Because this report draws heavily on data from six case studies conducted in time to be included in the report, we present background on these states in this chapter. The six states are: California, Colorado, Louisiana, Missouri, New York, and Texas. The findings from the case studies are presented in greater detail in Hill, Harrington, and Hawkes (2002).
Four of the six case study states responded promptly when Title XXI was enacted in the Balanced Budget Act of 1997 (BBA). Within four months of the August 1997 passage of the BBA, California, Colorado, Missouri, and New York had submitted SCHIP plans to the Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) (HCFA(now known as CMS)); 15 by April 1998, each of these states except Missouri had implemented its program. 16 Texas and Louisiana submitted their initial state plans in April and July 1998, respectively, and both implemented at least the initial phases of their SCHIP initiatives during 1998 (see Table 4). The timing of the study states' responses to the SCHIP legislation fairly closely reflects the national pattern: within six months of the SCHIP legislation's passage, 18 states had submitted plans to CMS and four had been approved; by the first anniversary of the law, 48 states had submitted plans, and 41 had received federal approval; by early 2000, every state and the District of Columbia had approved plans in place. 17, 18, 19 Title
XXI originally called for all states to have approved plans by September 30, 1998. Congress extended this deadline to September 30, 1999.
|Dates of Approved Submission|
|State||Program Name||Program Type||Submitted||Approved||Implemented|
|California||Healthy Families||Combination||11/19/97||3/24/98||3/1/98 (Medicaid expansion)
7/1/98 (Separate program)
|Colorado||Child Health Plan Plus||Separate||10/14/97||2/18/98||4/22/98|
|Missouri||MC+ for Kids||Medicaid||9/2/97||4/29/98||7/1/98 children
|New York||Child Health Plus||Combination||11/5/97||4/1/98||4/15/98|
|7/1/98 (Medicaid expansion)
4/3/00 (Separate program)
Centers for Medicare & Medicaid Services (CMS), California Title XXI Program Fact Sheet. CMS Web site http://cms.hhs.gov/schip/chpfsca.pdf ]
Centers for Medicare & Medicaid Services (CMS), Colorado Title XXI Program Fact Sheet. CMS Web site http://cms.hhs.gov/schip/chpfsco.asp]
Centers for Medicare & Medicaid Services (CMS), Louisiana Title XXI Program Fact Sheet. CMS Web site http://cms.hhs.gov/schip/chpafsla.asp]
Centers for Medicare & Medicaid Services (CMS), "Missouri Title XXI state Plan Summary Fact Sheet." Web site http://www.hcfa.gov/init/chpfsmo.htm ] Missouri Statewide Health Reform Demonstration Fact Sheet. Web site [http://cms.hhs.gov/schip/chpfsmo.pdf] The State Of Missouri 1915(b) Program. Web site [http://www.hcfa.gov/medicaid/1915b/mo03fs.htm]
Centers for Medicare & Medicaid Services (CMS), New York Title XXI Program Fact Sheet. CMS Web site http://cms.hhs.gov/schip/chpfsny.pdf] New York Governor's Press Office, Child Health Plus Expansion Means Healthier Kids, Press Release, June 18, 1998. Department of Health and Human Services, "HHS Approves Changes in New York SCHIP Program" HHS News, July 12, 2001.
Centers for Medicare and Medicaid Services (CMS), Texas Title XXI Program Fact Sheet. CMS Web site [http://cms.hhs.gov/schip/chpfstx.pdf]
Title XXI provides states with three options for expanding coverage under SCHIP: (1)expanding Medicaid, (2) creating a new insurance program separate from Medicaid, or (3)implementing a combination of the two. Our six study states include examples of each approach, illustrating both that states' made different choices based on the variables and considerations facing them, and that the statutory options, rather than a "one-size-fits-all" authority suited the diversity of state circumstances. Louisiana and Missouri enacted Medicaid expansions; Colorado created a separate program; and California, New York, and Texas each chose to adopt combination approaches. 20 This distribution of program types is similar to that seen nationally--16 states, or roughly one-third of the 50 states and the District of Columbia, implemented Medicaid expansions under SCHIP; whereas 35 states, roughly two-thirds, have created separate programs, either alone or in combination with Medicaid expansions. 21
As illustrated in Table 5, the maximum income eligibility thresholds ultimately adopted by the study states vary considerably--from 185 percent of the federal poverty level (FPL) in Colorado, to 300 percent of the FPL in Missouri. Before SCHIP, the average income threshold for children in all six states was 119 percent of the FPL. After SCHIP, the average income threshold increased to 231 percent of the FPL, an increase of 112 percentage points. 22 This increase is somewhat higher than the increase across all 50 states and the District of Columbia--nationally, the average income threshold for children was 121 percent of poverty before SCHIP, and 214 percent after SCHIP, an increase of 93 percentage points. 23
The three states with the most low-income uninsured children in the nation during the period 1997 to 1999 (California, New York, and Texas) are among the six study states. The other three states were above the mean on this measure. Uninsured children comprised between 22 percent
|Income Eligibility Levels|
|Infants||Ages 1 to 6||Ages 6 to 15||Ages 15 to 19|
|California||N.A.a||201 to 250||N.A. a||134 to 250||N.A. a||101 to 250||86 to 100||101 to 250|
|Colorado||N.A.b||134 to 185||N.A. b||134 to 185||N.A. b||101 to 185||N.A. b||38 to 185|
|Louisiana||134 to 200||N.A. c||134 to 200||N.A. c||101 to 200||N.A. c||11 to 200||N.A. c|
|Missouri||186 to 300||N.A. c||134 to 300||N.A. c||101 to 300||N.A. c||101 to 300||N.A. c|
|New York||N.A.||186 to 250||N.A.||134 to 250||N.A.||101 to 250||88 to 100d||101 to 250|
|Texas||N.A.a||186 to 200||N.A. a||134 to 200||N.A. a||101 to 200||19 to 100||101 to 200|
Income less than the lower-income eligibility band represent the Medicaid standards for children in effect March 31, 1997.
N.A. = not applicable.
aIn California and Texas, children under 16 years in Medicaid were already covered to 100 percent of the FPL; the
Medicaid expansion under SCHIP does not apply.
bIn Colorado, there is no Medicaid expansion.
cLouisiana and Missouri do not operate a separate children's health insurance program.
dAn expansion up to 133 percent has been approved but will not be implemented until April 2002.
Centers for Medicare & Medicaid Services (CMS), California Title XXI Program Fact Sheet. CMS Web site [http://cms.hhs.gov/schip/chpfsca.pdf] State of California. State Child Health Plan under Title XXI of the Social Security Act: California's Healthy Families program. November 18, 1997 Web site [http://www.dhs.cahwnet.gov/org/Director/healthy_families/stplan.pdf]
Donna Cohen Ross and Laura Cox, Making It Simple: CHIP Income Eligibility Guidelines and Enrollment procedures: Findings from a 50-State Survey. Kaiser Commission on Medicaid and the Uninsured, October 2000.
Centers for Medicare & Medicaid Services (CMS), "Eligibility Standards in the 50 States and District of Columbia," January 2001.
Louisiana Department of Health and Hospitals (DHH), Annual Report of State Children's Health Insurance Plans Under Title XXI of the Social Security Act, 2000, March 22, 2001.
Centers for Medicare & Medicaid Services (CMS), "Eligibility Standards in the 50 States and District of Columbia (01/01/01)."
Louisiana DHH, "More Children Now Eligible for Health Insurance," January 9, 2001.
State of Missouri, Department of Social Services, Missouri's Children Health Insurance Program Evaluation." Submitted to the Health Care Financing Administration, March 31, 2000.
American Academy of Pediatrics, Improving Access to Children's Health Insurance in New York. AAP: 2000 Web site: [http://www.aap.org/advocacy/chi2/ny.pdf]
Centers for Medicare & Medicaid Services (CMS), Texas Title XXI Program Fact Sheet. CMS Web site [http://cms.hhs.gov/schip/chpfstx.pdf]
(New York) and 38 percent (Texas) of all low-income children in five of the six states, all figures close to or above the national average of 25 percent. 24 Because of the large numbers of low- income children and the high percentages of low-income children without insurance before SCHIP, the study states also have above-average numbers of children enrolled in SCHIP. Indeed, the study states include the three states with the largest SCHIP enrollment in the nation--again, New York, California, and Texas--with approximately 480,000, 476,000, and 433,000 children participating, respectively, as of September 2001. 25 The remaining three states had far smaller programs--Missouri (approximately 76,000 children); Louisiana (56,000 children); and Colorado (37,000 children)--but each still fell above the national median of 20,389 children.26
15. In 2001, the agency was renamed the Centers for Medicare & Medicaid Services (CMS). To avoid confusion, all further references to the agency in this report are to CMS, regardless of whether the agency was named HCFA(now known as CMS) or CMS in the period under discussion.
16. New York had an existing state children's health insurance program in place before passage of Title XXI, and recognized in Title XXI.
17. Ian Hill, "Charting New Courses for Children's Health Insurance," Policy and Practice, vol. 58, no. 4, December 2000.
18. Frank Ullman, Ian Hill, and Ruth Almeida, CHIP: A Look at Emerging Programs Washington, DC: The Urban Institute, September 1999.
19. Centers for Medicare & Medicaid Services, Web site: [www.cms.hhs.gov/schip/]
20. On October 1, 2002, all of these programs will become "separate" state child health programs, (with the possible exception of New York due to recent federal approval of an additional Medicaid expansion), as opposed to "combination" programs, as the federal mandate for phasing in poverty-level Medicaid coverage of children under age 19 born after September 30, 1983 will be complete. Thus, these states' initial Title XXI efforts, which accelerated the phase-in of Medicaid coverage for children between the ages 15 and 19 living in families with incomes below poverty, will be subsumed within Title XIX, as of October 2002.
21. Centers for Medicare & Medicaid Services, Web site [http://cms.hhs.gov/schip/]
22. Average income eligibility thresholds for children were generated by determining the income eligibility threshold for children of all ages up to age 19, summing the income thresholds, then dividing by 19.
23. Frank Ullman, Ian Hill, and Ruth Almeida, CHIP: A Look at Emerging Programs, Washington, DC: The Urban Institute, September 1999.
24. Catherine Hoffman and Mary Pohl, Health Insurance Coverage in America: 1999 Data Update. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured, December 2000. These data were not available for Missouri.
25. Drawn from SCHIP administrative data and information provided by Marilyn Ellwood from the CMS sponsored study of SCHIP.
26. Vernon K. Smith, CHIP Program Enrollment: December 2000. Kaiser Commission on Medicaid and the Uninsured: September 2001.