from 14.9
percent in 1997 to 4.8 percent in 2015, the lowest rate ever
recorded.\2\
---------------------------------------------------------------------------
\1\ Medicaid and CHIP Payment and Access Commission, Child
Enrollment in CHIP and Medicaid by State, FY 2016 (Washington, DC:
MACPAC, 2017), Exhibit 31, https://www.
macpac.gov/wp-content/uploads/2015/01/EXHIBIT-31.-Child-Enrollment-in-
CHIP-and-Medicaid-by-State-FY-2016.pdf (accessed August 15, 2017).
\2\ Jason Gates et al., Uninsurance Among Children, 1997-2015:
Long-Term Trends and Recent Patterns (Washington, DC: Urban Institute,
2016), http://www.urban.org/research/publication/uninsurance-among-
children-1997-2015-long-term-trends-and-recent-patterns (accessed
August 2017), and Sonya Schwartz et al., ``Latino Children's Coverage
Reaches Historic High, But Too Many Remain Uninsured'' (DC: Georgetown
University Health Policy Institute Center for Children and Families and
National Council of La Raza, December 2016), http://
publications.nclr.org/handle/123456789/1672 (accessed August 2017).
UnidosUS recognizes the power of this program and, along with our
Affiliates, has worked over the past 20 years to expand access to CHIP
coverage for Latino children. Most recently, we have engaged with
partners at the state level to ensure that children have access to
coverage through the CHIP program in their states. For example, in
2016, we worked with child advocacy groups in Arizona to reinstate
their CHIP program, expanding access to quality, affordable health
coverage for an estimated 30,000-40,000 children.\3\
---------------------------------------------------------------------------
\3\ Vera Gruessner, ``Arizona's Children's Health Insurance Program
Back in Action,'' Health Payer Intelligence, July 26, 2016.
Despite this success, funding for this vital program ends on September
30, 2017. If CHIP funding is delayed or allowed to expire, the health
and well-being of nearly 9 million children currently enrolled in CHIP
will suddenly be at risk, along with the tremendous progress made in
narrowing health inequities experienced by all children of color,
including Latinos. With the uncertainty surrounding other important
health programs like the Affordable Care Act and Medicaid, it becomes
---------------------------------------------------------------------------
even more important for Congress to meet this deadline.
This written testimony will focus on the importance of the CHIP program
to the Latino community, narrowing inequities in health coverage for
Latino children, and the steps Congress must take to safeguard the
well-being of millions of children.
CHIP Narrows Coverage Gaps for Latino Children
While CHIP plays an important role in health coverage for nearly 9
million children, it has been especially influential in providing
access to health coverage and care for Latino children, who have
historically been more likely to be uninsured than their peers. Every
child deserves to grow up healthy and thrive, and many Latino children
and families depend on CHIP coverage for this opportunity:
Along with the Affordable Care Act, CHIP is responsible for
reducing the rate of uninsured Latino children from 28.6 percent in
1997, to 7.5 percent in 2015.\4\
---------------------------------------------------------------------------
\4\ Jason Gates et al., Uninsurance Among Children, 1997-2015:
Long-Term Trends and Recent Patterns (Washington, DC: Urban Institute,
2016), http://www.urban.org/research/publication/uninsurance-among-
children-1997-2015-long-term-trends-and-recent-patterns (accessed
August 2017), and Sonya Schwartz et al., ``Latino Children's Coverage
Reaches Historic High, But Too Many Remain Uninsured'' (DC: Georgetown
University Health Policy Institute Center for Children and Families and
National Council of La Raza, December 2016), http://
publications.nclr.org/handle/123456789/1672 (accessed August 2017).
---------------------------------------------------------------------------
Most Latino children (61 percent) live in families earning below
200 percent FPL, which makes them income-qualified for Medicaid/CHIP
coverage in nearly every state. 56 percent of Latino children are
enrolled in Medicaid or CHIP coverage.\5\
---------------------------------------------------------------------------
\5\ The Annie E. Casey Foundation, Children Below 200 Percent of
Poverty by Race (Baltimore, MD: Annie E. Casey, 2016), http://
datacenter.kidscount.org/data/tables/6726-children-below-200-percent-
poverty-by-race?Ioc=1&loct=1#detailed/1/any/false/573/12,1/13819,13820
(accessed August 2017), and Georgetown Center for Children and
Families, Snapshot of Children's Coverage by Race and Ethnicity
(Washington, DC: CCF, 2017), https://ccf.george
town.edu/wp-content/uploads/2017/04/Snapshot-of-Children%E2%80%99s-
Coverage-by-Race-and-Ethnicity.pdf (accessed August 2017).
---------------------------------------------------------------------------
Latino children account for the largest share of Medicaid and
CHIP enrollees (37 percent) of any ethnic group, despite accounting for
only 25 percent of the child population.\6\
---------------------------------------------------------------------------
\6\ Georgetown Center for Children and Families, Snapshot of
Children's Coverage by Race and Ethnicity (Washington, DC: CCF, 2017),
https://ccf.georgetown.edu/wp-content/uploads/2017/04/Snapshot-of-
Children%E2%80%99s-Coverage-by-Race-and-Ethnicity.pdf (accessed August
2017).
CHIP not only has allowed more children to have health coverage, it has
dramatically reduced health-care inequities affecting children of color
from working families. From 1997 to 2015, the coverage disparity
between White children and Latino children narrowed from 13 percentage
points to 3.7 percentage points, with CHIP accounting for much of this
decline.\7\ Further, a recent federally mandated evaluation of CHIP
enrollment across 10 states found that over half of CHIP enrollees (54
percent) were Latino.
---------------------------------------------------------------------------
\7\ Genevieve M. Kenney et al., CHIPRA Mandated Evaluation of the
Children's Health Insurance Program: Final Findings (Washington, DC:
Urban Institute, 2014), https://www.
medicaid.gov/chip/downloads/chip_report_congress-2014.pdf (accessed
August 2017).
Finally, the coverage provided by CHIP is unique in our health-care
system because its benefits are specifically tailored for children in
working families and may be more effective in detecting or preventing
certain conditions. Children with Medicaid or CHIP coverage are more
likely than children with private insurance to have had a routine
checkup, and are just as likely to have a primary, consistent source of
care.\8\ Most children enrolled in CHIP have access to the Early and
Periodic Screening, Diagnostic, and Treatment Benefit (EPSDT), which
enables these children to receive medically necessary services--like
treatment for vision, dental, and hearing problems--ensuring that
children of all ages in this income bracket have access to the specific
services appropriate at their current stage of development.\9\
---------------------------------------------------------------------------
\8\ Medicaid and CHIP Payment and Access Commission, The Future of
CHIP and Children's Coverage, Chapter 1 (Washington, DC: MACPAC, 2017).
\9\ Anita Cardwell et al., Benefits and Cost Sharing in Separate
CHIP Programs (Washington, DC: Georgetown CCF and National Academy for
State Health Policy, 2014), http://ccf.george
town.edu/wp-content/uploads/2014/05/Benefits-and-Cost-Sharing-in-
Separate-CHIP-Programs.
pdf (accessed August 2017).
---------------------------------------------------------------------------
Moving Forward with CHIP Funding Reauthorization
Since its inception, CHIP has enjoyed bipartisan support, including the
last time the program was reauthorized in the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA). This bipartisan support has helped
make CHIP an especially effective program, capable of reducing child
uninsured rates regardless of the political or economic climate.
While most states do not officially exhaust their CHIP funding until
later this year or next year, the state budget cycle requires many to
begin winding down their programs and sending out cancellation letters
several months in advance. If Congress does not authorize funding past
September 30th, children across the nation will face coverage
disruptions, causing them to fall behind on their well-child visits or
delay medically necessary treatment. Any delay in reauthorizing this
funding could reverse course on the tremendous progress that has been
made in reducing the number of uninsured children.
We believe that CHIP funding should be reauthorized in a way that
enables the program to continue to meet the unique health-care needs of
children in working families, including Latinos. As Congress considers
ways to continue to fund the CHIP program, we urge you to put children
first, and build on the foundation laid under previous reauthorizations
of this program including MACRA and the Children's Health Insurance
Program Reauthorization Act of 2009 (CHIPRA). UnidosUS strongly
believes that Congress should consider the following priorities as they
work to reauthorize funding for CHIP:
1. Extend federal CHIP funding on time. It is essential for the
health and well-being of our children that Congress reauthorize CHIP
funding by the September 30th deadline. This will allow states the
budgetary certainty they need to continue providing coverage for
children eligible for CHIP. Given the tremendous uncertainty
surrounding other parts of our health-care system, congress must ensure
that CHIP funding is not allowed to lapse for any period of time or
children will lose their health coverage.
2. Extend current funding levels established in the Medicare
Access and CHIP Reauthorization Act of 2015 (MACRA) and the Affordable
Care Act (ACA). The enhanced Federal Medical Assistance Percentage (E-
FMAP) authorized under MACRA, along with the current CHIP Maintenance
of Effort provision established under the ACA, has given states the
ability to provide coverage, without gaps, for children in families
earning under a specific income threshold. The increase of funding
authorized by MACRA provides states the ability to continue expanding
access to coverage to more children, and opened the doors for Arizona
to reinstate its program. If CHIP is not funded at current levels, some
states will once again impose waiting lists and enrollment caps on
their programs and currently eligible children may suddenly find
themselves without access to CHIP coverage.
3. Authorize a five-year extension of federal CHIP funding through
FY 2022. Renewing federal funding for an additional 5 years, as opposed
to a more short-term extension, will provide states with long-term
budgetary certainty necessary to develop and test approaches for a more
coordinated delivery system of comprehensive, affordable coverage for
children. A 5-year extension, at current funding levels, would also
better synchronize the program's funding with the current CHIP
authorization timeline.\10\
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\10\ Ibid.
4. Ensure the eligibility of at least as many children as allowed
under current law. When it comes to children's coverage, we should
always be looking forward, not back. It is critical to the success of
this program, and to the health and well-being of America's children,
that current eligibility standards are maintained or expanded. All
children, no matter who they are or where they are from, deserve the
opportunity to live healthy lives and thrive. Congress must ensure that
CHIP continues to play this role within our health-care system.
Conclusion
Despite undeniable success, long-standing bipartisan support, and
program reauthorization through 2019, funding for this vital program is
at risk. UnidosUS believes that the stakes--the health and well-being
of nearly 9 million children, a significant share of whom are Latino--
are too high for any delay or lapse in funding. CHIP is a foundational
part of our nation's health-care system, and helps ensure a stronger
and brighter future for our children. The millions of children enrolled
in CHIP cannot afford to go without coverage; children with health
coverage are more likely than those who go without to graduate high
school, attend college, and attain economic success in adulthood. By
investing in our children today we help ensure not only their
individual success but that of our nation. CHIP is a truly effective
program that helps give our children the healthiest start they need in
life. It is paramount that funding for this program remains strong for
years to come.
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