This toolkit was compiled and written by Sam Takvorian.
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Place your cursor over underlined terms to see definitions. You can also click on underlined terms to see definitions in the glossary at the end.
- Uninsured children are much more likely than insured children to have unmet medical needs. 1
- Nearly 8.7 million children in the U.S. lacked health insurance for all of 2006, up from 8 million in 2005, according to the latest Census Bureau data. 2
- Uninsured rates for children vary dramatically by state, from a 2005-2006 low of 5 percent in Michigan to a high of 21 percent in Texas. 3
- Largely due to public coverage, the uninsured rate is significantly lower among children than adults. In 2006, 11.7 percent of children were uninsured, compared to 17.2 percent of all adults (20.2 percent of non-elderly adults). 4
- About 28 million children were covered through Medicaid for at least part of 2006. 5 Most children on Medicaid qualify based on family income, but children may also qualify for Medicaid through other, largely disability-based, eligibility categories.
- Approximately 6.6 million children were enrolled at some time during 2006 in the State Children's Health Insurance Program (SCHIP), which helps cover children who lack health insurance but do not qualify for Medicaid.6
- Legislation reauthorizing and expanding SCHIP passed in the U.S. House and Senate in September 2007. President Bush vetoed the legislation. At press time, neither chamber of Congress had overridden the veto.
HOW DO CHILDREN GET COVERAGE?
Health insurance is a key factor in determining whether children receive the medical care they need. Uninsured children are much more likely than insured children to forgo necessary medical care due to costs and to have unmet medical needs. 7
Most children have coverage through a parent's employer. About 44 million children (60 percent) had private group coverage in 2006, mostly through employers, according the Census Bureau. 8 Whether a child has private coverage is influenced by its availability and cost. Large firms are more likely than small firms to offer coverage, 9 but even if offered, some employees may be ineligible or the costs may be prohibitively high. This is particularly true for family coverage plans, whose average monthly premiums have grown more rapidly than those for individual plans. 10 In 2007, the average yearly premium for family-based coverage was $12,106 and the average worker contribution was $3,281. 11
While employer-based coverage remains the primary source of insurance for both children and adults, it has declined in recent years. From 2000 to 2007, the percentage of firms offering health benefits dropped from 69 to 60 percent, leaving even children from working families uninsured. 12 In 2006, seven out of ten uninsured children had someone in the family who worked at least part time during the year; six in ten had a full-time worker in the family. 13
Some have noted that the decline in employer-sponsored coverage might be cyclical, as levels of insurance rose during the tight labor market of the late 1990s. 14 Nevertheless, according to the latest Census Bureau reports, employer-sponsored coverage declined at all income levels for children in 2006 and declined more steeply for children than adults. 15
MEDICAID'S ROLE FOR CHILDREN
Medicaid, an entitlement program financed jointly by states and the federal government, is the single largest insurer of children. 16 About 28 million children nationwide were covered through Medicaid for at least part of 2006. 17
Most children on Medicaid qualify based on family income. The federal government sets minimum eligibility requirements by which states must abide if they choose to participate in the program (and all do). States must provide coverage to children under 19 whose family income is at or below 100 percent of the federal poverty level (FPL), or $17,170 a year in 2007 for a
family of three. 18,19 Children under age six must be covered if their family income is at or below 133 percent of the FPL. Many states have chosen to broaden coverage to children with higher family incomes.
SCHIP'S ROLE FOR CHILDREN
Even with expanded coverage, Medicaid does not reach all low-income children. To cover this gap, Congress enacted the State Children's Health Insurance Program (SCHIP) in 1997 with strong bipartisan support. The program targets uninsured children in families with incomes too high to be eligible for Medicaid, but who still cannot afford private insurance. In 2006, nine out of ten children enrolled in SCHIP had family incomes at or below 200 percent of the FPL. 20
Like Medicaid, SCHIP is administered by states within broad federal guidelines, and the federal government matches state spending on eligible children (at a higher rate than under Medicaid). States can use SCHIP funds to expand coverage through a separate child health program, a Medicaid expansion, or a combination of the two approaches.
Together with Medicaid, SCHIP has helped reduce the uninsured rate among low-income children (under 200 percent of the FPL) by more than a third over the past decade. 21 Some 6.6 million children were enrolled in SCHIP at some point during 2006. 22
Despite the success of SCHIP, 8.7 million children remain uninsured today. 23 According to Congressional Budget Office estimates, five to six million of these children are eligible but unenrolled in Medicaid or SCHIP. 24 Other estimates are much lower, however, complicating the question of whether SCHIP is meeting the needs of its target population. 25
Moreover, SCHIP was authorized and funded for a 10-year period ending in September 2007. SCHIP's pending reauthorization has prompted debate over the extent to which the program should be reauthorized and expanded, if at all. Bills reauthorizing and expanding SCHIP passed the House and Senate in September 2007, but President Bush vetoed the legislation, based on concerns over SCHIP coverage unduly "crowding out" private coverage.
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Child Health Coverage Statistics
- U.S. Census Bureau
This table displays current Census Bureau data on coverage status and type of coverage for children under 18. The Census Bureau estimated that almost 8.7 million children lacked health insurance in 2006, up from 8 million in 2005. For comparison with earlier years, nationally and state-by-state, go to www.census.gov/hhes/www/hlthins/historic/hihistt5.html
- "State Health Facts: Medicaid and SCHIP"
Kaiser Family Foundation, 2007
This website, run by the Kaiser Family Foundation, provides comparative data on state health coverage programs for low-income families and children. The website's left column has links to state eligibility, spending and enrollment data. This resource is useful for comparing Medicaid and the State Children's Health Insurance Program (SCHIP) data across states.
- "Protecting America's Future: A State-by-State Look at SCHIP & Uninsured Kids"
Cover The Uninsured, August 2007
This data set, sponsored by the Robert Wood Johnson Foundation, provides a comprehensive state-by-state analysis of children's access to health insurance and health care. According to the analysis, a total of 6.6 million children nationwide were enrolled in SCHIP at some point during 2006. (11 pages)
- "Improving Children's Health: A Chartbook about the Roles of Medicaid and SCHIP"
Leighton Ku and others, Center on Budget and Policy Priorities, 2007
This chartbook, published by the Center on Budget and Policy Priorities and updated for 2007, provides a wealth of figures, charts and statistics on the impact of SCHIP and Medicaid on covering low-income children, along with information on children's health and access to needed care. (50 pages)
- "Improving Children's Health: Understanding Children's Health Disparities and Promising Approaches to Address Them"
Children's Defense Fund, 2006
This report discusses ethnic and racial disparities in children's access to health care. It has several useful tables comparing access among different child populations. The report shows that 21.3 percent of Hispanic children lacked health insurance in 2002, compared to 6.8 percent of white children and 10.1 percent of black children. (93 pages)
Children and Private Coverage
- "What Happened to the Insurance Coverage of Children and Adults in 2006?"
John Holahan and Allison Cook, Kaiser Commission on Medicaid and the Uninsured, September 2007
In this report, Holahan and Cook discuss the Census Bureau data released in August 2007 with respect to changes in insurance coverage among children and adults. The authors note that employer-sponsored coverage of children declined at all income levels, contributing to the growth in the number of uninsured children. Furthermore, they found that almost half of the increase in uninsurance among children was in families with incomes between 200 and 399 percent of the federal poverty level. (11 pages)
- "Comparing Public and Private Health Insurance for Children"
Leighton Ku, Center on Budget and Policy Priorities, May 2007
This report compares public and private health insurance for children. The author finds that public health coverage is less expensive than private insurance and provides comparable, and in some cases better, access to health care for children. (3 pages)
- "Children Who Lose Employer-Based Health Insurance Risk Remaining Uninsured"
Pediatric Academic Societies, May 2005
Most children are insured through a parent's employer, but for an estimated 3 million children who lose employer-based health insurance annually, 75 percent subsequently become uninsured, and almost a million remain uninsured for a year or longer, according to this article. (1 page)
The State Children's Health Insurance Program (SCHIP): An Overview
- "State Children's Health Insurance Program (SCHIP) at a Glance"
Kaiser Commission on Medicaid and the Uninsured, January 2007
This two-page fact sheet provides the basics on SCHIP - who's eligible, who's enrolled, how the program is administered, how it's financed, what services are covered, and key issues around SCHIP reauthorization. (2 pages)
- "Insuring All Children - The New Political Imperative"
John K. Iglehart, New England Journal of Medicine, Vol. 357, September 2007
John Iglehart, the New England Journal's national correspondent and founding editor of Health Affairs journal, provides a review of SCHIP's history and evolution. He emphasizes the prominent role that children's health coverage is playing on the national agenda in 2007 and touches on the basic differences in the approaches to SCHIP favored by the Bush Administration and Congress. (7 pages)
- "The Success of SCHIP: How the State Children's Health Insurance Program Helps America's Working Families"
Cover The Uninsured, 2007
This publication gives personal stories of SCHIP's impact on children and families in Colorado, the District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Maine, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New York, Ohio, Pennsylvania, Tennessee, Texas, Utah, Virginia and Washington State. (15 pages)
- "Increasing Children's Coverage and Access: A Decade of SCHIP Lessons"
Margo Rosenbach, Mathematica Policy Research, September 2007
This issue brief summarizes the findings of Mathematica's national 10-year evaluation of SCHIP, commissioned by the Centers for Medicare and Medicaid Services. The report synthesizes state data to provide national estimates of enrollment and crowd-out. (5 pages) The full 246-page report, "National Evaluation of the State Children's Health Insurance Program: A Decade of Expanding Coverage and Improving Access," is available at: www.mathematica-mpr.com/publications/pdfs/SCHIPdecade.pdf
Enrollment in SCHIP and Medicaid
- "Making Sense of Recent Estimates of Eligible but Uninsured Children"
Lisa Dubay, Kaiser Commission on Medicaid and the Uninsured, August 2007
As Congress deals with SCHIP reauthorization, accurate estimates of the number of children who are eligible for Medicaid and SCHIP but remain uninsured are critical for policy and budget development. The Congressional Budget Office (CBO) concluded that there are between 5 and 6 million children in this category. "CBO's assessment is in sharp contrast to estimates released recently by the Bush Administration indicating that there were only 1.1 million eligible but uninsured children," the authors note. This brief describes the methodologies underlying the two sets of widely varying estimates on one of the important SCHIP reauthorization issues. (15 pages)
- "Enrolling Uninsured Low-Income Children in Medicaid and SCHIP"
Kaiser Commission on Medicaid and the Uninsured, January 2007
This fact sheet traces factors affecting enrollment in Medicaid and SCHIP. It provides a profile of eligible but uninsured children, discusses the greatest barriers to enrollment, and offers strategies to improve enrollment. Also, it says that nearly three out of four uninsured children are eligible for Medicaid or SCHIP. (2 pages)
- "SCHIP Turns 10: An Update on Enrollment and the Outlook on Reauthorization from the Program's Directors"
Vernon Smith and others, Kaiser Commission on Medicaid and the Uninsured, May 2007
This report provides SCHIP enrollment data from June 2006. It also reports the findings from interviews of 10 SCHIP directors about the accomplishments of and future challenges facing SCHIP as it is due for reauthorization 2007. (35 pages)
- "Automatically Enrolling Eligible Children and Families Into Medicaid and SCHIP: Opportunities, Obstacles, and Options for Federal Policymakers"
Stan Dorn and Genevieve M. Kenney, The Commonwealth Fund, June 2006
This report notes that most uninsured children are eligible for Medicaid or SCHIP. The authors examine whether and how automatic enrollment programs could extend health coverage to eligible but currently uninsured children and families. Though careful to point out that enrollment does not guarantee access, the authors find potential for SCHIP and Medicaid in the success of other auto-enrollment plans. (54 pages)
SCHIP & Crowd-Out
- "Who's Counting? What is crowd-out, how big is it and does it matter for SCHIP?
Alliance for Health Reform briefing, Aug. 29, 2007
How much private coverage is displaced, or "crowded out", when public programs like SCHIP and Medicaid are expanded? This Alliance for Health Reform briefing, supported by the United Health Foundation, explored this issue, including the types of crowd-out, anticipated crowd-out effects of recently passed House and Senate legislation, and how to minimize these effects.
- Presentation on crowd-out by Peter Orszag, director of the Congressional Budget Office
PowerPoint presentation for Alliance for Health Reform briefing, Aug. 29, 2007
This presentation offers detailed estimates by the CBO on how many uninsured children would gain coverage under different SCHIP reauthorization bills passed by the U.S. House and Senate, and how many newly enrolled children would drop previous private insurance - the crowd-out factor. (3 slides)
- "The State Children's Health Insurance Program"
Congressional Budget Office, May 2007
This paper provides an overview of SCHIP, including federal spending, the difference between the federal match provision in SCHIP and the one in Medicaid, state eligibility thresholds, the effect of SCHIP on children's health insurance coverage, and an analysis of funding and policy options to sustain the program. CBO concludes that the reduction in private coverage among children is between 25 and 50 percent of the increase in public coverage resulting from SCHIP. (36 pages)
- "SCHIP and 'Crowd-Out': How Public Program Expansion Reduces Private Coverage"
Andrew Grossman and Greg D'Angelo, The Heritage Foundation, June 21, 2007
This web memo cites several recent studies on crowd-out and argues that expansions in public programs invariably lead to progressively higher levels of crowd-out. In other words, as more money is invested in SCHIP's expansion, less funds will go to providing coverage to uninsured children. (4 pages)
- "On Covering The Kids' Health"
Jonathan Cohn, The New Republic, September 8, 2007
The author says that two important provisions in both the Senate and House SCHIP expansion bills regard recruitment and outreach to encourage currently eligible kids to enroll in existing Medicaid and SCHIP programs. He argues that the expansion to higher income populations will inevitably attract some children from families who have private coverage, but that most of the money will still be spent on poor kids. Cohn outlines some reasons why middle-class families might need government assistance to get health insurance, especially in states with very high costs of living. He concludes with his solution for avoiding crowd-out. This website includes comments from readers. (2 pages)
SCHIP Reauthorization: Issues in the Current Debate
(For the latest developments on SCHIP reauthorization, see the four links at the bottom of this section.)
- "The Battle Over SCHIP"
John K. Iglehart, New England Journal of Medicine, Vol. 357, September 6, 2007
In this article, Iglehart provides a thorough introduction to the debate over SCHIP's reauthorization. Included is a brief discussion of the House and Senate reauthorization proposals and the Bush Administration's new guidelines for expansion. (4 pages)
- "SCHIP Reauthorization: Key Questions in the Debate"
Kaiser Commission on Medicaid and the Uninsured, August 2007
This brief highlights some of the key issues underlying the debate on the reauthorization of SCHIP. It concludes with a side-by-side comparison of the Senate and House reauthorization proposals. (10 pages)
- "Children's Health Insurance Program Reauthorization Act of 2007 (CHIPRA)"
Kaiser Commission on Medicaid and the Uninsured, October 2007
This issue brief outlines the latest developments in the SCHIP debate at press time. The Children's Health Insurance Program Reauthorization Act of 2007 (CHIPRA), a bill designed to reauthorize and expand SCHIP, was passed with broad bi-partisan support in Congress and vetoed by the President on October 3, 2007. This brief provides an overview of the key provisions in CHIPRA. (5 pages)
- "Federal Study Offers Dire Outlook on Child Insurance"
Robert Pear, New York Times, October 31, 2007
This article reports on the findings of a recent Congressional Research Study, showing that 21 states will run out of money for children's health insurance in the coming year and at least nine of those will exhaust their allotments in March if funding remains at current levels. This finding underscores the urgency of the debate over SCHIP reauthorization.
- "CBO Estimates Show SCHIP Agreement Would Provide Health Insurance to 3.8 Million Uninsured Children"
Edwin Park, Center on Budget and Policy Priorities, September 25, 2007
Congressional Budget Office estimates show that by 2012, a total of 3.8 million children who otherwise would be uninsured would have health coverage under the compromise SCHIP reauthorization agreement by Senate and House negotiators. (4 pages)
- "SCHIP Reauthorization: How Will Low-Income Kids Benefit Under House and Senate Bills?"
Genevieve M. Kenney and others, The Urban Institute, September 2007
Approximately 70 percent of children who are projected to benefit from both the Senate and House bills to reauthorize SCHIP have incomes below 200 percent of the Federal Poverty Level, according to this report. An even higher share (between 78 and 85 percent) of the uninsured children who stand to gain coverage under the bills have incomes below 200 percent of the FPL. This article demonstrates that overall very few of the children targeted under both bills have incomes above 300 percent of the FPL. (4 pages)
- "Reauthorizing SCHIP: Opportunities for Promoting Effective Health Coverage and High-Quality Care for Children and Adolescents"
Lisa Simpson and others, The Commonwealth Fund, August 9, 2007
This report presents a framework for promoting effective health coverage and high quality in SCHIP and Medicaid through the following strategies: 1) ensuring access to care through eligibility, enrollment, and retention policies; 2) providing a robust benefit package; 3) strengthening provider capacity; 4) measuring performance; 5) improving quality; 6) providing incentives for quality; and 7) promoting the use of health information technology. (44 pages)
- "Sinking SCHIP: A First Step toward Stopping the Growth of Government Health Programs"
Michael F. Cannon, The Cato Institute, September 13, 2007
In this briefing paper, Michael Cannon, director of health policy studies at Cato, argues against the expansion of SCHIP, saying that the program insures families who can obtain insurance for themselves. Rather than expand SCHIP, Cannon urges Congress to "make private health insurance more affordable by allowing consumers and employers to purchase less expensive policies from other states, and fold federal Medicaid and SCHIP funding into block grants that no longer encourage states to open taxpayer-financed health care to non-needy families." (16 pages)
- "The SCHIP Open: Hidden Incentives for States to Spend Federal Funds"
Robert B. Helms, American Enterprise Institute, August 28, 2007
This policy brief discusses the fiscal impact that SCHIP's reauthorization might have on unfounded liabilities in the federal government. The author argues that both the House and Senate proposals move SCHIP away from block grant funding, making it more closely resemble an entitlement program. (5 pages)
- "The Administration's SCHIP Regulations: A Sound Prescription"
Nina Owcharenko, The Heritage Foundation, August 27, 2007
The author praises the Bush Administration for its efforts to refocus SCHIP back to its original calling-providing insurance to children in families at or below 200 percent of the federal poverty level. (2 pages)
- "Fixing SCHIP and Expanding Children's Health Care Coverage"
Nina Owcharenko, The Heritage Foundation, May 2, 2007
The author argues against SCHIP expansion as a way to cover uninsured children, citing crowd-out and fiscal concerns. She suggests refocusing SCHIP to help low-income working families, as originally intended. Included is a brief critique of current House and Senate reauthorization proposals, as well as a look at the Bush Adminstration proposal. Finally, the author comments on specific ways to improve SCHIP in its reauthorization. (11 pages)
- "CMS Letter to State Health Officials"
Dennis Smith, Centers for Medicare and Medicaid Services, August 17, 2007
In this letter, the Centers for Medicare and Medicaid Services identifies SCHIP crowd-out prevention strategies that state plans should include. It provides guidance especially for states that expand eligibility above 250 percent of the federal poverty level (FPL), requiring these states to establish a one-year minimum for uninsurance prior to SCHIP enrollment; and provide assurance that 95 percent of children below 200 percent of the FPL are already enrolled.
- "Medicaid and SCHIP Participation Rates: Implications for New CMS Directive"
Genevieve M. Kenney, The Urban Institute, September 12, 2007
In August 2007, the Centers for Medicare and Medicaid Services (CMS) issued a directive requiring that states reach participation rates of 95 percent among children in families with incomes below 200 percent of the federal poverty line in Medicaid and the State Children's Health Insurance Program (SCHIP) before using SCHIP funds to cover higher-income children. In this brief, Genevieve Kenney concludes that there are serious methodological challenges involved with obtaining valid and policy-relevant state-level participation rate estimates. Kenney also reviews recent trends in Medicaid and SCHIP participation rates and comments on participation estimates released by CMS. (7 pages)
- "U.S. Rejects New York's Bid to Insure More Children"
Robert Pear, New York Times, September 8, 2007
New York's proposal to expand SCHIP to cover children up to 400 percent of the federal poverty line was rejected based on the CMS guidance issued on August 17, 2007. According to the NY Times, "Federal officials said the change would divert resources from lower-income children and 'crowd out' private health insurance."
For Updates on SCHIP Reauthorization:
- Some 14 states were facing SCHIP funding shortfalls on October 1, 2007. 26 These states were Alaska, Georgia, Illinois, Iowa, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, Rhode Island and Wisconsin. What's the latest with SCHIP funding in your state?
- Coming out of tight fiscal times, some states are again looking to expand and improve children's coverage. If your state is expanding coverage, are policymakers and the public pleased with the results?
- The Deficit Reduction Act allows states, for the first time, to charge children in Medicaid co-payments and in some cases premiums. Is your state imposing new copayments? Is there a discernible impact on children's enrollment and access to care? If there are copays that families cannot pay, are they being turned away by providers?
- The DRA requires states to collect documents from families to prove citizenship before their children can be enrolled in Medicaid (this new requirement applies just to citizen children; immigrant children are already subject to verification requirements). How is this new rule working, or has your state decided to delay this requirement? What is the impact on enrollment numbers?
- "Waivers" allow states to operate their Medicaid programs in ways that do not conform to regular federal rules. Does your state have a waiver in progress or in the planning stage for children's coverage under SCHIP or Medicaid? If so, are the benefits offered under the waiver richer or leaner? Is income eligibility easier? What is the impact on costs for families and the state?
- Do uninsured children in your area have any access to health care services outside of the emergency room? How reliable are such services, what is the quality, and what do they cost?
- How are the current SCHIP guidelines impacting your state? Will some children lose coverage as a consequence? How is your state responding to this?
Drawn from the Alliance for Health Reform's Find-an-Expert Service for reporters. Descriptions in quotes are written by the experts themselves. Credentialed reporters can see full profiles for these and other experts,
including after-hours contact numbers, by going to
- JOAN ALKER
Senior Researcher, Center for Children and Families, Georgetown University
Washington DC 20057-1485
"My primary focus is on federal and state public policy as it relates to the health care needs of low-income families (i.e. Medicaid, SCHIP). Special interest in state Medicaid waivers especially Florida."
- CHRISTINA BETHELL
Associate Professor/Director, Oregon Health & Science Univ. School of Medicine, Dept. of Pediatrics, The Child and Adolescent Health Measurement Initiative
Portland OR 97239
"My focus is on valid sources of data on child, youth and family health and the relevant link of this data to local, state and national health policy issues. I have 25 years of experience in reforming the culture, financing and infrastructure of health care and am happy to be a resource for you."
- M. GREGG BLOCHE
Nonresident Senior Fellow, Economic Studies, The Brookings Institution
1775 Massachusetts Ave., NW, Washington, DC 20036
"Primary subjects: Health care law & regulation; biomedical ethics; international health law & policy. Recent writings have appeared in the New Eng. J. of Med., Health Affairs, JAMA, law journals, & the N.Y. Times & other newspapers."
- RICHARD BUCCIARELLI
Vice President for Government Relations, University of Florida
Gainesville FL 32611-3157
"Main interest in access to care for children. Have worked on Medicaid/SCHIP expansions. Chair of AAP Committee on Federal Government Affairs and Chair of workgroup on Access to care for children."
- STUART M. BUTLER
Vice President, Domestic and Economic Policy Studies, Heritage Foundation
214 Massachusetts Ave, NE, Washington, DC 20002
"Senior health expert in America's foremost conservative research organization. Expert on the uninsured -- especially tax credit solutions -- and Medicare. Frequently testifies and speaks on health issues."
- MICHAEL F. CANNON
Director of Health Policy Studies, Cato Institute
1000 Massachusetts Avenue, NW Washington, DC 20001
"Expanding patient and provider freedom. Using market mechanisms to improve quality, reduce cost, generate information for patients, and drive IT innovation. Encouraging regulatory competition among governments, incl. devolving power over health care to states."
- OLIVIA CARTER-POKRAS
Associate Professor, University of Maryland School of Medicine, Department of Epidemiology and Preventive Medicine
Baltimore MD 21201-1596
"I am an expert in racial and ethnic data issues, minority health, health disparities with a particular emphasis on Latino health."
- NANCY CHOCKLEY
President and CEO, NIHCM Foundation
Washington, D.C. DC 20016
"I run an organization that does work on the following topics: the uninsured, pharmaceutical issues, obesity, changing market dynamics, children's health, and prevention efforts."
- GARY CLAXTON
Vice President, Director, Health Care Marketplace Project, Henry J. Kaiser Family Foundation
Washington DC 20005
"Gary Claxton is a Vice President and the Director of the Health Care Marketplace Project at the Henry J. Kaiser Family Foundation. The Project provides information, research, and analysis about trends in the health care market and about policy proposals that relate to health insurance reform and our changing health care system. Prior to joining the Foundation, Mr. Claxton worked as a senior researcher at the Institute for Health Care Research and Policy at Georgetown University, where his research focused on health insurance and health care financing. From March 1997 until January 2001, Mr. Claxton as the Deputy Assistant Secretary for Health Policy at the U.S. Department of Health and Human Services, where he advised the Secretary on health policy issues including: improving access to health insurance, Medicare reform, administration of Medicaid, financing of prescription drugs, expanding patient rights, and health care privacy."
- KAREN DAVENPORT
Director of Health Policy, Center for American Progress
Washington DC 20005
"As Director of Health Policy at CAP, I focus on issues related to health care reform and the uninsured. Reforming our nation's health care system to provide affordable coverage to all Americans is one of CAP's top priorities, which we pursue through political advocacy (under the umbrella of the CAP Action Fund), as well as research and analysis. I also draw on my Congressional, Executive Branch and philanthropic experience when CAP develops work on Medicaid, SCHIP, Medicare, health disparities and other policy issues."
- MICHAEL DAVERN
Assistant Professor, Health Policy & Management School of Public Health
University of Minnesota
Mayo Mail Code 729
420 Delaware Street S.E.
Minneapolis, MN 55455-0392
"Michael Davern, Ph.D., is an Assistant Professor in the Division of Health Policy and Management in the School of Public Health, and is Research Director and Co-Principal Investigator of the State Health Access Data Assistance Center (SHADAC). His research expertise is in survey methods and demographic health data, and in applying these to inform health policy. His survey methods research includes work in non-response, measurement error, imputation, sampling error estimation, weighting, and production of federal survey data, as well as other survey data used for state level policy work."
- KAREN DAVIS
President, The Commonwealth Fund
New York NY 10021
"My primary interests are the uninsured, Medicare, Medicaid, health policy, quality and organization of health services, international health, minority health, and women's health. My training is in economics with experience in government health policy, academia, and currently private foundation sponsoring independent research on health and social issues."
- LISA DUBAY
Associate Professor, Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205
"Dr. Dubay is an Associate Professor at the Johns Hopkins Bloomberg School of Public Health with over 20 years of health policy experience. Prior to this, she was a Principal Research Associate at the Urban Institute where she focused on the effects of public policies on insurance coverage, access to care, and health outcomes for children, pregnant women, and parents. Dr. Dubay has led numerous national evaluations of public expansions in coverage for federal agencies and private foundations. Dr. Dubay has written extensively on the extent to which expansions in public coverage lead to reductions in uninsurance and improvements in access to care. Dr. Dubay's work has been published in both peer-reviewed journals and as briefs and papers targeted to policy makers and stakeholders."
- PAUL FRONSTIN
Director, Health Research Program, Employee Benefit Research Institute
Washington DC 20037
"I specialize in economic security issues related to employment-based health benefits, health insurance coverage, and the uninsured."
- ROBYN GABEL
Executive Director, Illinois Maternal and Child Health Coalition
Chicago IL 60622
"I have worked in the health care field for 25 years focusing on women's and children's health -- specifically, immunizations, school health, prematurity, State Children's Health Insurance Program in Illinois, the uninsured and postpartum depression."
- ANNE GAUTHIER
Senior Policy Director, The Commonwealth Fund
Washington DC 20006
"My primary interests fall within the broad area of health care financing and organization, following closely the hot policy issues. For example, in late 2004, consumer-driven health care, the uninsured, Medicare drug benefit implementation, administrative simplification, and incentives to improve quality for the chronically ill are topics on which I'm working."
- PAUL GINSBURG
President, Center for Studying Health System Change
Washington DC 20024
Contact Alwyn Cassil: 202-264-3484
"As a health economist, my primary interests include health care costs, the uninsured, managed care and insurance trends, physician issues, market changes and Medicare issues."
- EDMUND F. HAISLMAIER
Senior Research Fellow in Health Policy Studies, Heritage Foundation
214 Massachusetts Ave, NE, Washington, DC 20002
Edmund Haislmaier is an expert in health care policy and markets. Prior to rejoining Heritage in 2005 as a research fellow, Mr. Haislmaier was a health policy consultant (1998-2004) and director of health care policy in the Corporate Strategic Planning and Policy division of Pfizer (1994-1998). Before that (1987-1994), he was the senior policy analyst for health care issues at The Heritage Foundation. Mr. Haislmaier is the author of numerous papers on health policy topics including: health care tax policy, employer-based and individual health insurance, Medicare, Medicaid, foreign health systems, long-term care, pharmaceuticals, and health care price controls. He is also frequently called upon to assist federal and state lawmakers in designing and drafting health reform proposals and legislation.
- MICHAEL HASH
Principal, Health Policy Alternatives, Inc.
Washington DC 20001
"I have worked on health policy issues -- mainly Medicare & Medicaid -- for nearly 30 years in Washington. Work experience includes the American Hospital Association, the House Commerce Committee, my current employer (HPA), and CMS (HCFA) where I served as deputy administrator in the Clinton Administration."
- ROBERT B. HELMS
Resident Scholar, American Enterprise Institute
1150 Seventeenth Street, NW, Washington, DC 20036
"I am an economist who has worked in the health policy area in Washington for about 30 years, including 8 years at HHS/ASPE during the Reagan years. I have written on the tax treatment of health insurance, private health insurance, tax credits for expanding coverage, Medicare and Medicaid reform, and the economics of the pharmaceutical industry."
- JOHN HOLAHAN
Director, Health Policy Center, The Urban Institute
Washington DC 20037
202 261 5666
"My principal areas of interest are Medicaid policy, the uninsured and the uninsured."
- EDWARD F. HOWARD
Exec V-P, Alliance for Health Reform
Washington DC 20005
"Has run the nonpartisan Alliance for Health Reform since its founding in 1991, where he has arranged hundreds of policy briefings for Congressional staff and media in Washington and around the country."
- ANDREW HYMAN
Senior Program Officer, Health Care Group, Robert Wood Johnson Foundation
Princeton, NJ 08543
"Andrew D. Hyman, J.D., team leader for the Robert Wood Johnson Foundation's Coverage Team, is responsible for developing and executing strategies designed to achieve the Foundation's goal of securing for all Americans meaningful access to health care coverage. He recognizes that 'the promise of equal opportunity in this country is empty while we permit millions to be uninsured.' Having joined the Foundation in 2006 as a senior program officer in the Health Care Group, he and the Coverage Team work with policy-makers, researchers and advocates to help our nation's leaders craft and enact policies designed to expand coverage…. From 1998-2001 Hyman was the deputy director and then director of the Office of Intergovernmental Affairs at the U.S. Department of Health and Human Services (HHS), serving as Secretary Donna Shalala's liaison to state, local, and tribal governments. His work at HHS also included efforts to combat tobacco use and to implement state children's health insurance programs."
- CHRIS JENNINGS
President, Jennings Policy Strategies, Inc.
Washington DC 20001
"Former senior health care advisor to President Clinton for eight years and ten year veteran of Senate Aging/Finance Committee. Expertise in insurance coverage, cost containment, Medicare, Medicaid, CHIP, long term care and overall politics of health care."
- GENEVIEVE KENNEY
Principal Research Associate, The Urban Institute
Washington DC 20037
"My primary research interests include Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance coverage and access issues among low-income children and families."
- ANN CLEMENCY KOHLER
Deputy Commissioner, New Jersey Department of Human Services
Trenton, NJ 08618
"Ann Clemency Kohler was promoted to deputy commissioner of the New Jersey Department of Human Services in March 2007. Previously, Ms. Kohler was director of the New Jersey Division of Medical Assistance and Health Services. She began her career in health care administration in 1977 with the Division of Medical Assistance and Health Services and rose through the ranks to the position of deputy director in 1993. After leaving state government to work for a health maintenance organization (HMO), she returned in 1996 as Medicaid director for the State of New York, the largest Medicaid agency in the country. In 2000, Ms. Kohler returned to New Jersey and was appointed to a management position in the Office of Management and Budget (OMB). While at OMB, she was responsible for the oversight of the budget and fiscal operations for both the Departments of Human Services and Health and Senior Services."
- LEIGHTON KU
Senior Fellow, Center on Budget and Policy Priorities
Washington DC 20010
"My main areas of interest are health insurance coverage and how we pay for it; this particularly includes Medicaid and SCHIP. My organization is engaged in timely research and advocacy at both federal and state levels."
- WENDY LAZARUS
Founder and Co-President, The Children's Partnership
Santa Monica CA 90401
"Brings extensive experience on children's health policy and advocacy issues. Led successful policy reform efforts at the federal level and in a number of states including California."
- JOHN LEWY
Immediate Past Chairman, Committee on Federal Government Affairs, American Academy of Pediatrics
Washington DC 20037
"I am the Emeritus Chairman of Pediatrics at Tulane Medical School and the Immediate Past Chair of the AAP Committee on Federal Government Affairs. I have 25 years of experience in Pediatric Health Affairs. I am currently constantly involved with the AAP and all its efforts in behalf of children on the federal level."
- TRUDI MATTHEWS
Associate Director for Health Policy, The Council of State Governments
Lexington KY 40578
"I work for a 70-year old national, nonpartisan organization of state officials in all three branches of government, including governors, state legislators, and executive branch appointees. It is my job to monitor health policy developments, trends and innovations and know what they mean for states."
- LAWRENCE MCANDREWS
President & CEO, National Association of Children's Hospitals
Alexandria VA 22314
"Mr. McAndrews is an expert in children's health care and federal policy issues that affect children's health and children's hospitals' ability to serve all children. These issues include Medicaid, quality measurement and improvement in pediatrics, graduate medical education and pediatric research funding. Mr. McAndrews is also an expert in the (children's) hospital industry and can provide commentary on health care trends as they impact children's hospitals."
- MARK MCCLELLAN
Senior Fellow and Director, Engelberg Center for Health Care Reform, The Brookings Institution
1775 Massachusetts Ave., NW, Washington, DC 20036
"Dr. Mark B. McClellan is the former administrator for the Centers for Medicare and Medicaid Services (CMS) and the former commissioner of the Food and Drug Administration (FDA) in the U.S. Department of Health and Human Services. In October 2006, Dr. McClellan joined the AEI-Brookings Joint Center for Regulatory Studies as a visiting senior fellow. At AEI and Brookings, Dr. McClellan works on developing and implementing ideas to drive improvements in high-quality, innovative, affordable health care. Dr. McClellan is also an associate professor of economics and associate professor of medicine at Stanford University, from which he was on leave during his government service. Dr. McClellan has had a highly distinguished tenure of public service. In the George W. Bush administration, he served as a member of the President's Council of Economic Advisers and senior director for health care policy at the White House (2001-2002), FDA commissioner (2002-2004), and CMS administrator since March 2004. In these positions, he developed and implemented major reforms in health policy."
- BRENDAN MCTAGGART
Communications Director, National Health Law Program
Washington DC 20005
"I am the communications director for the National Health Law Program, which employs some of the nation's foremost experts on Medicaid law. Areas of focus include children's health, immigrant access to health care, reproductive health, and racial disparities in health care. I am not an expert on health care law myself but can direct you to the appropriate staff attorney."
- ROBERT E. MOFFIT
Director, Center for Health Policy Studies, Heritage Foundation
214 Massachusetts Ave, NE, Washington, DC 20002
"Former Deputy Assistant Secretary of HHS; former Assistant Director of the Office of Personnel management, Moffit is Director of Domestic Policy Studies and has more than 20 years experience in federal health care policy, including Medicare and the FEHBP."
- JUDITH MOORE
Senior Fellow, National Health Policy Forum
Washington DC 20037
"Principle expertise and interest in public programs and health insurance for low income people, particularly the Federal-state Medicaid program and the State Children's Health Insurance Program (SCHIP). Knowledge of Medicaid enrollment, eligibility, benefits, state and federal program administration, recent policy changes, and policy history of the programs."
- ROSE NAFF
Executive Director, Florida Healthy Kids Corporation
Tallahassee FL 32302
850 701 6101
"Administering child health insurance coverage since 1990."
- LEN NICHOLS
Director of Health Policy Program, New America Foundation
Washington DC 20009
"I study, write, and speak about private health insurance markets (decisions by employers, workers, health plans, and regulators), coverage expansion policy options, sources of and reactions to health care cost growth, and Medicare reform. I was the Senior Advisor for Health Policy at OMB during the Clinton health reform process of 1993-94, taught at Wellesley College, and did research at both AHRQ and the Urban Institute before joining the Center."
- NINA OWCHARENKO
Senior Policy Analyst, Center for Health Policy Studies, Heritage Foundation
214 Massachusetts Ave, NE, Washington, DC 20002
Nina Owcharenko is a senior policy analyst for health care at The Heritage Foundation's Center for Health Policy Studies. In this position, Ms. Owcharenko researches and writes on a variety of health-care policy, including the uninsured, Medicaid, and prescription drugs. She has presented before numerous national, states and professional conferences. She has also been a guest on dozens of radio and television programs advocating her opinions and policies. Ms. Owcharenko served for nearly a decade on Capitol Hill focusing on health-care issues. Before coming to Heritage, she served as the legislative director for Rep. Jim DeMint, R-S.C., and Rep. Sue Myrick, R-N.C. She started her Hill career working for Sen. Jesse Helms, R-N.C.
- EDWIN PARK
Senior Health Policy Analyst, Center on Budget & Policy Priorities
Washington DC 20002
"Medicaid, SCHIP, Medicare, and tax issues related to health care Previously, health care policy advisor for the National Economic Council at the White House and Medicaid health professional staff member for the Senate Finance Committee (minority staff, Senator Daniel Patrick Moynihan). Also, an associate practicing health law for the law firm of Hogan & Hartson. Graduated from Harvard Law School and Princeton University."
- JAMES PERRIN
Professor of Pediatrics, MGH Center for Child and Adolescent Health Policy
Boston MA 02114
"My main interests relate to chronic conditions and disability in children and adolescents, including recent major increases in rates. Related work follows insurance and other public programs for children with disabilities and their families."
- RON POLLACK
Executive Director, Families USA
Washington, D.C. DC 20005
"Families USA is the national organization for health care consumers. As executive director of Families USA, health care expertise includes health coverage for the uninsured, prescription drugs costs and affordability, Medicare and Medicaid, patients' rights legislation, and health care ombudsman issues."
- NICOLE RAVENELL
President and CEO, Southern Institute on Children and Families
Columbia, SC 29201
"Nicole Ravenell is President and CEO of the Southern Institute on Children and Families. She provides leadership for all initiatives of the Southern Institute. Ravenell has 17 years of experience working in public policy related to the well-being of children and families in the areas of public education and health coverage. Ravenell managed and provided policy technical assistance to 51 statewide projects and more than 140 local projects as Deputy Director of Policy during the Covering Kids & Families national initiative. She provides policy technical assistance to teams participating in collaboratives led by the Southern Institute's Process Improvement Center. Ravenell also provides technical assistance to public and private agencies on Medicaid and State Children's Health Insurance Program policy. She is the author and co-author of nine Southern Institute reports featuring data and policy information on a variety of issues related to child and family well-being, including child care and early education, health coverage and obesity awareness and prevention…."
- MARTHA ROHERTY
Director, National Association of State Medicaid Directors
Washington DC 20002
202-682-0100 ext. 299
"Martha Roherty is the Director of the National Association of State Medicaid Directors and the Center for Workers with Disabilities. The National Association of State Medicaid Directors (NASMD) is a bipartisan, professional, nonprofit organization of representatives of state Medicaid agencies (including the District of Columbia and the territories). Since 1979, NASMD has been affiliated with the American Public Human Services Association (APHSA). The primary purposes of NASMD are: to serve as a focal point of communication between the states and the federal government, and to provide an information network among the states on issues pertinent to the Medicaid program."
- SARA ROSENBAUM
Chair, Department of Health Policy, George Washington University
Washington DC 20006
Sara Rosenbaum is Hirsh Professor and founding chair of the Department of
Health Policy at the George Washington University School of Public Health and Health
Services. She has devoted her career to issues of health law and policy
affecting low income, minority, and medically underserved populations, and the health
care safety net. Between 1993 and 1994, she worked for President Clinton, directing the
legislative drafting of the Health Security Act and developing the Vaccines for Children
program. She has written more than 250 articles and studies focusing on all phases of
health law, as well as health care for medically underserved populations, and is coauthor
of Law and the American Health Care System (Foundation Press, NY).
- DIANE ROWLAND
Executive Vice President, Kaiser Family Foundation
Washington DC 20005
"My primary interests are Medicare and Medicaid policy, health coverage and the uninsured, coverage and access to care for the low-income population, and health care reform. As executive director of the Kaiser Commission on Medicaid and the Uninsured, much of my work examines coverage for the low-income and uninsured populations."
- MATT SALO
Director of Health Legislation, National Governors Association
Washington DC 20001
"I have been the director of health legislation for the National Governors Association since January 1999. Prior to that I spent 5 years working for the National Association of State Medicaid Directors."
- JUDITH SOLOMON
Senior Fellow, Center on Budget and Policy Priorities
Washington DC 20002
"My expertise is in the area of the provision of services to children and families in Medicaid and SCHIP (HUSKY in Connecticut)as well as eligibility for these programs. This includes knowledge of state and federal statutory and regulatory requirements governing eligibility and the provision of services."
- JANET TRAUTWEIN
Executive Vice President and CEO, National Association of Health Underwriters
Arlington, VA 22201
Janet Trautwein is executive vice president and CEO of the National Association of Health Underwriters (NAHU) in Arlington, Virginia. Her responsibilities include oversight of all NAHU activities and primary representation of the association to the media, government agencies, elected officials, the insurance industry, and the public. Prior to this, Ms. Trautwein served as head of NAHU's government affairs department, developing policy recommendations for NAHU. In 2001, she was appointed to President Bush's health advisory transition team to advise the president and the incoming Secretary of Health and Human Services on health issues facing the nation. Ms. Trautwein's background includes 17 years in the insurance business as a principal in an insurance agency specializing in health insurance, employee benefits, and related products and four years as the legislative director and lobbyist for the Texas State Association of Health Underwriters. In 2004, she received the Harold R. Gordon Memorial Award, which honors the "Health Insurance Person of the Year" and is considered the most prestigious award in the health insurance industry.
- REED TUCKSON
Senior Vice President of Consumer Health and Medical Care Advancement, UnitedHealth Group
Minnetonka MN 55343
A graduate of Howard University and Georgetown University School of Medicine, Dr. Tuckson is currently Senior Vice President of Consumer Health and Medical Care Advancement at UnitedHealth Group. He has served as Senior Vice President, Professional Standards, for the American Medical Association (AMA). He is former President of the Charles R. Drew University of Medicine and Science in Los Angeles from 1991 to 1997; has served as Senior Vice President for Programs of the March of Dimes Birth Defects Foundation from 1990 to 1991; and from 1986 to 1990, Dr. Tuckson was the Commissioner of Public Health for the District of Columbia. He currently is a member of Institute of Medicine of the National Academy of Sciences and serves as a member of the Secretary of Health and Human Services' Advisory Committee on Genetics, Health and Society and has held a number of other federal appointments, including cabinet level advisory committees on health reform, infant mortality, children's health, violence, and radiation testing."
- GRACE-MARIE TURNER
President, Galen Institute
Alexandria VA 22320
"Primary interests are the uninsured, Medicare reform, and prescription drugs, with a focus on free-market policy alternatives such as tax credits for the uninsured and premium support for Medicare"
- CORINNE WALENTIK
Professor of Pediatrics-Division of Neonatology, SSS Cardinal Glennon Children's Hosp/Saint Louis University
St. Louis MO 63104
"I am a neonatologist who spent 17 years directing Neonatal services in St. Louis public hospitals and returned full time to ST. Louis U/ Cardinal Glennon when the public hospital closed. I have been involved with community and state maternal child health initiatives for over 20 years. I currently serve on the St Louis Regional Health Commission where I chair the Provider Services Advisory Board. I also serve as vice chair of the Citizen Advisory Committee of the Missouri Foundation for Health and on its program and grants committee. I also serve on the Board of Nurses for Newborns Foundation, the St. Louis ARC and the Childgarden Child Development Center. At SSM Cardinal Glennon Children's Hospital I serve as chair of Pediatric medical management and am the pediatrics representative to the SSM St. Louis Network committee."
- ELIE WARD
Executive Director, Statewide Youth Advocacy
Albany NY 12207
"I have considerable expertise in the areas of children's health program, policy and financing. I am also expert in New York State's children's health insurance programs and programs for special needs children."
- JUDY WAXMAN
Vice President Health and Reproductive Rights, National Women's Law Center
Washington DC 20009
202 588 5180
"I have represented consumers on access to health care issues for 25 years."
- ALAN WEIL
Executive Director, Natl Academy for State Health Policy
Washington DC 20036
"My research focuses on Medicaid, the uninsured and state/federal issues. I also have experience as a state Medicaid administrator."
- TIM WESTMORELAND
Visiting Professor of Law, Research Professor of Public Policy, Georgetown University
Washington DC 20007
"I have been health staff for the U.S. House on and off for the last 25 years. I was also the director of the Medicaid program."
- PETERS WILLSON
Vice President, Public Policy, National Association of Children's Hospitals
Alexandria VA 22314
"My areas of expertise include Medicaid policy - its impact on children and safety net providers, specifically children's hospitals; and graduate medical education in children's hospitals."
- JUDITH WOOLDRIDGE
Senior Vice President, Mathematica Policy Research
Princeton NJ 08543-2393
609 275 2370
"My current area of study is Medicaid and SCHIP health insurance coverage policy and the use of managed care in these programs, especially for vulnerable populations. I have a long term interest in diabetes secondary prevention among Medicare beneficiaries."
Glossary on Children's Health Coverage
ADVANCEABLE TAX CREDIT - A subsidy to help pay for health insurance that is available when the insurance premium is due, without having to wait until a year-end tax return is filed. Also see "tax credit."
ACUTE CARE - Medical services provided to treat an illness or injury, usually for a short time. Contrast with "chronic care."
BLOCK GRANT - A lump sum of money given to a state or local government to be spent for certain purposes. Normally, it is based on a formula, the objectives are broadly defined and the grant's source places relatively few limits on the money's use.
CAPITATION - Method of payment for health services in which a health care provider is paid a fixed amount for each person on the provider's patient roster, regardless of the actual number or nature of services provided to each person.
CARVE-OUTS - A payer strategy in which an HMO or insurance company isolates ("carves out") a benefit and hires another organization to provide this service. Common carve-outs include behavioral health and prescription drugs. The technique is intended to allow the insurer to better control its costs.
CASE MANAGEMENT - A process where a health plan identifies covered persons with specific health care needs, then devises and carries out for them a plan to achieve the best patient outcome in the most cost-effective manner.
CATEGORICAL ELIGIBILITY - Medicaid's eligibility pathway for individuals who can be covered. The program's 25+ categories can be organized into five broad groups - children, pregnant women, adults in families with dependent children, individuals with disabilities and the elderly. Certain individuals, notably single adults without children, cannot qualify for Medicaid, even if their incomes are low enough to meet financial eligibility standards.
CHRONIC CARE - Medical services provided to those with chronic conditions. Contrast with "acute care."
CHURNING - The cycle involving a person's enrollment in a health insurance program (such as Medicaid or employer-sponsored coverage), then losing eligibility, the regaining it and re-enrolling.
COINSURANCE - A portion of the bill for a medical service, that is not covered by the patient's health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance refers to a percentage, e.g., 10 percent of the total charge up to a specified maximum. Contrast with "copayment."
COMMUNITY HEALTH CENTER (CHC) - Organization providing comprehensive primary care to medically underserved populations, regardless of their ability to pay. These public and non-profit entities receive federal funding under Section 330 of the Public Health Service Act, as amended.
COPAYMENT - A flat dollar amount that a patient must pay out of pocket for a medical service, e.g. $5 per office visit.
COST SHIFTING - The practice by which a seller of a health service, such as a hospital, increases charges for some payers to offset losses due to uncompensated or indigent care or lower payments from other payers.
CROSS-SUBSIDY - The concept of certain purchasers paying more for medical services than they otherwise would so that others can pay less (or nothing at all), or another activity can be funded. In the U.S. health system, this mechanism has been used to pay for medical services for the poor and uninsured, medical education and research.
CROWD-OUT - A phenomenon whereby public programs or expansions of public programs designed to extend coverage to the uninsured encourage some employers to drop health coverage, urging their employees instead to take advantage of the expanded public subsidy.
DEDUCTIBLE - A fixed amount, usually expressed in dollars in the form of an annual fee, that the beneficiary of a health insurance plan must pay directly to the health care provider before a health insurance plan begins to pay for any costs associated with the insured medical service.
DEFICIT REDUCTION ACT OF 2005 (DRA) - The DRA made significant changes to the Medicaid program - for example, allowing states to increase premiums and cost-sharing for families and to base benefits on private plans. The law also tightened long-term care asset transfers and capped the amount of home equity that can be disregarded in measuring eligibility at $500,000. A DRA provision in effect since July 1, 2006 requires Medicaid beneficiaries to show proof of citizenship upon applying for or renewing their benefits. For more information, see www.kff.org/medicaid/7465.cfm.
DEFINED BENEFIT - A health insurance model used by an employer or government program where specified health services covered under the plan are standardized and guaranteed. The cost of providing the standard benefits may fluctuate. One example of a defined benefit plan is Medicare. Contrast with "defined contribution."
DEFINED CONTRIBUTION - A health benefit model used by employers or government programs where health services covered may fluctuate based on choice of plan, but the employer or government contributes a set amount (percentage or dollar amount) towards the purchase of the selected health plan. A defined contribution plan limits the financial liability of employers or the government, because the contribution is defined, or fixed. An example of a defined contribution plan is the State Children's Health Insurance Program. Contrast with "defined benefit."
DISPROPORTIONATE SHARE HOSPITAL (DSH) ADJUSTMENT - An increased payment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large number of low-income uninsured patients.
FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP) - Percentage used to determine the amount of federal matching funds for state Medicaid expenditures. By law, FMAP cannot be less than 50 percent or exceed 80 percent. Slightly higher Enhanced Federal Medical Assistance Percentages are used to determine matching payments for the State Children's Health Insurance Program (SCHIP). These payments cannot exceed 85 percent of the state's total SCHIP expenditures. For more information, see http://aspe.hhs.gov/health/fmap07.htm.
FEDERAL POVERTY GUIDELINES - Income amounts set each February by the U.S. Department of Health and Human Services used to determine an individual's or family's eligibility for various public programs, including Medicaid and the State Children's Health Insurance Program. Sometimes called Federal Poverty Level/Line (FPL). (The poverty guidelines are different from the U.S. Census Bureau's "poverty thresholds," which are used for Census statistical purposes.) For the 2007 poverty guidelines, see http://aspe.hhs.gov/poverty/07poverty.shtml,/A>
HEALTH INSURANCE FLEXIBILITY AND ACCOUNTABILITY (HIFA) DEMONSTRATION INITIATIVE - A Bush Administration initiative to encourage states to apply for certain Medicaid Section 1115 and SCHIP waivers. HIFA waivers make it possible for states to offer private health insurance coverage or employer-sponsored coverage, with subsidies, as an alternative to enrolling beneficiaries in traditional Medicaid or SCHIP.
HEALTH OPPORTUNITY ACCOUNT (HOA) - A type of health savings account for Medicaid beneficiaries created by the Deficit Reduction Act of 2005 . States may deposit annual sums of up to $2,500 per adult and $1,000 per child into the account, to be used to pay for medical expenses not covered by the high deductible health plan with which the account is coupled. Beginning January 1, 2007, as many as 10 states could initiate HOA demonstration projects. Compare to "Health Savings Account" and "Health Reimbursement Arrangement."
HOME AND COMMUNITY-BASED SERVICES (HCBS) - State-designed HCBS encompass case management, adult day care, home health aide assistance, personal care, assisted living services and respite care. Section 1915(c) of the Social Security Act permits the HHS Secretary to approve Medicaid waivers that allow for long-term care services to be delivered in community instead of institutional settings. The Deficit Reduction Act also created a new capped HCBS option that allows states to offer these services without having to obtain administrative waiver approval. See "Medicaid Section 1915 Waiver."
INTERGOVERNMENTAL TRANSFER (IGT) - Transfer of funds among or between different levels of government, including state-owned or operated facilities and local governments. The term is most often used in Medicaid, where transfers of non-federal public funds to the state Medicaid agency are used to draw down federal matching funds. States also use IGTs to draw down federal "disproportionate share hospital adjustment" and "upper payment limit" funds.
MANAGED CARE - Care provided by a health care organization, such as a health maintenance organization (HMO) or preferred provider organization (PPO), that contracts to provide medical services to a group of enrollees in exchange for capitated monthly premiums. Payments to physicians and other practitioners in HMOs are often lower than fee-for-service payments.
MEANS-TESTING - Determining eligibility for government benefits based on an individual's lack of means, as measured by income and/or assets. Under Medicaid, means-testing differs for different eligibility groups (see "categorical eligibility").
MEDICAID - Public health insurance program that provides coverage for an estimated 60 million low-income persons for acute and long-term care. It is financed jointly by state and federal funds (the federal government pays at least 50 percent of the total cost in each state), and is administered by states within broad federal guidelines. Contrast with "Medicare."
MEDICAID SECTION 1115 WAIVER - Under Section 1115(a) of the Social Security Act, the secretary of Health and Human Services may waive most provisions of Medicaid law for demonstrations "likely to assist in promoting the objectives" of the program. Under long-standing policy, these waivers must be cost-neutral. Demonstration waivers may be granted for research purposes, to test a program improvement, or investigate a new way of delivering services.
MEDICALLY NEEDY - A Medicaid category for income eligibility in which states can choose to cover individuals and families who quality for coverage because of high medical expenses, usually for hospital or nursing home care. To qualify, individuals must be categorically eligible and their monthly incomes minus accumulated medical bills must be below state income limits for the Medicaid program. This allows Medicaid coverage for people who have extensive health care needs but too much income to be eligible for Medicaid. Also see "spend-down."
MEDICARE - Federal health insurance program for virtually all persons age 65 and older, and permanently disabled persons under age 65, who qualify by receiving Social Security Disability Insurance. Contrast with "Medicaid."
PREMIUM ASSISTANCE - The use of federal funds available through public health coverage programs -- especially Medicaid and the State Children's Health Insurance Program -- to purchase or help purchase private insurance.
PRIMARY CARE CASE MANAGEMENT, INITIATIVE, OR CLINICIAN - (PCCM/PCI/PCC) - A Medicaid managed care program in which an eligible individual may use services only with authorization from his or her assigned primary care provider. That provider is responsible for locating, coordinating, and monitoring all primary and other medical services for enrollees. Those services are usually paid on a fee-for-service basis.
SAFETY NET PROVIDERS - Providers that have a primary focus of servicing low-income and uninsured people. They include community and migrant health centers and public hospitals.
SPEND-DOWN - Process by which individuals in many states can qualify for Medicaid because high medical expenses, usually hospital or nursing home care, reduce their monthly income to below state income limits for the Medicaid program. The amount that each individual must "spend down" is determined at the time eligibility is determined. Also see "medically needy."
STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) - A program enacted by Congress in 1997 that provides federal matching funds for states to spend on health coverage for uninsured kids. The program is designed to reach uninsured children whose families earn too much money to qualify for Medicaid but not enough to afford private coverage.
SUPPLEMENTAL SECURITY INCOME (SSI) - A federal income support program for low-income disabled, aged and blind individuals. Eligibility for SSI monthly cash payments does not depend on previous employment or contributions to a trust fund. Eligibility for SSI usually confers eligibility for Medicaid.
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) - The block grant program that, in 1996, replaced categorical welfare assistance such as Aid to Families with Dependent Children. Under TANF, time limits are set for cash benefits, and recipients are expected to accept work or be enrolled in training programs. TANF was reauthorized in 2005 as part of the Deficit Reduction Act with $16.4 billion in annual funding through FY 2010. For more information, see www.acf.hhs.gov/programs/ofa/.
TRANSITIONAL MEDICAL ASSISTANCE (TMA) - Medicaid coverage for up to one year for families leaving welfare to become self-supporting through work. During this transition period, states are required to continue Medicaid benefits even if earnings increase. For more information, see http://opencrs.cdt.org/document/RL31698/.
UPPER PAYMENT LIMIT (UPL) - Federal regulatory payment limit governing what states can pay eligible public facilities for Medicaid services. The UPL is usually the rate Medicare would pay for the same service. In some cases, states request federal matching funds in amounts that exceed the state's standard Medicaid reimbursement rate, and use the new revenues generated for other goods or services. Also see "Intergovernmental Transfer."
WAIVER (MEDICAID SECTION 1115 WAIVER) - Under Section 1115(a) of the Social Security Act, the secretary of Health and Human Services may waive most provisions of Medicaid law for demonstrations "likely to assist in promoting the objectives" of the program. Under long-standing policy, these waivers must be cost-neutral. Demonstration waivers may be granted for research purposes, to test a program improvement, or investigate a new way of delivering services.
1 Kaiser Commission on Medicaid and the Uninsured, "The Uninsured: A Primer," Figure 7, p.8, October 2007 (www.kff.org/uninsured/upload/7451-03.pdf) and "No Shelter From the Storm: America's Uninsured Children," Families USA, Campaign for Children's Health Care, September 2006, pp. 7-8 (www.childrenshealthcampaign.org/tools/reports/Uninsured-Kids-report.PDF)
2 U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table 6. People with or without health insurance coverage by selected characteristics: 2005 and 2006." www.census.gov/hhes/www/hlthins/hlthin06/p60no233_table6.pdf Retrieved August 30, 2007.
3 Kaiser State Health Facts, "Health Insurance Coverage of Children 0-18, States (2005-6), U.S. (2006)" Available at: http://www.statehealthfacts.org/comparetable.jsp?ind=127&cat=3&yr=1&typ=2&sort=162&o=a Retrieved September 24, 2007.
4 Alliance for Health Reform analysis of U.S. Census Bureau Data: U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table 6. People with or without health insurance coverage by selected characteristics: 2005 and 2006." Available at: http://www.census.gov/hhes/www/hlthins/hlthin06/p60no233_table6.pdf Retrieved August 30, 2007; U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table HI05. Health Insurance Coverage Status and Type of Coverage by State and Age for All People: 2006." Available at: http://pubdb3.census.gov/macro/032007/health/h05_000.htm. Retrieved September 28, 2007.
5 Leighton Ku et al., "Improving Children's Health: A Chartbook about the Roles of Medicaid and SCHIP," Center on Budget and Policy Priorities (January 2007), p. 2. www.cbpp.org/schip-chartbook.pdf
6 Congressional Budget Office, "State Children's Health Insurance Program," (May 2007), p vii. Available at: http://www.cbo.gov/ftpdocs/80xx/doc8092/05-10-SCHIP.pdf Retrieved September 25, 2007.
7 Kaiser Commission on Medicaid and the Uninsured, "The Uninsured: A Primer," Figure 7, p.8, October 2007 (www.kff.org/uninsured/upload/7451-03.pdf) and "No Shelter From the Storm: America's Uninsured Children," Families USA, Campaign for Children's Health Care, September 2006, pp. 7-8 (www.childrenshealthcampaign.org/tools/reports/Uninsured-Kids-report.PDF)
8 U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table HI08. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics for Children Under 18: 2006." Available at: http://pubdb3.census.gov/macro/032007/health/h08_000.htm. Retrieved August 30, 2007.
9 Kaiser Family Foundation and Health Research and Education Trust (2007). "Employer Health Benefits: 2007 Annual Survey." Exhibit 2.2 Available at: http://www.kff.org/insurance/7672/upload/EHBS-2007-Full-Report-PDF.pdf. Retrieved September 13, 2007.
10 Paul Fronstin, "Employment-based Coverage: Is the Erosion in Coverage a Tipping Point?" Presentation at Alliance for Health Reform/Robert Wood Johnson Foundation Briefing (September 21, 2007). Available at: http://www.allhealth.org/briefing_detail.asp?bi=113. Retrieved September 27, 2007.
11 Kaiser Family Foundation and Health Research and Education Trust (2007). "Employer Health Benefits: 2007 Annual Survey." Exhibit 6.3 Available at: http://www.kff.org/insurance/7672/upload/EHBS-2007-Full-Report-PDF.pdf. Retrieved September 13, 2007.
12 Kaiser Family Foundation and Health Research and Education Trust (2007). "Employer Health Benefits: 2007 Annual Survey." Exhibit 2.2 Available at: http://www.kff.org/insurance/7672/upload/EHBS-2007-Full-Report-PDF.pdf. Retrieved September 13, 2007.
13 U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table HI08. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics for Children Under 18: 2006." (http://pubdb3.census.gov/macro/032007/health/h08_000.htm). Retrieved August 30, 2007.
14 Paul Fronstin, "Employment-based Coverage: Is the Erosion in Coverage a Tipping Point?" Presentation at Alliance for Health Reform/Robert Wood Johnson Foundation Briefing (September 21, 2007). Available at: http://www.allhealth.org/briefing_detail.asp?bi=113. Retrieved September 27, 2007.
15 John Holahan and Allison Cook, "What Happened to the Insurance Coverage of Children and Adults in 2006?" Kaiser Commission on Medicaid and the Uninsured (September 2007). Available at: http://www.kff.org/uninsured/upload/7694.pdf. Retrieved September 25, 2007.
16 National Association of Children's Hospitals and Related Institutions, "Medicaid Matters to Children's Hospitals Fact Sheet," (September 2007) Available at: http://www.childrenshospitals.net/AM/Template.cfm?Section=Homepage&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=29394. Retrieved September 28, 2007.
17 Leighton Ku et al., "Improving Children's Health: A Chartbook about the Roles of Medicaid and SCHIP," Center on Budget and Policy Priorities (January 2007), p. 2. www.cbpp.org/schip-chartbook.pdf
18 Centers for Medicare and Medicaid Services, "Medicaid At-A-Glance 2005," (2005). Available at: http://www.cms.hhs.gov/MedicaidGenInfo/Downloads/MedicaidAtAGlance2005.pdf. Retrieved September 25, 2007.
19 Dept. of Health and Human Services, "The 2007 HHS Poverty Guidelines," (2007). Available at: http://aspe.hhs.gov/poverty/07poverty.shtml. Retrieved September 25, 2007;
20 Robert Greenstein, "The Administration's Dubious Claims About the Emerging Children's Health Insurance Legislation: Myth and Reality," Center on Budget and Policy Priorities (July 2007). Available at: http://www.cbpp.org/7-17-07health.htm. Retrieved September 28, 2007.
21 Leighton Ku, Mark Lin, and Matthew Broaddus, "Improving Children's Health - A chartbook about the roles of Medicaid and SCHIP, 2007 Ed.," Center on Budget and Policy Priorities, January 2007. Available at: http://www.cbpp.org/schip-chartbook.htm. Retrieved September 25, 2007.
22 Congressional Budget Office, "State Children's Health Insurance Program," (May 2007), p. vii. Available at: http://www.cbo.gov/ftpdocs/80xx/doc8092/05-10-SCHIP.pdf. Retrieved September 25, 2007.
23 U.S. Census Bureau, Current Population Survey, 2007 Annual Social and Economic Supplement. "Table HI08. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics for Children Under 18: 2006." Available at: http://pubdb3.census.gov/macro/032007/health/h08_000.htm). Retrieved August 30, 2007.
24 Peter Orszag, "Estimates of the Number of Uninsured Children who are Eligible for Medicaid or SCHIP" Letter to the Honorable Max Baucus, July 24, 2007. Available at: http://www.cbo.gov/ftpdocs/83xx/doc8357/07-24-Estimates_of_Uninsured_Children.pdf. Retrieved September 25, 2007.
25 Lisa Dubay, "Making Sense of Recent Estimates of Eligible but Uninsured Children," Kaiser Commission on Medicaid and the Uninsured (August 2007). Available at: http://www.kff.org/medicaid/upload/7685.pdf. Retrieved September 25, 2007.
26 U.S. Government Accountability Office, "Children's Health Insurance: States' SCHIP Enrollment and Spending Experiences and Considerations for Reauthorization." March 1, 2007, p. 31. http://www.gao.gov/new.items/d07558t.pdf