Geiger Gibson Program in Community Health Policy Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Research Brief # 39 Community Health Centers and Their Role for Patients Enrolled in the Children’s Health Insurance Program (CHIP) Jessica Sharac, MSc, MPH Peter Shin, PhD, MPH Sara Rosenbaum, JD The George Washington University Milken Institute School of Public Health Department of Health Policy and Management February 23, 2015 About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at The George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit operating foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long- standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at http://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at rchnfoundation.org. 2 Overview The Children’s Health Insurance Program (CHIP) provides access to affordable health insurance coverage for millions of people. In FY 2013, over 8 million individuals, more than 97% of whom were children, were enrolled in CHIP at some point during the year. 1 Medicaid and CHIP together insure over 37 percent of all U.S. children. 2 The families that depend on CHIP are overwhelmingly low income: in about two thirds of all states, the upper income eligibility standard for CHIP is slightly more than twice the federal poverty level (slightly more than $40,000 for a family of three in 2015). Low income families are significantly more likely than non-low income families to reside in medically underserved urban and rural communities that experience elevated health risks and a shortage of primary health care. For this reason, the nation’s more than 1,200 community health centers provide an important source of health care for CHIP- enrolled patients. Furthermore, low income families are likely to experience frequent income fluctuations throughout the year as a result of changes in work hours. In states that administer CHIP as a separate program either in whole or in part, CHIP beneficiaries may experience churn; that is, they may move between Medicaid and CHIP multiple times over the course of a year. 3 Since health centers play such a vital role in caring for Medicaid beneficiaries, importance to medically underserved families whose incomes hover between Medicaid and CHIP – the poorest CHIP families – is noteworthy. Table 1 presents data on the number of health center patients who are Medicaid- enrolled children (the US total excludes the territories) or individuals enrolled in CHIP, either through the CHIP Medicaid expansion option or through a separately administered CHIP program. Table 1 draws its data from the Uniform Data System 1 Medicaid and CHIP Payment and Access Commission (MACPAC). (2014). Report to the Congress on Medicaid and CHIP. Table 3. https://a7d050c2-a-10078ef1-s- sites.googlegroups.com/a/macpac.gov/macpac/reports/2014-03- 14_Macpac_Report.pdf?attachauth=ANoY7cpzMs0L9yGORKRP0yO7PV3ezRei5mY0OzmjLK_35zcZdAZT4OjGq 1uj6fNn7Z-g_QBqFWhvQyRj0aB4IQVqPIY42vLOP5s0VOaZQ0mwWiYuL_BL0RX3mE_g2UOP- n9KzYUru7hqLSy5AWRTdTXn0Xmca3EJ7Dnf9cKTYHw0jEFmJw9IZndsIm7UQk95B6cuEjdT_YCa19ZwhAVOo 2Wtuwpby6CUvauLjsJ5SUZ6esXSISugoBM%3D&attredirects=0 2 MACPAC. MACStats (2014) Part Two https://a7d050c2-a-10078ef1-s- sites.googlegroups.com/a/macpac.gov/macpac/macstats/2014_06_MACStats.pdf?attachauth=ANoY7cqqnjJW RLb-ra4YdXQf1PnckhsqKyWAnn8bLi_19P4- vX3NkNOXdllj8ZblcWxhGJAU8DbnsHJXEFSNLdATihsTf8a6D0gMtaZOgUdNDhxWA_8ez_6ZxLRCrYyqYb385H QIjMzVTQIa9vSepqXtfeYxR1jO1Du_Zrdul-dH7kWzEhbBk-qLmfEQJBAoxOWeP2SKB3pu7sVKE- UN5xxf7u23uQIB_2qXRfnIQVwQRKHJ3DFrqsk%3D&attredirects=0 3 Czajka, J. L. (2012). Movement of children between Medicaid and CHIP, 2005 to 2007. Final report to the Centers for Medicare & Medicaid Services. Washington, DC: Mathematica Policy Research. http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and- Systems/MedicaidDataSourcesGenInfo/Downloads/Medicaid_and_CHIP_Transitions.pdf 3 (UDS), a federal reporting system covering all health centers. Eight in ten (81 percent) CHIP-enrolled health center patients were children age 0-17 and 19 percent were ages 18 and older. Table 1. Medicaid-enrolled children and CHIP-enrolled individuals served by community health centers, 2013 CHC patients calendar year 2013: Medicaid- enrolled children and CHIP-enrolled patients (Medicaid expansion and separate CHIP program) Total state Percentage Medicaid CHC CHIP Total CHC CHIP of CHIP children CHC CHIP/ Separate CHIP enrollment enrollees ages 0-17 Medicaid program enrollment (FY 2013) all served by State all ages all ages all ages ages CHCs AL 60,329 423 1,626 2,049 113,490 1.8% AK 9,713 6,335 0 6,335 16,566 38.2% AZ 4 97,039 2,010 0 2,010 80,238 2.5% AR 23,173 7,962 0 7,962 119,726 6.7% CA 883,427 13,915 31,241 45,156 1,603,283 2.8% CO 131,981 205 17,141 17,346 131,042 13.2% CT 80,159 1,876 12 1,888 18,999 9.9% DE 6,764 195 0 195 13,180 1.5% DC 30,384 0 0 0 9,057 0.0% FL 268,841 7,217 10,504 17,721 473,415 3.7% GA 53,694 1,066 0 1,066 269,906 0.4% HI 32,312 0 0 0 30,979 0.0% ID 16,553 0 0 0 45,791 0.0% IL 350,563 19,378 0 19,378 337,097 5.7% IN 107,663 7,176 806 7,982 152,415 5.2% IA 41,220 44 387 431 83,670 0.5% KS 32,449 2,176 448 2,624 76,164 3.4% KY 56,402 4,836 0 4,836 84,069 5.8% LA 62,125 5 0 5 149,968 0.0% ME 23,527 1 0 1 29,712 0.0% MD 70,056 3,465 185 3,650 135,454 2.7% MA 101,982 0 1 1 148,719 0.0% MI 140,308 6,290 0 6,290 89,670 7.0% MN 26,838 0 0 0 3,835 0.0% MS 54,188 1,361 6,410 7,771 93,120 8.3% MO 120,205 700 0 700 92,918 0.8% 4 Arizona ended its CHIP program in 2014. 4 CHC patients calendar year 2013: Medicaid- enrolled children and CHIP-enrolled patients (Medicaid expansion and separate CHIP program) Total state Percentage Medicaid CHC CHIP Total CHC CHIP of CHIP children CHC CHIP/ Separate CHIP enrollment enrollees ages 0-17 Medicaid program enrollment (FY 2013) all served by State all ages all ages all ages ages CHCs MT 8,414 716 885 1,601 31,496 5.1% NE 13,863 0 0 0 55,783 0.0% NV 16,042 0 0 0 20,277 0.0% NH 10,129 1,345 0 1,345 19,450 6.9% NJ 73,255 60,157 1,478 61,635 390,769 15.8% NM 42,757 476 0 476 24,158 2.0% NY 353,586 0 50,081 50,081 490,114 10.2% NC 66,497 4,339 31 4,370 283,572 1.5% ND 3,794 79 64 143 11,281 1.3% OH 118,973 9 0 9 286,817 0.0% OK 38,451 0 0 0 147,911 0.0% OR 79,598 0 0 0 128,061 0.0% PA 125,828 964 7,399 8,363 267,073 3.1% RI 30,851 0 0 0 26,926 0.0% SC 76,785 0 404 404 76,191 0.5% SD 6,146 3,889 0 3,889 17,632 22.1% TN 65,851 0 450 450 106,473 0.4% TX 208,185 3,116 41,959 45,075 1,034,613 4.4% UT 14,284 38 2,236 2,274 63,001 3.6% VT 15,697 0 0 0 7,393 0.0% VA 35,221 6,956 0 6,956 201,547 3.5% WA 226,167 1,562 182 1,744 44,073 4.0% WV 51,114 449 6,218 6,667 37,065 18.0% WI 90,348 0 0 0 167,292 0.0% WY 1,614 94 0 94 8,815 1.1% Source: GWU analysis of 2013 UDS data; MACPAC. (2014). Report to the Congress on Total US 4,655,345 170,825 180,148 350,973 8,350,266 4.2% Medicaid and CHIP. Table 3. CHIP Enrollment by State, FY 2013 Nationally, in 2013, health centers served about one in every 25 CHIP-enrolled individuals (350,973 out of 8.35 million total beneficiaries). By contrast, based on the number of children enrolled in Medicaid in FY2011 (32 million), 5 we estimate that health 5Medicaid and CHIP Payment and Access Commission (MACPAC). (2014). Report to the Congress on Medicaid and CHIP. Table 2. https://a7d050c2-a-10078ef1-s- 5 centers served 15% of children enrolled in Medicaid (one in seven children receiving Medicaid). These figures underscore the heavily impoverished nature of health center patients, with the great majority having family incomes that place their children within mandatory Medicaid eligibility range. Although health centers’ role in CHIP is more modest, the U.S. totals mask certain important considerations. First, health centers’ importance to CHIP fluctuates significantly from state to state; health centers play an important role in certain states whose residents face extensive medical underservice challenges (e.g., Alaska). Indeed, the data suggest that health centers play a key role in certain states. In seven states (Alaska, Colorado, Connecticut, New Jersey, New York, South Dakota, and West Virginia), health centers served one in ten CHIP beneficiaries or greater. Second, the data suggest that health centers may play a more important role in states that administer their CHIP programs as a Medicaid expansion (in whole or in part) as well as for the lowest income CHIP families whose incomes may fluctuate between Medicaid and CHIP. Because health centers play such a significant role in Medicaid, their services may be of special importance for children whose family incomes sit close to the CHIP/Medicaid divide throughout the year. Similarly, health centers could be expected to be particularly important for patients whose CHIP coverage is derived through a Medicaid expansion given lower participation rates by private physicians in Medicaid. For example, in North Carolina, health centers served over 4,300 enrollees whose CHIP coverage was through Medicaid, but only 31 enrollees covered under the state’s separate CHIP program. Similar patterns can be seen in Arkansas, Connecticut, Illinois, Indiana, Kansas, Kentucky, Maryland, Minnesota, New Jersey, North Carolina, South Dakota, Virginia, and Washington State. (At the same time, Table 1 also shows that about half of all CHIP-enrolled health center patients are covered through separately administered CHIP programs). Implications As they do for Medicaid beneficiaries, health centers are instrumental for health care access under CHIP, serving one in 25 CHIP beneficiaries nationally but a far greater proportion of the CHIP population in certain states. Their role in CHIP may be especially important for families whose incomes fluctuate between Medicaid and CHIP, CHIP families living in medically underserved communities, and CHIP families in states that administer CHIP as a Medicaid expansion, in whole or in part. sites.googlegroups.com/a/macpac.gov/macpac/reports/2014-03- 14_Macpac_Report.pdf?attachauth=ANoY7cpzMs0L9yGORKRP0yO7PV3ezRei5mY0OzmjLK_35zcZdAZT4OjGq 1uj6fNn7Z-g_QBqFWhvQyRj0aB4IQVqPIY42vLOP5s0VOaZQ0mwWiYuL_BL0RX3mE_g2UOP- n9KzYUru7hqLSy5AWRTdTXn0Xmca3EJ7Dnf9cKTYHw0jEFmJw9IZndsIm7UQk95B6cuEjdT_YCa19ZwhAVOo 2Wtuwpby6CUvauLjsJ5SUZ6esXSISugoBM%3D&attredirects=0 6 The data presented in this issue brief underscore the relationship between CHIP and health centers. This relationship carries policy implications for the future of both CHIP funding and sustained grant funding for health centers, because of their interdependent nature. In the case of CHIP, health centers’ presence in medically underserved communities is a means of ensuring appropriate access to care, especially the lowest income CHIP families. For health centers, continued CHIP funding directly affects their ability to deliver high quality, appropriate health care for their patients. 7