Georgetown University Health Policy Institute The Questions to Ask With the outcome of the November midterm elections, the risk of federal legislation to repeal and replace the When Assessing the Affordable Care Act (ACA) and impose a cap on federal Medicaid funding has receded. Instead, there is renewed Impact of Coverage attention by some policymakers on how to once again make substantial progress toward the goal of universal Expansion Proposals coverage. This has become more urgent with recent survey data on Children showing that the ranks of the uninsured are increasing. For example, data from the Census Bureau’s American Community Survey (ACS) show that in 2017, the uninsured rate among children increased for the first time since at least 2008 when the ACS first asked a health insurance question. The share of children without by Edwin Park and Joan Alker health insurance rose from 4.7 percent to 5 percent between 2016 and 2017 and the number of uninsured children increased by 276,000.1 Sixth in a series of briefs on the future of While the number of children with health insurance has children’s health care coverage reversed modestly, this troubling sign comes on the heels of extraordinary progress as a result of efforts at the federal and state levels to address children’s health March 2019 needs. Following decades of coverage expansions and eligibility simplifications through Medicaid and the Children’s Health Insurance Program (CHIP), the percent of insured children reached a historically high level of 95.5 percent in 2016.2 Children are also at risk when their parents and caregivers lack health insurance. The latest results from the Gallup National Health and Well-Being Index, for example, find that the uninsured rate among adults has increased by 2.8 percentage points since 2016 (from a low of 10.9 percent in the third quarter of 2016 to 13.7 percent in the fourth quarter of 2018), which translates to an increase of about 7 million people. According to Gallup, this is the highest uninsured rate among adults since the ACA’s major coverage expansions were implemented in 2014.3 CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 2 The health coverage expansion plans being proposed not Medicaid for those not currently eligible). Others would only by members of Congress but also by think tanks and provide a public health insurance plan option for the ACA’s health advocacy organizations vary considerably in their marketplaces. approach and scope. Some proposals would establish There is a wide diversity among these coverage expansion new universal coverage programs (often under the rubric proposals. This issue brief asks a number of key design of “Medicare for All”) that may or may not replace current questions to help assess the relative merits of expansion coverage sources like employer-sponsored insurance and proposals from the perspective of children, especially public programs such as Medicare, Medicaid and the ACA the tens of millions of low-income children who rely on marketplaces. Some proposals would expand coverage Medicaid and the CHIP today. to targeted populations (such as by lowering the age of Medicare eligibility or allowing a buy-in to Medicare or 1. How would the coverage expansion proposal affect Medicaid and CHIP coverage of children? More than 35 million low-income children rely on Medicaid Medicaid and CHIP enrollment increases, driven by and CHIP for their health coverage.4 Data from the eligibility expansions and efforts to increase participation American Community Survey indicate that 34.3 percent of among eligible families, were primary contributors to the children under age 19 (and 38.9 percent of children under dramatic reduction in the number and rate of uninsured age 6) rely on Medicaid and CHIP for their sole source of children since CHIP was enacted in 1997. As a result, a coverage.5 key question about any major health coverage expansion proposal is how it would affect children’s existing eligibility. Medicaid is highly efficient, providing health coverage Would Medicaid and CHIP be replaced with a new (including to children) at a lower cost per beneficiary than coverage program? If not, would the coverage expansion in private insurance largely due to lower provider payment build on Medicaid and CHIP or rely on a different or new rates and administrative costs. This is true even though program to cover children (both low-income and higher- Medicaid covers a more comprehensive array of benefits income) who remain uninsured? Under a new coverage and does not generally require any cost-sharing charges expansion proposal, would all eligible children be entitled for children.6 Moreover, overall Medicaid per-beneficiary to enroll, as under Medicaid today? costs have also been growing considerably more slowly than private insurance.7 These questions have serious consequences for the future of children’s health. Medicaid and CHIP have evolved over Medicaid also delivers high quality care, providing decades to address the needs of children for whom the children with needed access to care such as well-child private market is too expensive or is unable to address visits and enabling children to have a regular source of their special health care needs. In addition, the growing care, at rates comparable to or greater than in private recognition of the influence of poverty on development insurance. In addition, research has linked Medicaid with in early childhood underscores that a new coverage reduced infant and childhood mortality, because it leads to expansion program, if designed primarily for children greater utilization of preventive and acute health services. living in families with middle class incomes, may not be Research has also linked Medicaid coverage in childhood adequate to serve Medicaid’s vulnerable low-income to long-term benefits including higher educational children.9 attainment and better health and earnings in adulthood.8 CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 3 2. Would the new coverage expansion’s benefit package be tailored to children’s unique needs? Whether a coverage expansion proposal replaces about 48 percent of children with special health care Medicaid and CHIP or establishes a new program that needs are covered by Medicaid and CHIP.11 Medicaid also leaves Medicaid and CHIP in place but is intended to serves children in the child welfare system who tend to cover more uninsured children, another key question is have greater physical and behavioral health needs. While what benefits would be provided, and how they would separate CHIP programs are not required to cover EPSDT compare to those furnished under Medicaid and CHIP. benefits, all states are required to cover comprehensive Both programs have a pediatric benefits package designed pediatric benefits (with some states electing to provide with children in mind that provides a comprehensive array EPSDT-like benefits).12 of services intended to fully meet the needs of low-income In addition, Medicaid increasingly covers a variety of children, especially those with disabilities and special screening and referral services, care management, health care needs. program integration, health home and supportive housing For example, Medicaid (including CHIP-funded Medicaid, in services intended to help address the social determinants which more than half of CHIP child beneficiaries are enrolled) of health by more effectively connecting beneficiaries provides a comprehensive child-focused benefit: the Early to needs within and outside the health sector. Lack of and Periodic Screening, Diagnostic, and Treatment benefit access to affordable housing, economic insecurity for (EPSDT). It is designed to ensure that children receive families, unsafe neighborhoods and lack of access to recommended preventive screenings, follow-up diagnostic adequate and healthy nutrition can all negatively affect assessments, and all medically-necessary services that the health of low-income children.13 Medicaid can also health care providers deem essential to prevent, treat or provide financial support for home-visiting programs for improve the diagnosed condition, even if the services they pregnant women and young children, which offer social, need are not otherwise covered under the state’s Medicaid health and educational services that support healthy child program. The intent of the EPSDT benefit is to ensure development.14 The Medicare benefits package or the coverage for items and services that not only treat a Essential Health Benefits provided in marketplace plans, condition but also prevent it from occurring or worsening.10 for example, would not provide the same level of coverage This includes coverage of long-term services and supports to children that Medicaid’s EPSDT benefit provides. and other services that children with special health care needs require. According to the Kaiser Family Foundation, 3. What would be the premium and cost-sharing requirements under the new coverage expansion? To ensure access to needed care, most children covered relatively small levels of cost-sharing discourage use of by Medicaid are entirely exempt from premiums, needed care, particularly among low-income individuals. deductibles and co-payments. Other children, including Cost-sharing increases can lead to poorer health those covered by Medicaid with somewhat higher incomes outcomes and increased overall financial burdens.16 How and those enrolled in separate state CHIP programs, may much would families have to pay in premiums, deductibles be subject to modest premiums and nominal co-payments and other cost-sharing charges under the coverage but with total out-of-pocket costs limited to no more than expansion proposal and how would that compare to 5 percent of family income.15 Research is clear that even Medicaid and CHIP? CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 4 4. How would the coverage expansion measure and ensure quality of care? First enacted as part of CHIP’s funding extension in 2009, their performance. In the case of managed care, state the Child Core Set is a set of standardized, evidence- Medicaid programs are also required to conduct other based measures to assess the quality of care provided to quality improvement activities including External Quality children covered by Medicaid and CHIP. Measures include, Reviews and Performance Improvement Projects.17 A for example, well-child visits, immunization, timeliness of number of states also adopt Bright Futures for their EPSDT prenatal and postnatal care, percentage of low-birthweight periodicity schedule. Bright Futures is a national pediatric births, preventive dental care, and followup care for standard created by the American Academy of Pediatrics children hospitalized for mental illness. While reporting that establishes a recommended schedule of screenings, on the full set of measures is not mandatory until 2024, immunizations and procedures for children under EPSDT.18 the voluntary reporting to date has helped accelerate A key question is how any new coverage expansion would quality improvements in Medicaid and CHIP for children measure quality of care for children and support significant (and mandatory reporting will have an even larger impact). quality improvements as Medicaid does today. Standardized data reporting allows a comparison of quality of care across states and helps states identify gaps in 5. What would be the health care delivery system under the coverage expansion and how would health care providers be reimbursed? In 2016, more than two-thirds of Medicaid beneficiaries providers, such as community health centers and public were enrolled in comprehensive Medicaid managed hospitals. Would these institutions be included in the care plans and more than 80 percent were in some type network of health care providers furnishing care under an of managed care arrangement, including primary care expansion proposal? Moreover, Medicaid now reimburses case management.19 How would care be delivered under non-traditional providers, such as schools, for providing the new coverage expansion proposal? If a coverage Medicaid-covered services like screenings and therapy expansion similarly relies on managed care, what services to students covered by Medicaid.20 requirements and other beneficiary protections would Medicaid also provides additional payments to health apply to ensure access to needed services, and how care providers that disproportionately serve low-income would they compare to those required under Medicaid patients. Examples include the Medicaid Disproportionate today (as discussed further below)? How would health Share Hospital (DSH) program for hospitals that primarily care providers be generally reimbursed under the coverage serve Medicaid beneficiaries and the uninsured and other proposal, and how would the coverage expansion ensure supplemental payments to hospitals and nursing homes.21 sufficient participation by providers including pediatric Moreover, community health centers are reimbursed under specialists and children’s hospitals? a special prospective payment system (or a comparable In addition, in part because low-income children tend alternative payment arrangement) in Medicaid and CHIP.22 to reside in underserved urban and rural areas, children Would such payment mechanisms that support the health covered by Medicaid disproportionately rely on safety net care safety net be part of the new coverage expansion? CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 5 6. What are the beneficiary access protections under the coverage expansion? Medicaid includes a wide array of beneficiary requirements existing condition exclusions have never been permitted and protections. For example, because all eligible in Medicaid. In addition, Medicaid payments to health individuals are entitled to enroll, individuals (both care providers must be sufficient to ensure adequate applicants and beneficiaries) have a right to adequate participation so that care and services are available to notice and to a fair hearing, including the right to request the same extent as to the general population in the same a fair hearing before an impartial decisionmaker and the geographic area. right to the continuation of benefits pending the hearing There is also longstanding jurisprudence that has clarified decision and any appeals. This protection also applies to and expanded these beneficiary rights and protections denials or delays of covered services. Medicaid managed in Medicaid. For example, court cases interpreting the care plans are also required to establish a grievance EPSDT benefit have made clear that coverage limits for and appeals process, treat enrollees with respect and children are prohibited, except in the case of a lack of dignity, and ensure timely access to services, among medical necessity as determined from individual facts.24 other enrollee rights.23 Medicaid benefits must also be How would a proposed coverage expansion compare comparable across beneficiaries and not discriminate to these existing Medicaid protections and appeals based on diagnosis, type of illness or condition. Pre- processes? 7. How will the coverage expansion be administered? States are responsible for administering Medicaid and of health care such as education, housing and nutrition. CHIP programs, within federal requirements and with Many states operate integrated eligibility systems and federal oversight. Because states have expansive flexibility multi-benefit applications. These also include “hub and under Medicaid and CHIP, this results in substantial spoke” system changes in which a state Medicaid agency variation across Medicaid programs including in eligibility, takes responsibility for coordinating and supporting an benefits and provider payments. If a coverage expansion array of services and other government agencies and uses a federally administered system, it could have the community organizations. As discussed above, these are benefits of uniformity and continuity for children regardless all critical strategies in addressing the social determinants of where they live, but this would not be beneficial if these of health.25 How would a new coverage expansion take on standard protections for children were weaker than those these kinds of administrative activities if taking the place of in the existing Medicaid (or CHIP) program for children. a state Medicaid agency? Moreover, states are well-positioned to establish linkages across federal, state and local programs to connect beneficiaries to needed services, including those outside CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 6 8. What is the implementation timeline for the coverage expansion, and is there a transition period? If a coverage expansion proposal moves some or all a transition from Medicaid and CHIP to a new coverage children now covered by Medicaid and CHIP to a new program ensure sufficient outreach and education for program, one critical question would be how would a affected families to avoid children falling through the transition of up to 35 million low-income children be cracks and disruptions in coverage and care? Would implemented? For example, how would continuity of sufficient resources be available for linguistically and care be maintained, especially for those most vulnerable culturally appropriate community-based outreach efforts to children with disabilities and special health care needs help families navigate an entirely new system? who require particular providers and services? How would 9. How will children’s needs specifically be addressed in any new coverage expansion? The CHIP program has helped focus attention on how clout overall and because of the past progress towards to make substantial improvements to the enrollment covering all children, children’s needs may end up being and retention of eligible children in Medicaid. Having a a lower priority in the design considerations for a new program focused explicitly on children has contributed to coverage expansion program. As a result, children may a successful decades-long, child-focused effort to reduce get lost in the shuffle in larger debates about health care the rate of uninsurance and improve access to needed system reform in the United States. How would children’s care among children. Because children are less costly on a needs be specifically addressed? per-beneficiary basis and have considerably less political Conclusion The Congressional midterm elections have resulted in with Medicaid covering the vast majority of low-income a welcome, renewed focus on how to achieve universal children. Medicaid’s pediatric EPSDT benefit is the health coverage, including for children. While there is definitive standard for children’s care recommended by significant debate about the merits of various coverage the Academy of Pediatrics, and it is available to all eligible proposals in terms of policy and politics, one critical children nationwide at generally no cost. Any coverage approach in evaluating such proposals is through the lens expansion proposal should build on these successes and of children, particularly the tens of millions of low-income not allow children to fall through the cracks. children covered by Medicaid and CHIP today. Expansions of Medicaid and CHIP have been largely responsible for the historic decline in children’s uninsurance rates CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 7 Acknowledgments This brief was written by Edwin Park and Joan Alker. The authors would like to thank Elisabeth Wright Burak, Andy Schneider, Cathy Hope and Kelly Whitener for their contributions to the report. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. About this Series This issue brief is sixth in a series of papers from Georgetown University Center for Children and Families on the future of children’s health coverage. Other briefs in the series include: The Future of Children’s Coverage: Children in the Marketplace. Focuses on ways to improve marketplace coverage and the associated financial assistance for children. Fulfilling the Promise of Children’s Dental Coverage. Focuses on pediatric dental coverage and ways to improve children’s oral health. How Medicaid and CHIP Shield Children from the Rising Costs of Prescription Drugs. Focuses on how Medicaid and CHIP protect most children from the rising costs of prescription drugs. Promoting Young Children’s Healthy Development in Medicaid and the Children’s Health Insurance Program (CHIP). Focuses on ways that state and federal policymakers can use Medicaid and CHIP to more effectively put young children on the best path for success in school and in life. How to Strengthen the Medicaid Drug Rebate Program to Address Rising Medicaid Prescription Drug Costs. Focuses on the effectiveness of the Medicaid Drug Rebate program and how to improve it. CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 8 Endnotes Spending. 12 Anita Cardwell et al., “Benefits and Cost-Sharing in Separate CHIP 1 Joan Alker and Olivia Pham, “Nation’s Progress on Children’s Programs,” National Academy for State Health Policy and Georgetown Health Coverage Reverses Course,” Georgetown University Center University Center for Children and Families, May 2014, available at ccf. for Children and Families, November 2018, available at https://ccf. georgetown.edu/wp-content/uploads/2014/05/Benefits-and-Cost- georgetown.edu/wp-content/uploads/2018/11/UninsuredKids2018_ Sharing-in-Separate-CHIP-Programs.pdf. Final_asof1128743pm.pdf. 13 Tricia Brooks and Kelly Whitener, “Leveraging Medicaid to 2 Alker and Pham, op, cit. Address Social Determinants and Improve Child and Population 3 Dan Witters, “U.S. Uninsured Rate Rises to Four-Year High,” Gallup, Health,” Georgetown University Center for Children and Families, January 23, 2019, available at https://news.gallup.com/poll/246134/ February 2018, available at https://ccf.georgetown.edu/wp-content/ uninsured-rate-rises-four-year-high.aspx. uploads/2018/02/Leveraging-Medicaid.pdf and Samantha Artiga and Elizabeth Hinton, “Beyond Health Care: The Role of Social 4 Centers for Medicare and Medicaid Services, “October 2018 Medicaid Determinants in Promoting Health and Health Equity,” Kaiser Family and CHIP Enrollment Data Highlights,” December 27, 2018, available Foundation, May 1, 2018, available at http://files.kff.org/attachment/ at https://www.medicaid.gov/medicaid/program-information/medicaid- issue-brief-beyond-health-care. and-chip-enrollment-data/report-highlights/index.html. 14 Elisabeth Wright Burak, “How Are States Using Medicaid to Pay 5 Georgetown University Center for Children and Families comparison for Home Visiting? New Paper Offers More Clarity,” Say Ahhh! Blog, of 2016 and 2017 single-year national estimates of health coverage for Georgetown University Center for Children and Families, January 25, children using IPUMS ACS data. 2019, available at https://ccf.georgetown.edu/2019/01/24/how-are- 6 Leighton Ku and Matthew Broaddus. “Public And Private states-using-medicaid-to-pay-for-home-visiting-new-paper-offers- Health Insurance: Stacking Up the Costs,” Health Affairs, March more-clarity/. 2008, available at https://www.healthaffairs.org/doi/pdf/10.1377/ 15 Tricia Brooks et al., “Medicaid and CHIP Eligibility, Enrollment, hlthaff.27.4.w318 and Teresa Coughlin et al., “What Difference Does Renewal and Cost-Sharing Policies as of January 2018: Findings from a Medicaid Make?,” Kaiser Family Foundation, May 2013, available at 50-State Survey,” Kaiser Family Foundation, March 21, 2018, available https://kaiserfamilyfoundation.files.wordpress.com/2013/05/8440-what- at http://files.kff.org/attachment/Report-Medicaid-and-CHIP-Eligibility- difference-does-medicaid-make2.pdf. Enrollment-Renewal-and-Cost-Sharing-Policies-as-of-January-2018. 7 John Holahan and Stacey McMorrow, “Slow Growth in Medicare and 16 Samantha Artiga, Petry Ubri and Julia Zur, “The Effects of Premiums Medicaid Spending Per Enrollee Has Implications for Policy Debates,” and Cost-Sharing on Low-Income Populations: Updated Review of Urban Institute, February 11, 2019, available at https://www.urban.org/ Research Findings,” Kaiser Family Foundation, June 1, 2017, available sites/default/files/publication/99748/rwjf451631_1.pdf. at http://files.kff.org/attachment/Issue-Brief-The-Effects-of-Premiums- 8 Karina Wagerman, “Medicaid Provided Needed Access to Care for and-Cost-Sharing-on-Low-Income-Populations. Children and Families,” Georgetown Center for Children and Families, 17 Tricia Brooks, “No Changes in Child Core Set of Health Care March 2017, available at https://ccf.georgetown.edu/wp-content/ Quality Measures in Medicaid and CHIP for 2019,” Say Ahhh! Blog, uploads/2017/03/Medicaid-provides-needed-access-to-care.pdf and Georgetown University Center for Children and Families, December 12, Karina Wagerman, Alisa Chester and Joan Alker, “Medicaid Is a Smart 2018, available at https://ccf.georgetown.edu/2018/12/12/no-changes- Investment in Children,” Georgetown Center for Children and Families, to-child-core-set-of-health-care-quality-measures-in-medicaid-and- March 2017, available at https://ccf.georgetown.edu/wp-content/ chip-for-2019/ and Tricia Brooks, “Measuring and Improving Health uploads/2017/03/MedicaidSmartInvestment.pdf. Care Quality for Children in Medicaid and CHIP: A Primer for Child 9 Elisabeth Wright Burak and Mike Odeh, “Developmental Screenings Health Stakeholders,” Georgetown University Center for Children and for Young Children in Medicaid and the Children’s Health Insurance Families, March 2016, available at https://ccf.georgetown.edu/wp- Program,” Georgetown University Center for Children and Families, content/uploads/2016/03/Measuring_Health_Quality_Medicaid_CHIP_ March 2018, available at https://ccf.georgetown.edu/wp-content/ Primer.pdf. uploads/2018/03/Dev-Screening-3-15.pdf. 18 Brooks and Whitener, op cit. 10 Elisabeth Wright Burak, “Promoting Young Children’s Healthy 19 Centers for Medicare and Medicaid Services, “Medicaid Managed Development in Medicaid and CHIP,” Georgetown University Center Care Enrollment and Program Characteristics 2016, “ Spring 2018, for Children and Families,” October 2018, available at https://ccf. available at https://www.medicaid.gov/medicaid/managed-care/ georgetown.edu/wp-content/uploads/2018/10/Promoting-Healthy- downloads/enrollment/2016-medicaid-managed-care-enrollment- Development-v5-1.pdf. report.pdf. 11 MaryBeth Musumeci and Julia Foutz, “Medicaid’s Role for Children 20 Phyllis Jordan, “What’s At Stake for Schools and Students in Health with Special Health Care Needs: A Look at Eligibility, Services, and Care Debate?,” Say Ahhh! Blog, Georgetown University Center Spending,” Kaiser Family Foundation, February 22, 2018, available at for Children and Families, March 22, 2017, available at https://ccf. http://files.kff.org/attachment/Issue-Brief-Medicaids-Role-for-Children- georgetown.edu/2017/03/22/whats-at-stake-for-schools-and-students- with-Special-Health-Care-Needs-A-Look-at-Eligibility-Services-and- CCF.GEORGETOWN.EDU COVERAGE EXPANSION PROPOSALS 9 in-health-care-debate/. 21 Medicaid and CHIP Payment and Access Commission, “Medicaid Georgetown University Center for Base and Supplemental Payments to Hospitals,” June 2018, available Children and Families at https://www.macpac.gov/wp-content/uploads/2018/06/Medicaid- McCourt School of Public Policy Base-and-Supplemental-Payments-to-Hospitals.pdf. Box 571444 22 Medicaid and CHIP Payment and Access Commission, “Medicaid Payment Policy for Federally Qualified Health Centers,” 3300 Whitehaven Street, NW, Suite 5000 December 2017, available at https://www.macpac.gov/wp-content/ Washington, DC 20057-1485 uploads/2017/12/Medicaid-Payment-Policy-for-Federally-Qualified- Phone: (202) 687-0880 Health-Centers.pdf. Email: childhealth@georgetown.edu 23 Kim Lewis and Wayne Turner, “What Makes Medicaid, Medicaid? — Consumer Protections and Due Process,” March 21, 2017, available at https://9kqpw4dcaw91s37kozm5jx17- wpengine.netdna-ssl.com/wp-content/uploads/2017/03/ WhatMakesMedicaidConsumerProtectionsDueProcess-3.23.172.pdf www.ccf.georgetown.edu and see also Andy Schneider et al., “The Medicaid Resource Book,” Kaiser Family Foundation, July 2002, available at https://www.kff.org/ facebook.com/georgetownccf medicaid/report/the-medicaid-resource-book/. 24 Sara Rosenbaum, “Medicaid and the Role of the Courts,” twitter.com/georgetownccf Commonwealth Fund, June 12, 2018, available at https://www. commonwealthfund.org/publications/fund-reports/2018/jun/medicaid- and-role-courts. 25 Brooks and Whitener, op cit.