Childrens Coverage Healthy Ms Summit 2008

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Status of Children\'s Health Coverage and Issues in 2008

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  • How many of you can properly identify your type of health insurance coverage?
  • Older children have the highest numbers of uninsurance.
  • Largest number of uninsured live in rural areas of the state, as well as the largest number carrying public health insurance coverage.
  • Hispanic, Native American, and African American children have the highest percentage of uninsurance
  • Self-reported health status for children is highest among the privately insured. Uninsured and publicly insured children were more likely to report higher scores, using a scale where 1=Excellent and 5 = Poor health status.
  • Uninsured rate increases more for low income children than for children in higher income groups. This shows the break down by each federal poverty level.
  • Rise in uninsurance highest for Hispanic children, followed by African American children.
  • Full-time work does not mean access to health insurance coverage
  • Enrollment rates much lower for part-time employees than full-time employees
  • Around 60% of employees working for private firms in MS are eligible/qualify for health coverage. Less than half of private sector employees are enrolled in health insurance, with only 15% enrolled in family coverage.
  • Enrollment rates are lower for employees working in smaller firms.
  • Average family premiums for employers and employee contributions overall has increased steadily over time
  • Childrens Coverage Healthy Ms Summit 2008

    1. 1. Profile of Children’s Health Coverage in Mississippi Healthy Mississippi Summit May 22, 2008
    2. 2. Overview <ul><li>Methods </li></ul><ul><li>National Ranking </li></ul><ul><li>State Demographics </li></ul><ul><li>State Trends </li></ul><ul><li>Value of Health Insurance </li></ul><ul><li>Health Insurance Strategies Comparison </li></ul><ul><li>Policy Options </li></ul>
    3. 3. Objectives <ul><li>Identify demographic profile & trends associated with Mississippi children’s health coverage </li></ul><ul><li>Describe value of children’s health insurance coverage </li></ul><ul><li>Compare health insurance strategies & policy options to increase health insurance for children </li></ul>
    4. 4. Methods: Data Sources <ul><li>Current Population Survey (CPS), Annual Social & Economic Supplement (ASEC) </li></ul><ul><li>- Federal: U. S. Census Bureau </li></ul><ul><li>Medical Expenditure Panel Survey (MEPS) </li></ul><ul><li>- Federal: Agency for Health Care </li></ul><ul><li>Research & Quality (AHRQ) </li></ul>
    5. 5. Methods: CPS-ASEC <ul><li>Telephone & in-person survey of 78,000 households annually </li></ul><ul><li>Asks about health coverage over previous calendar year for all household members </li></ul><ul><li>Example: 2007 CPS-ASEC asks questions about health coverage over calendar year 2006 </li></ul><ul><li>Representative national & statewide health insurance estimates </li></ul>
    6. 6. Methods: Caveats CPS-ASEC <ul><li>Current health insurance rather than past year may be mistakenly reported </li></ul><ul><li>Relies on recall of health insurance type, problematic in particular with private insurance types & confusion with public coverage types </li></ul><ul><li>Example: Medicaid numbers known to be lower when compared to program administrative data </li></ul>
    7. 7. Methods: CPS-ASEC <ul><li>Contracted with State Health Access Data Assistance Center (SHADAC), University of Minnesota </li></ul><ul><li>Expertise in helping states monitor rates of health insurance </li></ul><ul><li>Aided in analysis of CPS data for Mississippi </li></ul><ul><li>Most recent available data estimates used on children between 0-18 years of age </li></ul>
    8. 8. Methods: MEPS <ul><li>Two components: Household & Insurance </li></ul><ul><li>Household component provides data from individual household units </li></ul><ul><li>Insurance component is a separate survey of employers </li></ul><ul><li>Insurance component ONLY utilized in these analyses </li></ul>
    9. 9. Methods: MEPS <ul><li>Mail & telephone survey of 40,000 establishments annually </li></ul><ul><li>Asks employers about employer-based health insurance over previous calendar year </li></ul><ul><li>Similar caveats with recall as CPS-ASEC </li></ul><ul><li>Representative estimates for national & statewide health insurance coverage </li></ul><ul><li>Data are most recent available estimates </li></ul>
    10. 10. Children’s Health Coverage: United States vs. Mississippi <ul><li>MS: Ranks 46 th in US for % children uninsured </li></ul><ul><li>Employment-based Private Insurance lower in MS </li></ul><ul><li>Uninsured higher in MS </li></ul><ul><li>Public Insurance higher in MS </li></ul>Source: 2005, 2006, and 2007 Current Population Survey data compiled by the C4MHP using IPUMS-CPS.
    11. 11. Health Coverage by Type – All Mississippi Children <ul><li>Nearly half covered by private-employment based, private-purchased, or military insurance </li></ul><ul><li>1/3 rd covered by public insurance via Medicaid or SCHIP </li></ul><ul><li>Less than 10% have a mixture of public/private insurance </li></ul><ul><li>1 out of every 7 (15%) Mississippi children are uninsured </li></ul>
    12. 12. Health Coverage by Age- All Mississippi Children
    13. 13. Health Coverage by Location- All Mississippi Children
    14. 14. Race/Ethnicity by Type of Coverage- All Mississippi Children
    15. 15. Health Coverage by Poverty Level- All Mississippi Children <ul><li>Public coverage highest for children with most poverty </li></ul><ul><li>Private coverage highest for children with least poverty </li></ul><ul><li>Uninsurance highest for children with most poverty </li></ul>
    16. 16. Health Coverage by Type – Low Income Mississippi Children <ul><li>Half of low income children covered by public insurance </li></ul><ul><li>Nearly1 in 4 low income children are uninsured </li></ul><ul><li>1 in 5 covered by employment based private insurance or privately purchased insurance </li></ul>
    17. 17. Uninsured Children by Potential Eligibility Based on Age & FPL- All Mississippi Children <ul><li>3 out of 4 uninsured children live in families whose incomes would qualify them for public (Medicaid or SCHIP) coverage </li></ul><ul><li>26% of uninsured children have family incomes above thresholds to qualify for Medicaid or SCHIP </li></ul>
    18. 18. Uninsured Children by Age Group- All Mississippi Children <ul><li>Range of uninsurance: 11% in 1-5 year olds & up to 20% in 13-18 year olds </li></ul><ul><li>13 to 18 year olds show highest uninsurance </li></ul>
    19. 19. Uninsured Children by Citizenship Status- All Mississippi Children <ul><li>Almost 100% of MS uninsured children are U.S. citizens </li></ul><ul><li>Only 4% are non-citizens </li></ul>
    20. 20. Uninsured Mississippi Children by Work Status of Adults in Household <ul><li>78% uninsured children live in households where at least 1 adult works </li></ul><ul><li>In 95% of these working households, at least 1 adult works full-time </li></ul>
    21. 21. Reported Health Status by Type of Coverage- All Mississippi Children
    22. 22. Trends: Change in Children’s Insurance by Type of Coverage, 2000-02 vs. 2004-06 <ul><li>Decrease in private coverage </li></ul><ul><li>Small drop in public coverage </li></ul><ul><li>Increase in number of uninsured </li></ul>
    23. 23. Trends: Percent Change in Uninsured Children by Federal Poverty Level, 2000-02 vs. 2004-06 <ul><li>Uninsured at higher income levels dropped </li></ul><ul><li>Low income uninsured increased 61% during same period </li></ul>
    24. 24. Trends: Percent Change in Uninsured Children by Income Level, 2000-02 vs. 2004-06 <ul><li>State’s increase in uninsured children was due entirely to increased uninsurance in low income families. </li></ul>
    25. 25. Trends: Uninsured Rate of Children by Federal Poverty Level, 2000-02 vs. 2004-06
    26. 26. Trends: Percent Uninsured Mississippi Children by Race/Ethnicity, 2000-02 vs. 2004-06
    27. 27. Employment-based Health Coverage in Mississippi by Firm Size, 2005 <ul><li>45% of all private firms offer health coverage to employees </li></ul><ul><li>Most large firms offer health insurance (93%) </li></ul><ul><li>Few small firms offer health insurance </li></ul><ul><li>74% of all private firms are small </li></ul>
    28. 28. Health Insurance Enrollment: Full-Time & Part-Time Employees in Private Establishments
    29. 29. Health Insurance Enrollment: Employees in Private Mississippi Establishments
    30. 30. Health Insurance Enrollment: Employees in Private Establishments in MS by Size of Firm
    31. 31. Average Family Premium/ Employee Contribution, Private Establishments Offering Health Insurance
    32. 32. Why is health insurance important? <ul><li>Uninsured children are less likely to receive timely care. </li></ul><ul><li>Coverage provides access to the health care system where health problems can be detected and treated early. </li></ul><ul><li>Delayed identification and treatment of health risks & problems may affect a child’s mental, physical, & emotional health. </li></ul>
    33. 33. Risks Associated with Lack of Insurance <ul><li>Three times more likely not to have seen a doctor in the past year; </li></ul><ul><li>More than thirteen times more likely to lack a usual source of medical care; </li></ul><ul><li>Almost five times more likely to have a delayed or unmet health care need; </li></ul><ul><li>Five times more likely to have an unmet dental need; and </li></ul><ul><li>Five times more likely to have an unmet vision care need. </li></ul>
    34. 34. Impact on Health Status <ul><li>Very difficult to evaluate due to compounding factors: </li></ul><ul><ul><li>Adverse selection </li></ul></ul><ul><ul><li>Churning </li></ul></ul><ul><ul><li>Point-in-time measurements </li></ul></ul>
    35. 35. The “Hidden Tax” <ul><li>Health care costs not covered by the uninsured are shifted to other payers. </li></ul><ul><li>Approximately 35 percent of charges are paid out-of-pocket by the uninsured. </li></ul><ul><li>Of the amount shifted to other payers, about 1/3 is paid by government programs & 2/3 paid through higher health insurance premiums. </li></ul>
    36. 36. Vicious Cycle Providers cost shift to third party payers Health Insurance Premiums Rise Employers & employees drop coverage
    37. 37. So… <ul><li>If it benefits everyone for all children to have health insurance coverage, why isn’t it a priority? </li></ul><ul><li>Who is going to pay for it? </li></ul>
    38. 38. Important Concepts <ul><li>Churning </li></ul><ul><li>Crowd-out </li></ul>
    39. 39. Churning <ul><li>Insurance coverage is dynamic, not static. </li></ul><ul><li>People move between pubic and private coverage, and they gain and lose coverage. </li></ul><ul><li>This shifting among various coverage options is generally referred to as “churning.” </li></ul>
    40. 40. Significance of Churning <ul><li>It complicates the measurement of the uninsured. </li></ul><ul><li>It contributes to crowd-out of private coverage (every break in coverage provides an opportunity to shift to public coverage). </li></ul><ul><li>It adds to administrative costs. </li></ul><ul><li>Gaps in coverage are associated with poor access to health care. </li></ul>
    41. 41. Measuring Churning <ul><li>Most of the research focuses on children with public coverage. </li></ul><ul><li>Measurement is complicated by retroactive coverage under Medicaid and transitions between Medicaid & SCHIP. </li></ul><ul><li>Research shows that almost half (45.4%) of children losing Medicaid are still eligible. </li></ul>
    42. 42. Causes <ul><li>Research indicates that families’ failure to submit renewal paperwork on time and administrative delays after submission play major roles in loss of coverage. </li></ul><ul><li>Many of these children are re-enrolled after a short period of time. </li></ul>
    43. 43. Crowd-Out <ul><li>Increasing eligibility for public programs generally results in some persons with private coverage dropping their private insurance and enrolling in the public program. </li></ul><ul><li>This occurrence is referred to as crowding out private insurance. </li></ul>
    44. 44. Common Crowd-Out Pathways <ul><li>A person drops private coverage for public coverage. </li></ul><ul><li>A public program enrollee refuses an offer of private coverage. </li></ul><ul><li>Employers encourage crowd-out. </li></ul>
    45. 45. Defining Crowd-Out <ul><li>Researchers do not agree on the definition of crowd-out. </li></ul><ul><li>Some consider it to include any shift from private coverage to public coverage. </li></ul><ul><li>Others only include shifts that would not have occurred in the absence of the public program. </li></ul>
    46. 46. Measuring Crowd-Out <ul><li>There is no standard measure and the range of estimates is large (0% to 60%). </li></ul><ul><li>The Congressional Budget Office reviewed the wide range of research and concluded that crowd-out due to SCHIP was between 25% and 50%. </li></ul><ul><li>The risk of crowd-out is greater for higher income families. </li></ul>
    47. 47. Significance of Crowd-Out <ul><li>Vetoed legislation to reauthorize SCHIP included authorization to expand eligibility from 200% FPL to 300% FPL. </li></ul><ul><li>In Mississippi, there are approximately 19,000 uninsured children with family incomes between 200% and 300% FPL. </li></ul><ul><li>There are over 100,000 children with private insurance in this income category. </li></ul>
    48. 48. State Strategies to Reduce the Number of Uninsured Children <ul><li>Enrollment Simplification & Outreach </li></ul><ul><li>Premium Assistance </li></ul><ul><li>Three-Share Premium Programs </li></ul><ul><li>Reinsurance </li></ul><ul><li>Risk Pool Models </li></ul><ul><li>Eligibility Expansion </li></ul><ul><li>Tax Credits </li></ul>
    49. 49. Enrollment Simplification & Outreach <ul><li>Research shows that parents of eligible children are often unaware that their children may be eligible. </li></ul><ul><li>The application and eligibility determination process can also present barriers to uninsured families. </li></ul><ul><li>States that simplified enrollment & conducted outreach significantly increased the number of eligible children enrolled. </li></ul>
    50. 50. Premium Assistance <ul><li>Many low income families with the option of employer coverage do not enroll because of the premium cost. </li></ul><ul><li>Premium assistance programs use public funds to subsidize private health insurance premiums for eligible families. </li></ul><ul><li>Premium assistance programs are cost effective and encourage parents to be covered as well. </li></ul>
    51. 51. Successful Premium Assistance Programs <ul><li>Require applicants to enroll in public coverage for which they are eligible if the coverage is cost effective. </li></ul><ul><li>Develop strategies to offer wrap-around coverage. </li></ul><ul><li>Minimize the administrative burden on employers. </li></ul>
    52. 52. Three-Share Premium Programs <ul><li>Premiums are shared three ways: </li></ul><ul><ul><li>Employer </li></ul></ul><ul><ul><li>Employee </li></ul></ul><ul><ul><li>Government Program </li></ul></ul><ul><li>To contain costs, benefit packages are often restricted. </li></ul><ul><li>Limitation is the perception of an “affordable” premium. </li></ul><ul><li>Most low income individuals will not purchase health insurance if their contribution is more than 5% of their income. </li></ul>
    53. 53. Reinsurance <ul><li>Reinsurance is insurance for organizations that accepted risk, e.g. insurance companies or self-insured employers. </li></ul><ul><li>It is activated after a certain expenditure threshold is met, which could be for an individual or a group. </li></ul>
    54. 54. The “80/20” Rule <ul><li>In any large group insurance plan, a small proportion of the plan members will be responsible for most of the costs. </li></ul><ul><li>Government reinsurance plans cover the costs for these outliers, thereby lowering premiums for the remainder of the group. </li></ul>
    55. 55. Risk Pool Models <ul><li>Most states have established high risk pools to provide access to coverage for persons considered “uninsurable” in the commercial market. </li></ul><ul><li>States often subsidize coverage for these individuals to reduce the premiums. </li></ul><ul><li>These programs improve access for a large number of persons, but are not a viable solution for low income families without additional subsidy. </li></ul>
    56. 56. Eligibility Expansions <ul><li>Some states have attempted to cover more uninsured children by raising eligibility limits for public programs like Medicaid & SCHIP. </li></ul><ul><li>Seventeen states have extended the upper limit to 300% or 350% FPL. </li></ul><ul><li>Illinois is in the process of implementing universal coverage for children. </li></ul>
    57. 57. Tax Credits <ul><li>In addition to serving as a way to subsidize health insurance coverage for the uninsured, tax credits may address current inequities in tax policies that discriminate against individuals that self-insure. </li></ul><ul><li>The number of individuals that are likely to benefit from this approach is relatively modest. </li></ul>
    58. 58. Potential Policy Options <ul><li>Administrative Simplification & Outreach </li></ul><ul><ul><li>Most cost effective approach </li></ul></ul><ul><ul><ul><li>Most of the uninsured children in Mississippi are already income-eligible for existing public programs. </li></ul></ul></ul><ul><ul><ul><li>These programs are highly subsidized by the federal government. </li></ul></ul></ul>
    59. 59. Administrative Simplification <ul><li>States’ experiences clearly document that simplifying enrollment procedures facilitates enrollment of eligible children. </li></ul><ul><li>Enrollment simplification & outreach can be implemented without compromising program accountability and integrity. </li></ul>
    60. 60. Other Strategies <ul><li>Eligibility expansions increase the risk of crowd-out and are less cost effective. </li></ul><ul><li>Premium assistance, shared premium programs, and tax credits are feasible for families that have access to private insurance. </li></ul><ul><li>These programs tend to discourage crowd-out and should be part of a comprehensive effort to encourage small employers to offer or retain health insurance coverage for their employees. </li></ul>
    61. 61. Subsidies <ul><li>To expand coverage through private insurance, subsidies must be sufficient to lower premiums to an “affordable” level. </li></ul><ul><li>Research in Mississippi in 2005 indicated the perceptions of “affordable” premiums: </li></ul><ul><ul><li>$40 - $70 per month for low income workers </li></ul></ul><ul><ul><li>Up to $50 per month per employee for small employers. </li></ul></ul>
    62. 62. Subsidy Cost <ul><li>The average annual group premium for small employers in Mississippi in 2005 was $4,033 for single coverage & $9,964 for family coverage. </li></ul><ul><li>It would likely take an annual subsidy in the range of $2,500 for single coverage & $8,500 for family coverage to induce low income employees & small employers to participate. </li></ul>
    63. 63. Cost Effectiveness <ul><li>The cost of expanding coverage is the biggest barrier to implementation. </li></ul><ul><li>Use of federal funds is most cost effective for the state. </li></ul><ul><li>For strategies not eligible for federal funding, use of employer contributions improves cost effectiveness. </li></ul>
    64. 64. Value <ul><li>What is the cost of covering uninsured children compared to the cost of leaving them uninsured? </li></ul><ul><li>Short-term cost vs. long-term cost </li></ul><ul><li>Direct cost vs. “hidden” cost </li></ul>
    65. 65. The Balancing Act <ul><li>Policy decisions must balance conflicting objectives and minimize unintended consequences. </li></ul><ul><ul><li>Access vs. accountability </li></ul></ul><ul><ul><li>Efficiency vs. equity </li></ul></ul><ul><ul><li>Benefit structure must balance cost, access, & quality. </li></ul></ul>
    66. 66. More Information on the Web Site www.mshealthpolicy.com

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