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Medicaid Expansion |
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| DESCRIPTION | PROS | CONS |
| By changing the income and asset
guidelines, Medicaid can be expanded to children under
age 19 with family incomes up to 200% of poverty. (In the 28 states where Medicaid eligibility is above 150% for some groups of children, states can expand Medicaid eligibility to 50% higher than the current level for those groups.) If a state choose this option, it is entitled to an enhanced FMAP (federal match) for children covered in this expansion. |
Benefits/Protections • Comprehensive benefits package including EPSDT and ancillary services for children with special health care needs. • Maintains individual entitlement • Medicaid consumer protections would apply. • State still has flexibility through 1115 waiver process. Eligibility/Enrollment • One eligibility determination process. • Can smooth out variation in income eligibility by age group and avoid having some family members enrolled in Medicaid and some in a state program. Administration • Implementation could happen more quickly and more easily than with a new state program. Does not create a new government bureaucracy. • Low administration costs. • No need to negotiate separate arrangements with health plans, physicians, and other providers. • Greater coordination of data collection and reporting functions at physician, plan and state levels. Expanded Purchasing Power • The state’s purchasing power goes further when SCHIP funding is combined with Medicaid funds. Enhanced Image for Medicaid • The image of Medicaid can be enhanced by recasting it as a program for children in working families. |
Patient Protections • If state is shifting to Medicaid managed care, Medicaid expansion would expose additional children to any deleterious conditions, especially "auto enrollment" (assigning individuals to health plans automatically), caused by this transition. • Could exacerbate any access to care problems in the Medicaid program. Political • Medicaid is still seen as a "welfare program" by some • In some states there is strong political opposition to Medicaid expansion. Financing • Medicaid is an individual entitlement, but SCHIP funds are a capped block grant to the states. If the state uses up its federal grant, the state will not receive the enhanced FMAP for additional expenditures and will have to pay for them at the regular FMAP rate. This may be an incentive to states to set lower Medicaid eligibility levels than allowed. • Because the benefits package is comprehensive, it may cost more per child than some of the other benefits package options. Provider Reimbursement • Physicians, hospitals and other providers are often paid poorly by Medicaid, resulting in constrained access for beneficiaries. |
State Health Insurance
Program
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|---|---|---|
| DESCRIPTION | PROS | CONS |
| The state purchases and makes available
subsidized children’s health insurance at a sliding
scale to eligible families. Monthly Premium/Child (New York) less than 120% FPL $0 120-159% FPL $9 ($36)* 160%-222% FPL $13 ($52)* * family maximum |
Administrative • State has greater flexibility • State already serving similar function for state employees. State may already have a program for the uninsured. • Centralized contracting/administrative procedures would be simpler and would allow for greater contracting leverage than a school-based enrollment program. Political • A program separate from Medicaid may win more public and political support. • State program gives greater visibility/PR to state, governor and other key decision makers. |
Administrative • Need to create a separate administrative structure to contract with providers, enroll participants, make payments, etc. • Implementation would be slower and more difficult than Medicaid expansion. • Need to develop ways to coordinate with Medicaid. Political • Would create or expand a government bureaucracy. Financing • Purchasing power of program less effective than when funds are combined with Medicaid funds. • Current cost-sharing structure must be revised to follow federal law. • Decreased federal funds due to cost sharing would decrease amount state could spend on administration (10% of smaller state allocation). |
School-based Enrollment (eg, Florida Healthy Kids) |
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| DESCRIPTION | PROS | CONS |
| Uses schools as the "group"
for purchasing health insurance. Uninsured, Medicaid
ineligible children who are actively attending school and
their younger siblings are eligible. Could be expanded to include child care facilities to reach pre-school children without school-age siblings. In the Florida model, state and county funding subsidize premiums. The local program contracts with commercial plans to provide both managed care and indemnity coverage. Monthly Premium Per Child (Florida) (Urban/Rural) less than 130% FPL $10 / $5 130-185% FPL $25 / $15 greater than 185% FPL $50 / $45 |
Administrative • Using schools simplifies outreach. Benefits • Offers basic comprehensive benefits package. Political • The parallel to employment-based coverage makes it easy for the general public to understand. • A program separate from Medicaid may win more public and political support. • Local focus and structure allows state to start small and to target funds to areas in greatest need. |
Administrative • Not well coordinated with Medicaid enrollment. There are many children in Florida Healthy Kids and on the waiting list who are eligible for Medicaid.1 • Decentralized implementation is more labor intensive, gives state less control, and will lead to greater program variability across the state. • Does not reach young children without school-age siblings. This could be improved by working with child care facilities. • Need to create a separate administrative structure to contract with providers, enroll participants, make payments, etc. • Need to find insurers willing to provide child-only coverage. Financing • Purchasing power of program less effective than when funds are combined with Medicaid funds. • Decreased federal funds due to cost-sharing would decrease amount state could spend on administration, including outreach (10% of smaller state allocation). |
| 1 Mann C. Unpublished data analysis. Center on Budget and Policy Priorities. 1997. | ||
AAP 4% Proposal*
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|---|---|---|
| DESCRIPTION | PROS | CONS |
| Subsidized vouchers for private health
insurance coverage provided to families with uninsured
children. States impose an income-related family share
for insurance premiums and collect that amount through
the state income tax system. Premium Structure Families below 133% FPL pay no premium. Higher income families pay between 3% and 5% of their family income in excess of 133% FPL. |
Political • Income tax collections gives positive image related to paying taxes, middle class, work, etc. • Cost-sharing could gain support among those who feel families should "pay their fair share." • Using tax collection enhances image of program as serving working families. Financing • Cost sharing could allow more people to receive coverage. |
Administrative • State must have an income tax. • Places additional burden on tax collection system. • Implementation would be slower and more difficult than Medicaid expansion. Financing • Although the proportion of total program cost paid by families is projected to be about 3 or 4 %, federal funds would decrease by the amount state collected from participating families. • Decreased federal funds would decrease amount state could spend on administration, including outreach (10% of smaller state allocation). |
Caring Program |
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|---|---|---|
| DESCRIPTION | PROS | CONS |
| These programs are sponsored by Blue Cross/Blue Shield and usually provide coverage of basic (primary care) services for low-income, Medicaid ineligible children. Benefits vary in the 26 programs operating throughout the country, and not all provide inpatient hospital care. | Political • Public/private partnership • Has been implemented in 26 communities. |
Administrative • Need to create individual partnerships in each location. • Relies on willingness of BC/BS (or other insurer) to participate. • Small programs in comparison to other state programs. Not proven that it can handle the numbers of children eligible under SCHIP. • Need to create a separate administrative structure to contract with providers, enroll participants, make payments, etc. • Need to develop ways to coordinate with Medicaid.
Financing |
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