CHAPTER 6 - CHILDREN'S HEALTH COVERAGE
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Originally written by Bruce Lesley, First Focus. Revised May 2010 by Bruce Lesley and Lisa Shapiro, First Focus. This chapter was made possible by the Robert Wood Johnson Foundation.
- There were approximately 7.3 million children in this country uninsured for all of 2008, according to the Census Bureau – 9.9 percent of the nation’s children.1
- Uninsured rates for children vary dramatically by state, from a low of 3.4 percent in Massachusetts to a high of 19.1 percent in Nevada in 2008. 2
- Hispanic children are almost three times as likely to be uninsured as non-Hispanic white children – 17.2 percent vs. 6.7 percent in 2008. Black children (10.7 percent) and Asian children (10.9 percent) were also more likely to be uninsured than whites, but significantly less so than Hispanic children.3
- More than half of children (58.9 percent) had health insurance coverage through their parent’s employer in 2008. Some 33.2 percent had public coverage and 5.1 percent had individually purchased private insurance.4
- Almost two out of every three uninsured children in 2007 were eligible for Medicaid or the Children’s Health Insurance Program. 5
- The Patient Protection and Affordable Care Act of 2010 affects children’s coverage in a number of ways. Beginning in 2014, it makes Medicaid coverage mandatory for children ages 6-19 in families between 100 percent and 133 percent of the federal poverty level.
- The reform law maintains the Children’s Health Insurance Program (CHIP) through 2019. In 2015, states will receive a 23 percentage point increase in the CHIP match rate, up to 100 percent of costs. Current match rates range from 65 to 85 percent.
- Effective in September 2010, private insurers must provide coverage for children with preexisting conditions. This means both providing coverage for preexisting conditions for currently insured children and not excluding children with preexisting conditions from future coverage.
Children’s advocates often cite the phrase “children are not little adults” to make the case that children have special health care needs related to their development that are unique and special.
Fortunately, health policymakers have long recognized and highlighted the unique needs of children. For instance, the Children’s Health Insurance Program (CHIP) was enacted to help children who don’t qualify for Medicaid but whose families can’t easily afford private coverage.
In Medicaid, broad pediatric coverage and benefits are provided through what is known as early and periodic screening, diagnosis, and treatment (EPSDT). This benefit, specific to children, was added to Medicaid in 1967 in response to high levels of preventable physical, dental, and mental health conditions among low-income children at that time, from preschool children enrolled in the Head Start program to young military draftees. 6
President Barack Obama likewise has acknowledged the needs of children in calling for universal health coverage for children. 7
How Do Children Get Health Coverage?
The majority of children, an estimated 58.9 percent, had coverage through their parent’s job-based insurance in 2008. 8 But this share has declined in recent years. In 2000, by contrast, 65.9 percent had job-based coverage.
Two trends have contributed to this shrinkage. A reduced percentage of small employers offered coverage in 2008 compared to 2000 - 20029 (and the percentage shrank even more in 2009). 10 And among employers who do offer coverage, employees are expected to pay more for premiums and for out-of-pocket expenses than in years past.11 (See Chapter 4, “Employer-Sponsored Coverage” for details.)
Employer-sponsored coverage is now less affordable for families with incomes at 300 percent of the federal poverty level (FPL) than it was for families at 200 percent of FPL in 1996, according to a study by the Urban Institute sponsored by the Robert Wood Johnson Foundation. 12
Medicaid and CHIP
Together Medicaid and CHIP cover almost one in three children (30.3 percent).13 (CHIP was previously called SCHIP—State Children’s Health Insurance Program—until passage of the program’s reauthorization in early 2009. Alliance Honorary Chairman Senator Jay Rockefeller in 1997 co-authored legislation that led to the development of CHIP. 14 )
While employer-sponsored coverage of children has dropped over time, Medicaid and CHIP coverage has increased, compensating for the employment-based decline. In 2008, an estimated 22.6 million children had Medicaid or CHIP for the full year, compared to 15 million in 2000. 15 (See Chapter 8, “Medicaid” for details on this program.)
Children represented 53 percent of all Medicaid enrollees in 2008.16 But children constitute only a fraction of total program costs, since they are relatively inexpensive to cover compared to other Medicaid enrollees. In 2005, Medicaid spending was about $1,600 per child compared to $13,500 per disabled enrollee and $11,800 per elderly enrollee. 17 (See chart, “Medicaid Enrollees and Expenditures by Enrollment Group, 2005.”)
Federal law requires state Medicaid programs to cover children age 6 to 18 living in families with incomes below 100 percent of the federal poverty level or less, and children under age 6 living below 133 percent of the FPL.18 In contrast, CHIP eligibility in most states goes up to at least 200 percent of FPL. ( Click here to see the 2009 Federal Poverty Guidelines).
In 1997, a Republican-led Congress passed and President Bill Clinton signed the legislation creating CHIP – the largest expansion of health insurance coverage for children in more than 30 years.19 CHIP was designed to expand upon and complement Medicaid by providing health coverage for uninsured children whose families earn too much to qualify for Medicaid, but who cannot afford private coverage.
Since the passage of CHIP, the percentage of low-income children in the U.S. who lack coverage has declined by one-third – from 23.3 percent in 1997 to 15.7 percent in 2008.20 (“Low-income” is defined here as a family income of 200 percent of the federal poverty level or less.) A total of 4.97 million children were enrolled in the program as of June 2009, up from 4.84 a year earlier. 21
Unlike Medicaid, which is an entitlement program, CHIP is funded as a capped block grant to states. Under CHIP, each state is given a certain amount of money per year, determined by a formula established by Congress at the program’s creation and modified several times since.
To give states incentives to cover an expanded population of low-income children, the federal government provides states with an “enhanced” matching rate in comparison to Medicaid. For every dollar states spend on CHIP, they get more federal money than they do for every dollar they spend for Medicaid.
For CHIP, the federal government is paying from 65 percent to 83 percent of total program costs in FY 2010, depending on the state, in contrast to a 50- to 76- percent matching rate for Medicaid.22 The Medicaid matching rate (also known as Federal Medical Assistance Percentages) temporarily increased by 6.2 percentage points for each state under the economic stimulus legislation passed by Congress in early 2009.23 The increase will be in effect through the “recession adjustment period” which ends December 31, 2010, though Congress is currently considering legislation that would extend this funding through June 30, 2011.
(For FY 2009 state-by-state matching rates for Medicaid and CHIP, go to http://aspe.hhs.gov/health/fmap09.htm. For FY 2010 rates, before the changes contained in the stimulus bill, go to http://aspe.hhs.gov/health/fmap10.htm.)
CHIP offers states wide latitude in designing and implementing their child health assistance programs, provided they meet certain minimum standards for benefits and design. Under CHIP, states can: (1) expand Medicaid beyond the June 1997 levels of coverage; (2) cover children through a program separate from Medicaid; or (3) combine the two approaches.24
Federal law requires that when children apply for CHIP coverage, their eligibility for Medicaid must be assessed first. Thus, many are found to be eligible for Medicaid, helping push up Medicaid enrollment.
Children often move from one program to the other as their family income fluctuates or even as they age out of Medicaid eligibility. Failed coordination between the two programs can sometimes result in a child “falling through the cracks” between Medicaid and CHIP. 25
Congress initially authorized CHIP for a 10-year period that expired at the end of September 2007. Congress and the Bush Administration deadlocked on the shape of CHIP for the future, and compromised by extending the program through March 2009. Ultimately, CHIP was reauthorized and enlarged early in 2009.26 The bill, signed by President Obama on February 4, 2009, increased CHIP funding by about $32 billion through 2013 to cover an additional 4 million children.27 Conceivably, this expansion could cut the number of uninsured children in half.
Children and National Health Reform
Immediately after the passage of CHIPRA, Congress began a year-long debate on comprehensive health reform legislation. On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (Pub. L. No. 111-148). This sweeping legislation included key provisions related to children’s health coverage. Most notably, the legislation preserves and extends CHIP through September 30, 2019 with full funding for the program extended through fiscal year 2015. The legislation also includes a Maintenance of Effort provision, requiring states to maintain their current eligibility standards through 2019. States also are barred from imposing new paperwork or other barriers that would make it harder for people to enroll in Medicaid or CHIP.
Other provisions in PPACA to improve access, coverage, quality and outcomes for children, include:
- Elimination of pre-existing condition exclusions. Private insurers must offer coverage for children with pre-existing conditions. This means both providing coverage for preexisting conditions for currently insured children and not excluding children with preexisting conditions from future coverage. This requirement becomes effective with the insurance plan year beginning after Sept. 23, 2010 (meaning Jan. 1, 2011 for most people).
- Simplified enrollment measures. The law requires streamlined enrollment under Medicaid, CHIP and the Exchange.
- Extended dependent coverage. The law allows dependent children to stay on their parents’ health plan until they reach age 26. This also becomes effective for most people on January 1, 2011.
- More affordability for low-income families in the new exchanges. Starting in 2014, the law provides refundable and advanceable tax credits to families with incomes between 133 and 400 percent of the federal poverty level to help them buy insurance through the exchanges.
- Elimination of lifetime limits. Effective six months from enactment, insurers may no longer place lifetime limits on the dollar value of coverage. Beginning in 2014, insurers may no longer impose annual limits on coverage.
- Extended Medicaid for foster youth. In 2014, the law extends Medicaid coverage to all foster youth below the age of 25 who were formerly in foster care for a period of six months.
- Home visiting. The law provides funding to states to develop and implement evidence-based Maternal, Infant and early Childhood Visitation models.
- School-based health care. The law creates a federal authorization program and $200 million in short-term funding for school-based health centers.
- Oral Health. The law creates an oral health prevention campaign, dental carries disease management, school-based dental sealant programs and cooperative agreements to improve infrastructure and surveillance systems.
- Bright Futures. The law requires that new health plans cover, at no cost, comprehensive screenings and preventative care for children as defined by the “Bright Futures” standards issued by the American Academy of Pediatrics.
- Coverage of Preventive Health Services. The legislation requires insurers to cover services that have received an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF), extending coverage for a broader range of preventive health services. •Child-only coverage option in the new exchanges. The legislation allows families to purchase child-only insurance packages in the exchanges, to allow children being cared for by grandparents, children with parents whose employers do not offer dependent coverage, and children in mixed immigrant-status households access to coverage.
- Childhood Obesity Demonstration Project. Authorized by Congress in CHIPRA, the legislation appropriates $25 million for a demonstration project to reduce childhood obesity.
LIKELY POLICY DEBATES
State Budget Woes and Health Care Funding
As noted, additional support for Medicaid was included in the economic stimulus bill passed by Congress and signed by President Obama in early 2009. The American Recovery and Reinvestment Act of 2009 temporarily increases each state’s Medicaid matching rate by 6.2 percentage points through December 31, 2010. This type of additional support for Medicaid was provided previously, during the economic recession that began in 2001. Congress provided states with $20 billion in federal fiscal relief, including $10 billion through an enhanced Medicaid matching rate to states from April 2003 through June 2004. In exchange for the additional funding, states were required to maintain Medicaid eligibility levels. 28
Children and National Health Reform
Now that the PPACA has been signed into law, efforts are underway to implement the provisions of the health reform legislation. The Department of Health and Human Services is already developing guidance related to a host of provisions, including most immediately for children those related to eliminating pre-existing condition exclusions and extending dependent coverage up to age 26.
Other key regulatory issues for children that are expected to be addressed in guidance in the coming weeks and months include: functionality issues related to exchange coverage, including how families will be treated with respect to eligibility for subsidies and transitions between public coverage and the exchanges; definitional issues related to pediatric benefits offered in the exchanges; and issues related to the elimination of cost-sharing for preventive care services.
TIPS FOR REPORTERS
- There is a unique children’s health angle in virtually every health care policy discussion, whether about emergency medicine, benefits, privacy, quality, comparative effectiveness, tax credits, or organ transplants. As issues arise during health care discussions, consider how children’s health issues are different from adult issues. Is there even a separate and distinct angle related to infant or adolescent health?
- Parents of young children have insights into children's health needs that often amaze, and impress, child health professionals. Talk with parents at places where they gather, such as day care centers, library story sessions or play groups.
- Some of the most powerful arguments for national health reform involve children with very expensive health conditions, and the devastating side effects this can have on their families and their finances. Get to know such families, and find out their views about changes needed in the health care system.
- Hispanic children are much more likely to be uninsured than children of other ethnicities. Why is this true? You will find many interrelated causes. What do Hispanic parents and advocates recommend as solutions?
- National health reform legislation is expected to improve health care access, coverage, and affordability, especially for low-income Americans and those who are currently uninsured. As PPACA is implemented, how does coverage that is offered through the new exchanges stack up again existing coverage options for low-income children? For example, CHIP provides comprehensive benefits for children and limits out of pocket costs to 5 percent of a family's income. Under health reform, will families have the option to retain this coverage? Will the Exchanges offer families coverage that provides comparable benefits and cost-sharing?
- Most states are facing budget shortfalls and growing needs for Medicaid and CHIP simultaneously during the economic recession. What is the impact on children’s coverage in your state? If the federal government includes additional Medicaid dollars as part of state fiscal relief, what difference will that make directly to children’s coverage in Medicaid and indirectly in CHIP?
- More than two-thirds of the uninsured children in the country are eligible for but not enrolled in either Medicaid or CHIP. How do these programs coordinate health care delivery and enrollment in your state? What is your state doing with respect to outreach and enrollment of these children?
- How does your state use health information technology to improve the enrollment of eligible but unenrolled children? Do they use mechanisms such as Express Lane Eligibility and SingleStop, which allow for sharing of data across programs to reduce bureaucracy and streamline enrollment? How can the eligibility system be improved to reduce the number of uninsured children in your state? According to your state, what are the federal barriers in place that preclude progress?
- Federal spending on children’s welfare programs has declined by more than 11 percent over the past five years, in inflation-adjusted terms, constituting now just 10 percent of the federal non-defense budget in 2008.29 This includes funding reductions (when adjusted for inflation) for programs such as Head Start, the Maternal and Child Health Block Grant, and Healthy Start. How do these types of federal budget actions impact overall child health (e.g., infant mortality, childhood obesity and the Medicaid and CHIP programs)?
- Dental caries (tooth decay) is the most prevalent, but also the most preventable chronic condition among children. What is your state or community doing to address this problem? The health concerns of adolescents generally involve behavioral practices – from questions about sexuality and experimentation with drugs and alcohol, to emotional problems, obesity or anorexia. If not handled well, these issues can become persistent health problems in adulthood. How is your community working to improve the lives and safety of adolescents? What are the health consequences for individuals in your community if behavioral issues have not been addressed?
EXPERTS AND WEBSITES
Melinda Abrams , Senior Program Officer, The Commonwealth Fund, 212/606-3800
Douglas Besharov , Joseph J. and Violet Jacobs Scholar in Social Welfare Studies, American Enterprise Institute, 202/862-5800
Linda Blumberg , Principal Research Associate, Urban Institute, 202/261-5769
Patrick Chaulk , Senior Associate, Annie E. Casey Foundation, 410/547-6600
Donna Cohen-Ross , Director of Outreach, Center on Budget and Policy Priorities, 202/408-1080, firstname.lastname@example.org
Karen Davenport , Director of Health Policy, Center for American Progress, 202/682-1611, email@example.com
Karen Davis , President, The Commonwealth Fund, 212/606-3800, KD@cmwf.org
Barbara Edwards , Principal, Health Management Associates, 517/482-9236, firstname.lastname@example.org
Judy Feder , Professor, Public Policy Institute, Georgetown University, 202/687-8397
Cheryl Fish-Parcham , Deputy Director of Health Policy, Families USA, 202/628-3030, email@example.com
Robert Helms , Resident Scholar, American Enterprise Institute, 202/862-5877, firstname.lastname@example.org
Ian Hill , Senior Research Associate, Health Policy Center, Urban Institute, 202/833-7200
John Holahan , Director of Health Policy Research, Urban Institute, 202/261-5666
Henry Ireys , Senior Researcher, Mathematica Policy Research, 202/554-7536
Christine James-Brown , President & CEO, Child Welfare League of America, 703/412-2400
Joy Johnson Wilson , Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400, email@example.com
Neva Kaye , Senior Program Director, National Academy for State Health Policy, 207/874-6524, firstname.lastname@example.org
Genevieve Kenney , Senior Fellow, Urban Institute, 202/833-7200
Risa Lavizzo-Mourey , President & CEO, Robert Wood Johnson Foundation, 888/631-9989, email@example.com
Wendy Lazarus , Founder and Co-President, The Children's Partnership, 310/260-1220
Bruce Lesley , President, First Focus, 202/657- 0672, firstname.lastname@example.org
Gene Lewit , Senior Program Manager, The Packard Foundation, 650/948-7658
Barbara Lyons , Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202-347-5270, email@example.com
Anne Markus , Associate Research Professor, George Washington University, 202/530-2339
Greg Martin , Analyst, State Government Relations, American Academy of Family Physicians, 202/232-9033, firstname.lastname@example.org
Margaret McManus , Co-Director of Maternal and Child Health Policy Group, Maternal and Child Health Policy Research Center, 202/223-1500, email@example.com
Jack Meyer , Principal, Health Management Associates, (202)785-3669, firstname.lastname@example.org
Robert Moffit , Director, Center for Health Policy Studies, The Heritage Foundation, 202/546-4400
Nina Owcharenko , Senior Policy Analyst, Center for Health Policy Studies, The Heritage Foundation, 202/608-6221
Edwin Park , Co-Director of Health Policy, Center on Budget and Policy Priorities, 510/524-8033
Lee Partridge , Health Policy Advisor, National Partnership for Women and Families, 202/986- 2600, email@example.com
Jane Perkins , Legal Director, National Health Law Program, 919/968-6308 ext.102
Ron Pollack , Executive Director, Families USA, 202/628-3030, Communications Director: David Lemmon -- firstname.lastname@example.org
Sara Rosenbaum , Chair of Department of Health Policy, George Washington University, 202/530- 2343
Diane Rowland , Executive Vice President, Kaiser Family Foundation, 202/347-5270, email@example.com
Matt Salo , Director, Health & Human Services Committee, National Governors Association, 202/624-5336, firstname.lastname@example.org
Edward Schor , Vice President, The Commonwealth Fund, 212/606-3866, email@example.com
Sarah Shuptrine , CEO and President, The Southern Institute on Children and Families, 803/779-2607, firstname.lastname@example.org
Vernon Smith , Principal, Health Management Associates, 517/482-9236
Judith Solomon , Senior Fellow, Center on Budget and Policy Priorities, 202/408-1080, email@example.com
James Tallon , President, United Hospital Fund, 212/494-0700, firstname.lastname@example.org
Judy Waxman , Vice President for Health and Reproductive Rights, National Women's Law Center, 202/588-5180, email@example.com
Alan Weil , Executive Director, National Academy for State Health Policy, 202/903-0101
James Cosgrove , Director, Health Care, Government Accountability Office, 202/512-7029, firstname.lastname@example.org
Jean Hearne , Specialist in Social Legislation, Congressional Research Service, 202/707-7362
Andy Schneider , Chief Health Counsel, House Committee on Energy and Commerce, 202-225-5051
Mary Lee Allen , Director, Child Welfare and Mental Health Division, Children's Defense Fund, 202/628-8787
Norman Anderson , Chief Executive Officer, American Psychological Association, 202/336- 5500
Joshua Brown , Senior Manager, Public Policy & Government Relations, Association of Maternal and Child Health Programs, 202/775-0436, email@example.com
Debbie Chang , Senior VP and Executive Director, Nemours Health and Prevention Services, 302/444-9127, firstname.lastname@example.org
Jerome Connolly , Senior Representative, Government Relations, American Academy of Family Physicians, 202/232-9033, email@example.com
Larry Gage, President , National Association of Public Hospitals, 202/585-0100, Larry.Gage@ropesgray.com
Karen Ignagni , President and CEO, America's Health Insurance Plans, 202/778-3200, firstname.lastname@example.org
Jim Kaufman, Vice President of Public Policy, National Association of Children's Hospitals, 703/797-6006
Lawrence McAndrews, President and CEO, National Association of Children's Hospitals, 703/684-1355
Nicholas Meyers , Director, Government Relations, American Psychiatric Association, 703/907-8585, communications department: email@example.com
Meg Murray , Chief Executive Officer, Association for Community Affiliated Plans, 202/204-7509, firstname.lastname@example.org
Jackie Noyes , Associate Executive Director, American Academy of Pediatrics, 202/347-8600, email@example.com
Aimee Ossman, Director of Policy Analysis, National Association of Children's Hospitals, 703/797-6023
Alliance for Health Reform www.allhealth.org
American Academy of Family Physicians www.aafp.org
American Academy of Pediatrics www.aap.org
American Enterprise Insititute www.aei.org
American Hospital Association www.aha.org
American Psychiatric Association www.psych.org
American Psychological Association www.apa.org
America's Health Insurance Plans www.ahip.org
America's Promise www.americaspromise.org
Annie E. Casey Foundation www.aecf.org
Association of Maternal & Child Health Programs www.amchp.org
Center on Budget and Policy Priorities www.cbpp.org
Centers for Medicare and Medicaid Services www.cms.hhs.gov
Child Welfare League of America www.cwla.org
Children's Defense Fund www.childrensdefense.org
Children's Partnership www.childrenspartnership.org
The Commonwealth Fund www.commonwealthfund.org
Covering Kids and Families www.coveringkidsandfamilies.org
Families USA www.familiesusa.org
First Focus www.firstfocus.net
George Washington University Department of Health Policy www.gwhealthpolicy.org
Georgetown University Health Policy Institute ttp://ihcrp.georgetown.edu
Government Accountability Office www.gao.gov
Health Management Associates www.healthmanagement.com
Healthcare Leadership Council www.hlc.org
Heritage Foundation www.heritage.org
Insure Kids Now, HHS www.insurekidsnow.gov
Kaiser Commission on Medicaid and the Uninsured www.kff.org/about/kcmu.cfm
Kaiser Family Foundation www.kff.org
Mathematica Policy Research www.mathematica-mpr.com
MCH Policy Research Center www.mchpolicy.org
National Academy for State Health Policy www.nashp.org
National Association of Children's Hospitals www.childrenshospitals.net
National Association of Community Health Centers www.nachc.com
National Association of Public Hospitals www.naph.org
National Conference of State Legislatures www.ncsl.org
National Governors Association www.nga.org
National Health Law Program www.healthlaw.org
National Partnership for Women and Families www.nationalpartnership.org
National Women's Law Center www.nwlc.org
Nemours Health and Prevention Services www.nemours.org
Packard Foundation www.packard.org
Robert Wood Johnson Foundation www.rwjf.org
United Hospital Fund www.uhfnyc.org
Urban Institute www.urban.org
Voices for America's Children www.childadvocacy.org
1 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls).
2 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls).
3 U.S. Census Bureau (2009). “Income, Poverty, and Health Insurance Coverage in the United States: 2008.” September, p. 25. (www.census.gov/prod/2009pubs/p60-236.pdf ).
4 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls). Some children had more than one type of insurance.
5 Genevieve Kenney (2009). “Uninsured and Eligible for Public Coverage: Underlying Causes and Policy Solutions.” NIHCM Foundation, November. (http://nihcm.org/pdf/EV-Kenney_FINAL.pdf)
6 Rosenbaum, Sara and Wise, Paul (2007). “Crossing the Medicaid-Private Insurance Divide: The Case of EPSDT,” Health Affairs, March/April, pp. 383. ( www.healthaffairs.org).
7 Obama for America (2008). “Barack Obama: A Champion for Children.” ( http://www.barackobama.com/pdf/issues/FactSheetChildAdvocacy.pdf).
8 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls).
9 Kaiser Family Foundation and Health Research and Educational Trust (2008). “Exhibit 10: Percentage of All Firms Offering Health Benefits, 1999 – 2008.” (http://ehbs.kff.org/images/abstract/7814.pdf).
10 Kaiser Family Foundation and Health Research and Educational Trust (2009). "Employer Health Benefits 2009 Annual Survey." Exhibit 2.2. ( http://ehbs.kff.org/?page=charts&id=2&sn=17&ch=1028)
11 Mercer (2009). “Tough economy leads employers to cut health benefit cost increases in 2010.” News release, Sept. 10. ( www.mercer.com/summary.htm?idContent=1357570)
12 Kenney, Genevieve;Pelletier, Jennifer (2009). “Setting Income Thresholds in Medicaid/SCHIP: Which Children Should be Eligible?” ( www.rwjf.org/files/research/coveragequickstrikejan2009.pdf).
13 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls).
14 For more information on Sen. Rockefeller’s involvement with CHIP, please see his website’s press releases, which can be found at: (http://rockefeller.senate.gov/press/record.cfm?id=291889), (http://rockefeller.senate.gov/press/record.cfm?id=281728), ( http://rockefeller.senate.gov/press/record.cfm?id=281817).
15 U.S. Census Bureau (2009). “Table HIA-5. Health Insurance Coverage Status and Type of Coverage by State--Children Under 18: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt5.xls).
16 U.S. Census Bureau (2009). “Table HIA-2. Health Insurance Coverage Status and Type of Coverage -- All Persons by Age and Sex: 1999 to 2008.” ( www.census.gov/hhes/www/hlthins/historic/hihistt2.xls).
17 Kaiser Commission on Medicaid and the Uninsured (2009). “Medicaid: A Primer, 2009.” P. 16. ( www.kff.org/medicaid/upload/7334-03.pdf).
18 Kaiser Commission on Medicaid and the Uninsured (2009). “Medicaid: A Primer, 2009.” P. 5. ( www.kff.org/medicaid/upload/7334-03.pdf).
19 Kenney, Genevieve;Yee, Justin (2007). “SCHIP at a Crossroads: Experiences to Date and Challenges Ahead,” Health Affairs. March/April , pp. 356-369. (www.healthaffairs.org).
20 Mann, Cindy (2008). “News from the States: Children’s Coverage Developments.” Presentation at Medicaid Health Plans of America Conference, October 28, 2008. And U.S. Census Bureau (2009). “Income, Poverty, and Health Insurance Coverage in the United States: 2008.” September, p. 25. (www.census.gov/prod/2009pubs/p60-236.pdf ).
21 Vernon Smith, Dennis Roberts and David Rousseau (2010). (2010). "CHIP Enrollment: June 2009: An Update on Current Enrollment and Policy Directions.” Kaiser Commission on Medicaid and the Uninsured, April. (http://www.kff.org/medicaid/upload/7642-04.pdf).
22 U.S. Dept. of Health and Human Services. “Federal Financial Participation in State Assistance Expenditures, FY 2010.” ( http://aspe.hhs.gov/health/fmap10.htm).
23 The American Recovery and Reinvestment Act of 2009 (H.R.1.) Section 5001, Temporary Increase of Medicaid FMAP. ( http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.1:).
24 Centers for Medicare and Medicaid Services. “State Children’s Health Insurance Summary.” ( http://www.cms.hhs.gov/MedicaidGenInfo/05_SCHIP%20Information.asp).
25 Bergman, David (2005). “Perspectives on Reauthorization: SCHIP Directors Weigh In.” NationalAcademy for State Health Policy, June 2005 ( www.nashp.org/FIles/CHIP25_final.pdf).
26 U.S. House Energy and Commerce Committee (2008). “Bill Summary: Children’s Health Insurance Program Reauthorization Act of 2009.” ( http://energycommerce.house.gov/Press_111/CHIPRA%20Bill%20Summary%201.13.09.pdf ).
27 Freking, Kevin; Elliott, Philip (2009). “Obama Signs Bill Insuring More Children.” Associated Press, February 5. ( http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/02/05/MNAS15NE9A.DTL ).
28 Kaiser Commission on Medicaid and the Uninsured (2008). “Short Term Options For Medicaid in a Recession.” December. ( http://www.kff.org/medicaid/7843.cfm).
29 First Focus (2008). “Children’s Budget 2008.” April 23. ( www.firstfocus.net/Download/CBook.pdf).