Blewett, Lynn A.
Principal Investigator

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e blewe001@umn.edu

The Children's Health Insurance Program: A Minnesota Perspective

Congress has still not fully reauthorized the Children’s Health Insurance Program (CHIP), and states are working to figure out how to keep their kids covered. CHIP provides essential coverage for millions of our nation’s poorest children and should not be used as a bargaining tool in federal budget negotiations. It’s time to put politics aside and reauthorize this program that is vital for vulnerable children and that both sides ofthe aisle claim to support.

Minnesota: A Pioneer in Covering Kids

Minnesota, as a national leader in health care, has a long history of providing coverage for its children--well before the passage of the federal CHIP program.  As far back as 1987, Minnesota provided coverage to low-income children who were just above the income level to qualify for Medicaid, and we paid for it with state funds alone. The program initially covered physician services for children under age six and low-income pregnant women who were not Medicaid-eligible. The state financed the program through an annual fee of $35 for pregnant women and $25 for children, and a one-cent tax on cigarette packs.

 

In 1991, Minnesota's public coverage for kids was expanded to all children under age 18, and in 1992, Governor Carlson passed comprehensive health reform legislation, the HealthRight Act, with broad bipartisan support. Renamed MinnesotaCare, the state's public coverage program provided subsidized health insurance for working families with incomes just above Medicaid eligibility levels (up to 275% of the Federal Poverty Level) who not eligible for employer-sponsored insurance. The program continued to be funded with state-only dollars, and the legislation behind it included earmarked funding from a new 2% provider tax, a 1% health insurance premium tax, as well as a five-cent increase in the cigarette tax.

Early analyses of the impact of MinnesotaCare found that between 1990 and 1995 the proportion of uninsured children (uninsured for 12 months or longer) in Minnesota decreased from 5.2% to 3.1%. This change translated to an increase in access to care for kids and a reduction in the amount of free care given by medical providers to the uninsured. 

CHIP's Evolving Role in Minnesota and the Nation

Minnesota and other states that had similarly funded their own safety net programs were thrilled when CHIP passed in 1997. Modeled in part on the Minnesota program, CHIP targeted families just above the eligibility level for Medicaid and provided needed support to low-income working families. In its early years, CHIP funded very few of Minnesota’s low-income children, as the program was targeted to states with larger numbers of uninsured children; in fact, a report from 2000 showed only 8 children in Minnesota covered by CHIP. However, Minnesota leveraged CHIP funding over time, and today Minnesota uses its CHIP dollars to support coverage for 127,000 children and pregnant women. Nationwide, the program is now well-established and covers close to 9 million children.   

The Uncertain Future of CHIP Puts the Most Vulnerable at Risk

Minnesota’s goal has always been to get and keep children and their families insured. We know that providing health insurance coverage enhances children’s school performance, increases parents’ work attendance, improves and sustains high immunization rates, and advances the health and economic future of children as they age into adulthood. Most of all, coverage assures that all have an opportunity to pursue their goals and aspirations in life.

Both the delay in the CHIP reauthorization and the real potential for no future funding affects the most vulnerable: poor children. It’s hard to believe, but close to one in every four children in this country lives in poverty. For African American children, the rate is over 40%.

States Employing Stopgap Measures 

With the end of CHIP’s authorization on September 30^th, states have been able to apply for emergency funding to keep their programs going. Oregon and Minnesota have both pledged to make up what they hope is a temporary funding gap with state dollars, but it puts their finances in jeopardy — Minnesota’s latest budget projection released in early December includes a $188 million shortfall if CHIP is not reauthorized.  Meanwhile, other states will need to shut down new enrollment and start notifying families of potential loss of coverage.

In the meantime, the stress to families of not knowing if coverage will continue and for how long, is real. States are scrambling to keep kids covered — making tremendous efforts to find alternative funding, notifying families of the potential phase out of the program, and placing limits on new enrollment in anticipation of a lack of funding.

 

Funding CHIP: A No-Brainer and the Right Thing to Do

Lynn A. Blewett, PhD, MPA, is Professor of Health Policy at the University of Minnesota, School of Public Health

SHADAC Staff

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e shadac@umn.edu

Lynn Blewett Discusses Minnesota’s 1332 Reinsurance Waiver on Health Affairs Blog

SHADAC Director Lynn Blewett discusses Minnesota’s 1332 reinsurance waiver request and the federal response in a new post on the Health Affairs Blog.

SHADAC Staff

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e shadac@umn.edu

SHADAC Comments on New Direction for Center for Medicare and Medicaid Innovation

On September 20, 2017, the federal Center for Medicare and Medicaid Innovation (Innovation Center) issued a request for stakeholder feedback on a proposed new direction for the Center, which is shifting its focus toward testing new models of patient-centered care that emphasize choice and competition.

The Innovation Center laid out a set of guiding principles for this shift as well as a list of potential models of interest (see text box).

Comments from SHADAC: Summary

Drawing on our experience providing evaluation services to states implementing innovative ways to deliver and pay for health care, SHADAC provided feedback to the Innovation Center. This feedback is summarized below.

Access the full text of SHADAC’s response.

Feedback: Guiding Principles

SHADAC commented on the principles of (a) transparent model design and evaluation and (b) small-scale testing.

Regarding transparency in model design and evaluation, we emphasized two key points:

• Successful model design should include planning and discussion of parameters for evaluation. Specifically, the information, data, and evidence needed to determine the impact of new models should be determined in advance, and data collection and evaluation requirements should be prioritized from the outset and revisited over time.
• Evaluations of innovations should include clear documentation of actual interventions to assess outcomes. Evaluations must determine how models are implemented in practice (versus planned interventions) in order to better associate interventions with changes in outcomes.

Regarding the principle of small-scale testing, SHADAC identified two considerations:

• The Innovation Center should focus on developing the capacity to monitor similar state-based models across states to inform intervention scalability. To this end, effort should be put toward developing measurement frameworks, standards for data collection, and metrics to respond to questions about the efficacy of reforms.
• Adequate funding should be provided to support state and local evaluations and to support the timely release of interim and final evaluation results in order to promote accountability and shared learning.

Feedback: Potential Models – State-based and Local Innovation, Including Medicaid-Focused Models

SHADAC identified two important lessons from our work with states implementing delivery system and payment reform that can inform future state-based models:

• Flexibility in model implementation must be balanced with participant accountability.
• It is important to determine and communicate the value (or return on investment) of payment reforms and to develop data collection systems to support this work.

Feedback: Opportunities and Challenges Associated with Potential Models

SHADAC also identified opportunities and challenges for states implementing payment and delivery system models.

The opportunities identified were (among others): accelerating progress and facilitating learning through access to external expertise; facilitating evaluation of market and payment reforms through APCD analytic work and development; and encouraging provider organization participation by promising data analytics during model design.

On the flipside, SHADAC identified the following challenges: performance measurement issues; the demand for more timely claims data and the integration of clinical data with administrative/claims data; data privacy legal issues; and limited capacity among provider organization for provider electronic data-sharing outside of their own organization walls.

Other Feedback: Dissemination of Evaluation Findings

SHADAC encouraged the Innovation Center to continue to support rapid-cycle feedback reporting from required state-led evaluations. We also noted that evaluation plans and interim findings could be more accessible to other states through Innovation Center website links and up-to-date inventories, infographics, or dashboards of evaluation and monitoring methods, activities, data sources, and results.

View the full text of SHADAC's response below or download the PDF here. 

SHADAC Staff

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e shadac@umn.edu

December 5th Webinar: Impact of Medicaid vs. Marketplace Coverage on Out-of-Pocket Spending for Near-Poor Adults

SHADAC will host a coffee-break webinar on December 5th at 12:00 p.m. Central featuring Urban Institute's Dr. Fred Blavin, whose SHARE-funded research asks how medical spending burdens for near-poor families in non-expansion states would change if the states were to expand Medicaid.

			EVENT DETAILS
			Medicaid vs. Marketplace Coverage for Near-Poor Adults: Impact on Out-of-Pocket Spending
				Presenter: Fred Blavin, PhD Date: December 5, 2017 Time: 12:00 p.m. - 12:30 p.m. Central  Register now.

In states that chose to expand Medicaid under the ACA, adults between 100% and 138% of the federal poverty level (i.e., the "near-poor") are Medicaid-eligible and typically face minimal or no premiums or cost-sharing for medical expenses. In states that have chosen not to expand Medicaid, this population cannot enroll in Medicaid but may quality for tax credits to purchase marketplace health insurance plans that entail out-of-pocket (OOP) premiums and cost-sharing. Dr. Blavin's analysis uses data years 2013 to 2015 from the Current Population Survey and state Medicaid expansion decisions as a natural experiment to estimate the impact of access to the Medicaid expansion on OOP health expenses, compared with access to subsidized marketplace coverage. 

Dr. Blavin will answer questions from attendees after the presentation.

SHADAC Staff

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e shadac@umn.edu

State Implementation of the ACA’s Medicaid Smoking Cessation Provisions: SHARE Findings at Dissemination & Implementation Conference

Dr. Sara McMenamin of University of California, San Diego, will present results from her SHARE-funded research at the 10th Annual Conference on the Science of Dissemination and Implementation in Health.

Presentation At-a-Glance

Dr. McMenamin’s SHARE research examined state progress in implementing the ACA’s four provisions regarding Medicaid coverage for smoking cessation treatments. These provisions address: (1) coverage for pregnant women; (2) coverage for all enrollees through an increased federal match incentive; (3) coverage for all enrollees through Medicaid formulary requirements; and (4) coverage for Medicaid expansion enrollees.

From January through June 2017, Dr. McMenamin and her team studied Medicaid programs in all 50 states and the District of Columbia and found that 46 Medicaid programs had increased coverage for smoking cessation treatments by executing one or more of the four provisions. The most commonly implemented provision was coverage of comprehensive treatments for pregnant women without cost-sharing, which 27 Medicaid programs had in place. In all, only 11 state programs had implemented all four smoking cessation treatment provisions in the ACA.

Access the full presentation abstract.

Logistics

The D&I Conference is co-hosted by the National Institutes of Health and AcademyHealth and will take place December 4th through 6th in Arlington, VA.

Dr. McMenamin’s presentation is on December 4th at 2:50 p.m. at the Crystal Gateway Marriott, Salon B.