Center for Public Policy Priorities 1 Texas Medicaid and CHIP Enrollment Update for Children’s...

Center for Public Policy Priorities www.cppp.org

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Texas Medicaid and CHIP Enrollment Update

for

Children’s Hospital Association of Texas

October 24, 2006Anne Dunkelberg, Associate Director

900 Lydia Street - Austin, Texas 78702Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org


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Texans and Health Insurance

US Census Bureau Statistics (March 2006 CPS):

• Approximately 5.5 million Texans uninsured in 2005–24.6% of Texans of all ages were uninsured (versus 15.7% U.S.)

–26.9% of Texans under age of 65 were uninsured

• Another three million Texans covered by Medicaid or CHIP (i.e., generally not insured through private coverage)

• Why are so many Texans uninsured?

Low percentage of employer-sponsored insurance (ESI)–8% below national average for < age 65 (54.5%, vs. 62.8%)–10.4% below national average for < age 18

–Only 12.0% of Texans below poverty have ESI

• Approximately 83% of Texas Medicaid recipients are below poverty (i.e., most are unlikely to be insured w/o Medicaid)


Texas’ Uninsured by Income, 2005

Income, % of Poverty

Uninsured

(millions)

As % of Group Max income, Family of 4

All 5.5 24.6%

<100% 1.55 42.2% $20,000

100-200% 1.92 37.5% $40,000

200-300% 1.04 26.5% $60,000

300-400% 0.446 14.8% $80,000

400-500% 0.172 9.4% $100,000

Above 500% 0.368 7.1% More than $100K


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How Does Immigration Factor In?

• Immigrants are NOT the primary cause of Texas’ last-place ranking – Census Bureau reported 2.4 million non-citizens

(includes both legal residents and undocumented persons); 1.3 million of them are uninsured (54.5% of non-citizens)

– BUT! If you removed non-citizens from the equation, Texas would still be tied with New Mexico for the worst uninsured rate at 20.6% uninsured (4.2 million), even if you left the non-citizens in the other state’s counts

• Without immigrants, New Mexico’s rate would drop to 18.9%


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Texas Health Insurance Stats:What They Tell Us About the Need for Outreach?

Texas Children who are Uninsured, 2004-05 – U.S. Census

All incomes, under age 19 (0-18*; 2-year average 2004-05 Census CPS)

20.4% 1.367 million

< 200% FPL; under age 19 (0-18; 2-year average 2004-05 Census CPS)

28% of <200%;

13.4% of all kids

919,000

•In other words, 2/3 of uninsured Texas children are below 200% of the federal poverty line, despite Medicaid and CHIP.

•Texas is home to an estimated 230,000 undocumented kids, and another 160,000 legal immigrant (LPR) children under age 18 (Pew Hispanic Center).

•But, the LPR kids can participate in CHIP. •Clearly, undocumented children are just a small part of our uninsured problem

•At least half of our uninsured kids (~689,000) could enroll in Medicaid or CHIP!


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Texas Medicaid: Who it Helps

Children, 1,784,302

Disabled, 360,974

Elderly, 362,953

Poor Parents, 60,445

TANF Parent, 25,411

Maternity, 97,161

August 2006, HHSC data.

Total enrolled 6/1/2006: 2,644,167


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Income Caps for Texas Medicaid and CHIP, 2006

0%

50%

100%

150%

200%

250%

PregnantWomen

Newborns Age 1-6 Age 6-18 TANFparent of

2, noincome

WorkingParent of

2

SSI (agedor

disabled)

LongTermCare

CHIP

Mandatory Optional

$22,078/yr

$30,710/yr $30,710/yr

185% 185%133%

$16,600

100%$2,256 $3,696

13.6% 22.3%74%

$7,476

222%

$21,708$33,200

200%

Income Limit as Percentage of Federal Poverty IncomeAnnual Income is for a family of 3,

except Individual Incomes shown for SSI and Long Term Care


8Medicaid in Texas: Who it HelpsMedicaid: As of September 2006, 2.6 million Texans were enrolled in Medicaid:•1.75 million were children

–about 96,000 of these children, or 5.5%, were receiving disability-related Medicaid (98% of these on SSI)

–about 13,100 were pregnant teens (0.8% of the kids; 0.5% of all Medicaid)

–125,600 in TANF cash assistance families ( 7.2% of the kids; 4.8% of total caseload)

–OTHER 1.5 MILLION predominantly in WORKING POOR FAMILIES

• About 1.2 million worker-headed families, • Other 20% are headed by disabled parents; living on child

support from non-custodial parent, or both)


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Medicaid in Texas: Who it HelpsMedicaid: As of September 2006, 2.6 million Texans were enrolled in Medicaid:895,000 were adults:

– 691,000 (79% of the adults) were elderly or disabled. Adults on SSI account for 60% of the aged and disabled recipients

– Other adults: 98,600 maternity coverage; 25,500 TANF parents (1.0% of total caseload);

– NOTE: there are fewer than 85,000 total poor parents on Texas Medicaid. 59,400 either TMA (Transitional Medicaid Assistance) or parents who are at or below TANF income, but not receiving TANF cash assistance

Children’s Health Insurance Program (CHIP):� as of September 1, 2003 — 507,259 children � as of October 1, 2006 — 300,685 (drop of 206,574, or 41%)


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Texas Child Medicaid and CHIP Enrollment (Jan. 2002-October 2006)

1,600,000

1,700,000

1,800,000

1,900,000

2,000,000

2,100,000

2,200,000

Jan-0

2

May

-02

Sep-0

2

Jan-0

3

May

-03

Sep-0

3

Jan-0

4

May

-04

Sep-0

4

Jan-0

5

May

-05

Sep-0

5

Jan-0

6

May

-06

Sep-0

6

Ch

ildre

n E

nro

lled

5,800,000

5,900,000

6,000,000

6,100,000

6,200,000

6,300,000

6,400,000

Ch

ild P

op

ula

tio

n

Source: Enrollment from Texas Health and Human Services Commission; Texas State Demographer's 0-17 Population Estimates

9/03: 2,150,543

10/06: 2,020,710


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Texas Child Medicaid Enrollment(February 2001-October 2006)

now:1,720,025

1,000,000

1,300,000

1,600,000

1,900,000

Feb-0

1

Jun-

01

Oct-0

1

Feb-0

2

Jun-

02

Oct-0

2

Feb-0

3

Jun-

03

Oct-0

3

Feb-0

4

Jun-

04

Oct-0

5

Feb-0

5

Jun-

05

Oct-0

5

Feb-0

6

Jun-

06

Oct-0

6

Source: Texas Health and Human Services Commission

Simplified Enrollment begins

High: 1,838,239


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Texas CHIP Enrollment(May 2000-Oct. 2006)

0

200,000

400,000

600,000

May

-00

Sep-0

0

Jan-0

1

May

-01

Sep-0

1

Jan-0

2

May

-02

Sep-0

2

Jan-0

3

May

-03

Sep-0

3

Jan-0

4

May

-04

Sep-0

4

Jan-0

5

May

-05

Sep-0

5

Jan-0

6

May

-06

Sep-0

6

Source: All figures from Texas Health and Human Services Commission;Compares most recent month with September 2003

Highest, 5/02: 529,271 9/03:

507,259

10/06: 300,685


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CHIP Caseloads: Now and Projected

2006 2007

September 2003 actual caseload 507,259

October 2006 actual caseload 300,685

decline, 9/03 to 10/06 (-40.7%) (-206,574)

HHSC 2/05 enrollment projection, if 12-month eligibility restored

386,110 467,404

SB 1 funded caseload, traditional CHIP (6 month renewal)*

344,750 351,132

Additional caseload, perinatal coverage 17,425 47,498

Total, SB 1 projected CHIP caseload, traditional & perinatal CHIP

362,175 398,630

*Rider 57 HHSC (SB 1) requires agency to request more $$ for CHIP from LBB if needed for enrollment and benefits.•HHSC Budget Request for 2008-09 would allow enrollment to grow to 339,037 in 2009.


14Recent Declines in Texas Children’s Medicaid Enrollment

December 2005

October 2006

Decline, December to October

State total 1,838,239 1,720,025 -118,214 -6.4%

Bexar 139,682 134,021 -6,478 -4.6%

Cameron 64,339 64,212 -1,347 -2.1%

Dallas 182,954 172,030 -12,900 -7.1%

El Paso 98,319 91,162 -9,054 -9.2%

Harris 316,896 301,042 -24,905 -7.9%

Hays 4,953 5,178 155 3.1%

Tarrant 97,908 91,296 -8,425 -8.6%

Travis 52,667 50,835 -3,400 -6.5%

Webb 36,473 33,347 -3,727 -10.2%



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Children’s Medicaid declines• Drop of over 99,000 children statewide from December 2005 to

April 2006 caused alarm.• As of April, Travis and Hays showing much greater loss since

December than statewide loss (-11.4% and -16.8%, vs. -5.4% statewide).

• However, caseloads improved June to September, and Travis and Hays county child enrollment rebounded by much larger margin than the statewide growth.

• Then dropped 35,607 from August to September; -28,670 from Sept. to Oct.

• Net decline since December now -118,214.• Travis and Hays counties now doing BETTER than state

average (Due to extra State attention to them?).• Of concern and unexplained: Webb and El Paso counties drop

more than Travis (-10.2, -9.2%)


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Adult Medicaid Trends - Statewide

Dec-05 Sept.-06 Dec 05 to Sept. 06

Change

Aged and Disabled

687,177 710,131 22,954 3.3%

Cash Assistance

31,876 25,527 -6,349 -19.9%

Maternity 93,617 98,614 4,997 5.3%

Other Parents

64,656 59,412 -5,244 -8.1%

Total 877,326 894,585 17,259 2.0%

•CAVEAT: Travis and Hays County Medicaid enrollment have DECLINED for adults from December 2005 to September 2006.

•Points to problems with the IE&E pilot and TIERS


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Adult Medicaid Trends – Travis CountyDec-05 Sept.-06 Dec 05 to

Sept. 06Change

Aged and Disabled

17,435 16,846 -589 -3.4%

Cash Assistance

4,089 4,352 263 6.4%

Maternity 1828 1,967 139 7.6%

Other Parents

1,692 1,596 -96 -5.7%

Total 25,044 24,761 -283 -1.1%

• From December 2005 to July 2006, Statewide Adult Medicaid enrollment grew by 1%, but Travis County enrollment DECLINED for adults, including aged and disabled and maternity (-6.5% overall)

• Enrollment since then shows some recovery; Statewide growth 2% since December, but Travis County enrollment dropped -1.1%

• Points to problems with the IE&E pilot and TIERS.


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Adult Medicaid Trends – Hays CountyDec-05 Sept.-06 Dec 05 to

Sept. 06Change

Aged and Disabled

1,956 1,658 -298 -15.2%

Cash Assistance

348 456 108 31.0%

Maternity 261 273 12 4.6%

Other Parents

119 106 -13 -10.9%

Total 2,684 2,493 -191 -7.1%

•From Dec. 2005 to Sept. 2006, Statewide Adult Medicaid enrollment grew by 2%, but Hays County enrollment DECLINED for aged and disabled and non-TANF parents (-7.1% overall)

•Hays County decline as of July was -10.1% (vs. +1.1% statewide), so some improvement over summer.

• Points to problems with the IE&E pilot and TIERS


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Recent Declines in Texas CHIP Enrollment

December 2005

September 2006

Decline, December to September

State total 322,898 291,530 -31,368 -9.7%

Bexar 20,915 18,443 -2,472 -11.8%

Cameron 7,814 7,770 -44 -0.6%

Dallas 33,325 30,470 -2,855 -8.6%

El Paso 13,628 11,571 -2,057 -15.1%

Harris 65,465 56,211 -9,254 -14.1%

Hays 1,489 1,342 -147 -9.9%

Tarrant 19,754 19,039 -715 -3.6%

Travis 8,550 8,847 297 3.5%

Webb 5,279 5,153 -126 -2.4%



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CHIP Declines• September ’06 county numbers show slight

improvement in SOME counties, while most remain well below December ’05 enrollment.

• Renewal rates ARE improved: back above 70% for June-Sept.-- compared to 50%-57% from January through May .

• However, thru September statewide enrollment continues to drop, new enrollment is low. Thus, too early to claim recovery trend for CHIP.


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What Texas Spendsand how much more it would cost to “Be Average”

State "Own Source" Budget, 2006-07: $90 Billion

All Other, $7.0 b, 8%

Business/Econ Devel., $9.2 b, 10%

Criminal Justice, $8.3 b, 9%

Other Health & Human Services,

$5.1 b, 6%

Medicaid, $14.1 b, 16%

Higher Education,

$17.7 b, 20%

K-12 Education, $28.6 b, 31%

"Own Source" = Excludes Federal Funds

If State Spending per Texan were equal to the U.S. Average,

this budget would

increase to $142

Billion

Source: LBB Fiscal Size Up 2006-07; NASBO State Expenditure Report 2004 (Jan 2006)


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Higher Ed: $17.7 $13.5 (tax swap)

HHS: $19.2 Higher Ed: $19.4

Prisons: $8.3 HHS: $22.8

Eco. Dev.: $9.2

Prisons: $8.7

Eco. Dev: $9.2

Other: $8.1

Other: $7.0

$-

$20

$40

$60

$80

$100

$120

2006-07 Spending 2008-09 Needs 2008-09 Revenue

$94 billion

$116 billion $114 billion

$2.1 (tax swap)

$6.6 b ending balance

$8 b rev growth

GR Dedicated: $1.3 bRainy Day Fund: $3.3 b

2008-09 Budget Will Be Very TightState Own-Source Spending and Revenue


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HHS Needs in 2008-09 “Above Baseline” Requests

• Restore 10% Cuts: HHSC $72 million/550 workers; Aging & Disability, $112 million/298 workers; Family & Protective Services, $40 million/Eliminate Prevention services; State Health Services, $236 million/693 workers; Assistive & Rehabilitative Services, $13 million/168 employees

• HHSC needs $1.8 billion GR ABOVE “base” to maintain caseload growth and inflation/cost increases in Medicaid and CHIP– $1.7 billion for Medicaid (allows for modest caseload growth)– $14.7 million for CHIP; Enrollment assumed to cap at 339,000 in

2009


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HHS Needs in 2008-09 (continued)

“Above Baseline” Requests• Other HHSC: $254 million for community care waiting lists;

$237 million to restore Medicaid and CHIP rate cuts from 2003

• State Health Services: $116 million for Mental Health and Substance Abuse programs

• Dept. Aging and Disability: $84 million to MAINTAIN community care: $10.7 million to restore 2003 rate cuts

• Family and Protective Services: $79.6 million to continue APS/CPS reform; $590 million to replace Rainy Day funds; $51.3 million for caseload growth


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Texas Unspent CHIP Funds Lost to Other States

• FFY 1998 Federal SCHIP Funds Lost - $170 million• FFY 1999 Federal SCHIP Funds Lost - $324.5 million • FFY 2000 Federal SCHIP Funds Lost - $123.7 million • FFY 2001 Federal SCHIP Funds Lost - $85.3 million • FFY 2002 Federal SCHIP Funds Lost - $104.6 million • FFY 2003 Federal SCHIP Funds Lost - $23.8 million • Total lapsed to date (2000-2005): $831.9 million• For perspective, TOTAL Texas CHIP spending in FY 2005 was

$401.6 million, of which $110 million was state dollars• Expected to soon lapse another $26.5 million from the 2004

allocation, based on state estimates as of 8/2006.

Source: Center on Budget and Policy Priorities, analysis of CMS data.


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History/Context of Texas CHIP and our

Federal CHIP Funding Allocation • BEFORE 2003 CHIP cuts, Texas was projecting a

CHIP federal funding shortfall by late 2006. • Had spending held flat at Texas’ fiscal year 2002 high (i.e., no

inflation and no enrollment growth) we’d still have had a federal shortfall at least by 2008.

• Now, state is assuming (in current state budget and in official reports to CMS) that CHIP enrollment will rebound, PLUS a perinatal option is scheduled to begin in January 2007.

• The latest (unofficial) state projection for federal CHIP shortfall in Texas is 2010.

• Texas projects 24% growth in CHIP spending from 2006 to 2007; based on this projected (but as yet non-existent) enrollment rebound PLUS new perinatal program

• Additional Texas CHIP spending planned (pending approval), but not included in current state projections: – SCHIP premium assistance waiver; Galveston regional “3-share”

waiver which will include SCHIP


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Federal SCHIP Reauthorization, 2007

• Other states want Texas’ lapsed funds (Other states have used all their and need more…)

• Texas’ CHIP allocation (share of the pie) will be targeted to be reduced based on our lower enrollment

• WILL Congress add money to CHIP to allow for population growth, inflation, or expansion?

• This is a cautionary example of the problems with block grants


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Federal SCHIP Reauthorization, 2007Priorities:• No loss of SCHIP ground in enrollment or benefits

(Need $12-$14 b/5 yrs new $$ to sustain) • Enough growth to cover all eligible/not enrolled @

current eligibility thresholds• Room to cover more uninsured kids• NO cuts to Medicaid to offset SCHIP

Other issues:• Fair treatment of states that did more prior to CHIP


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