Children s Health Insurance Coverage: Children’s Progress, Challenges, and Opportunities Cathy Schoen Schoen, Senior Vice President The Commonwealth Fund www.commonwealthfund.org g Academy Health Annual Research Meeting S Di San Diego, June J 10 10, 2014 Children’s Coverage and Access to Care Affordable Care Act and Beyond • Coverage Goals: access + financial protection – What care system? Coverage and care systems matter – Insurance is a family affair: parents’ coverage matters • Baseline: Important to know the starting point – Uninsured or underinsured • Affordable Care Act: Key provisions • Challenges and opportunities – Eligibility if low-income: Medicaid, CHIP and the ACA – Cost sharing and health care networks – Need for research to inform action 2 3 47 Million Uninsured 2012: Children’s Rates Lower than Adults in All States as a Result of Medicaid/CHIP Adults 25% - 31% 19% - 24% Children 13% - 18% 8% - 12% Source: Commonwealth Fund analysis U.S. Census Bureau, March 2012-13 Current Population Survey 3% - 7% 4 Uninsured and Underinsured: 2012 Total Under Age g 65 Children 18 or y younger g Adults 19 to 64 47 3 million 47.3 illi 7 2 million 7.2 illi 40 1 million 40.1 illi Underinsured: Insured in Underinsured Family 31.7 million 12.3 million 19.4 million Total: Uninsured or Underinsured 79.0 million 19.5 million 59.5 million 29% 25% 31% U i Uninsured d Percent Uninsured or Underinsured Data Source: Commonwealth Fund Analysis Current Population Survey, March 2013. Also see C. Schoen, et al. Uninsured in America Commonwealth Fund March 2014. for state estimates. Underinsured or Uninsured by State, 2011–2012 5 Ranges from 14 to 38 percent of population Percent of under-65 population 50 Uninsured Insured but underinsured* 40 30 National average (2012): 29% 20 0 Massachusettss Dist. of Columbia D Minnesotaa Connecticutt Vermontt Hawaiii North Dakotaa New Hampshiree Delawaree Iowaa Pennsylvania n Wisconsin Maryland Mainee Rhode Island New Yorkk Michigan n Virginiaa Nebraska New Jerseyy Kansass South Dakotaa Washington n Indiana Missourii Illinoiss Ohio o Kentuckyy Alabamaa West Virginia o Colorado South Carolina n Oregon California Oklahomaa Tennesseee Arizona Alaskaa Utah h North Carolina Georgiaa Wyomingg Louisiana Mississippii Montanaa Arkansass Idaho o Floridaa Nevadaa New Mexico o Texass 10 • Underinsured defined as insured in household that spent 10% or more of income on medical care (excluding premiums) or 5% or more if income under 200% poverty. Data source: March 2012–2013 Current Population Survey (states: two-year average). Source: America’s Underinsured, The Commonwealth Fund, March 25, 2014. 6 Parents’ Perspective on Children’s Insurance: Percent Said Coverage Usually/Always Meets Needs, 2011-2012 2011 2012 Bottom State 100% 84% 80% All-State Median Top State 91% 81% 76% 68% 73% 60% 40% 20% 0% Public Insurance Public Insurance= Medicaid or CHIP. Data Source: National Survey of Children’s Health, 2011/12 Private Insurance Percent of Children with a Medical Home, 2011-12 7 Percent 80 Best State 69 60 State Median 57 Worst State 45 40 • Share of children with a medical home declined in 27 states from 2007 to 2011/12 • Percent of low-income children with medical homes far less than higher income children higher-income 20 – 15 to 33 percentage point gap g p in 2011/12 0 2011/12 Data: Commonwealth Fund analysis of 2007 and 2011/2012 National Survey of Children’s Health. Children with a Medical Home, 2011-12 Income at or Above 400% FPL State Rate Income Under 200% Federal Poverty Level (FPL) 80 70 60 50 40 30 20 VT IA WI ME UT WY TN ID NH MA KY OH RI DE LA MI AR PA GA AK MD CO TX NY DC AZ CA WV MO WA ND SD MT NE OK OR KS HI VA IN SC MN NC NJ CT AL MS NM IL FL NV Data: 2011/12 National Survey of Children’s Health. SOURCE: Commonwealth Fund Scorecard on State Health System Performance for Low-Income Populations, 2013 8 9 ACA Coverage Expansions and Children  2010-2013  CHIP authorized to 2015  Young adults covered on parent’s plans until age 26  Children with pre pre-existing existing conditions not denied coverage  2014: Medicaid expands, Insurance Marketplaces open  Medicaid M di id to t 138% off poverty t children hild and d adults d lt up to t 65 • CHIP ages 6 to 19 to Medicaid if income <138% of poverty  Foster children may stay on/come back on Medicaid to age 26  Marketplaces subsidies from 100 to 400% poverty  Interaction parents’ job-based coverage • If CHIP or Medicaid eligible may turn down offer and choose public • Eligible for marketplace subsidies only if single-person premium exceeds 9.5% of income ACA Coverage Expansions and Children As of April 2014  Marketplace: 8 Million signed up  Nearly 500,000 children under age 18  Early gain in 3 million young adults on parent’s plans  Medicaid/CHIP: 4.8 million net enrollment increase  643,000 643 000 iincrease iin states t t th thatt did NOT expand d  Likely high percent children – eligible but not enrolled  3 million back-log: waiting for “paper-work” to clear  Electronic “no-wrong no-wrong door door” not yet working well  Started with 7.2 million kids uninsured – potential net gain of at least 1 million by April 2014? 10 Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act FPL Income Premium contribution as a share of income Out-of-pocket limits Actuarial value: if in Silver plan <100% 100% S <$11,490 S: $ , 90 F: <$23,550 0% (M (Medicaid) di id) $0 (M (Medicaid) di id) 100% (M (Medicaid) di id) 100%–132% S: $11,490 – <$15,282 F: $23,550 – <$31,322 2%, or 0% if Medicaid 133%–149% S: $15,282 $15 282 – <$17,235 <$17 235 F: $31,322 – <$35,325 3.0%–4.0% 150%–199% S: $17,235 – <$22,980 F: $35,325 – <$47,100 4.0%–6.3% 200%–249% S: $22,980 – <$28,725 F: $47,100 – <$58,875 6.3%–8.05% 250%–299% S: $28,725 – <$34,470 F: $58,875 – <$70,650 8.05%–9.5% 300%–399% S: $34,470 – <$45,960 F: $70,650 – <$94,200 9.5% 400%+ S: $45,960+ F: $94,200+ — Four levels of cost-sharing: Bronze: actuarial value: 60% Gold: actuarial value: 80% 94% S: $2,250 $2 250 F: $4,500 94% 87% S: $5,200 F: $10,400 73% 70% S: $6,350 F: $12,700 70% — Silver: actuarial value: 70% Platinum: actuarial value: 90% Note: FPL refers to federal poverty level as of 2013. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan. Out-of-pocket limits for 2014. Source: Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111-148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx. 11 12 Children’s Subsidized Coverage, 2014 Source: Prater & Akler, Georgetown University Center for Children and Families, “Aligning Eligibility for Children: Moving Stairstep Kids to Medicaid,” The Kaiser Commission on Medicaid and the Uninsured, August 15, 2013. Status of State Participation in Medicaid Expansion, As of May y 2014 NH WA VT ND MT AK MN OR ID NY WI SD MI WY PA IA NE NV OH IL UT CO CA IN MO KS WV VA KY NC TN AZ ME NM OK SC AR MS HI TX AL GA LA FL Expanding (22 + DC) Expanding with variation (6) Options under discussion (3) Not expanding (19) Note: CMS has approved waivers for expansion with variation in Arkansas, Iowa, and Michigan. Pennsylvania’s waiver is under review by CMS. Source: Avalere State Reform Insights; Center of Budget and Policy Priorities; Politico.com; Commonwealth Fund analysis NJ MA RI CT DE MD DC 13 14 Children’s Eligibility for Medicaid and CHIP, 2014 Map from Rudowitz et al., Children’s Health Coverage: Medicaid, CHIP, and the ACA, Kaiser Commission on Medicaid and the Uninsured, March 2014. 15 16 Projections of Uninsured After ACA, 2024 30% 45% Opting Not to Purchase Insurance Undocumented Immigrants 20% Eligible for Medicaid,, Not Enrolled 5% Would be eligible for Medicaid if states expanded Estimated 30 Million Uninsured, Uninsured 11% of Population Source: The Congressional Budget Office, Updated Estimates Of The Effects Of The Insurance Coverage Provisions Of The Affordable Care Act, April 2014 Opportunities and Challenges Ahead: Need for Targeted Research to Inform Action o Insuring children and their parents  To what extent will ACA streamlined coverage expansions reduce the numbers eligible but not enrolled?  Already can see “woodwork” effect as more aware of choices  Will CHIP and Medicaid expansions for kids continue? o Continuity C ti it and d lower l churning h i gaps in i coverage? ?  Interaction of Medicaid, Marketplaces and Job-based coverage as income jobs or circumstances change? o Better coverage, access and care?  Benefits, cost-sharing, primary care and care matter o Need for targeted analyses at state and national level to inform future action 17