John's response: States are permitted to determine age and income within limits. Changes must be approved by the feds. And regarding income limits, the Congressional bill Bush vetoed would set much stricter income limits than existed under the first SCHIP law.
There is, in SCHIP, a provision to limit “crowd-out” or “substitution”, usually a six month waiting period before one is eligible for SCHIP if one had private insurance coverage. These limits largely work, though not perfectly. There are three essential choices:
1. Cover every child through a public program (my preference — not at all in the political deck of cards;
2. Cover no kids because you risk substitution;
3. Cover kids with clear rules on who is and who is not eligible, and expect some slippage, because life can get slippery for folks under 300%fpl, moving in and out of employment, along with other life dislocations.
The SCHIP choice is #3 — you don't like it, then you can choose 1 or 2.
*Did you know that this is a matching program (as opposed to a pass-through program)?* This means that if states are going to receive any more funding, they will first need to spend more. Massachusetts already spends $12B annually on public health. Where is the funding increase at the state level going to come from? And why is no one demanding an explanation of why it costs MA $4B more to insure through MassHealth than through the GIC?
RESPONSE: Medicaid is a matching program too, though it's an entitlement for individuals who meet eligibility criteria. SCHIP is subject to available funds, meaning if funds run out, kids who qualify have to wait for funding to appear. Massachusetts does not spend $12B on public health; public health takes up a much smaller portion. MA spends something like that on subsidizing coverage through Medicaid. MA — and all other states — like SCHIP because the program provides a higher level of reimbursement than does Medicaid — 65 cents on the dollar as opposed to 50 cents under Medicaid. The Commonwealth has committed to providing coverage for eligible kids up to 300%fpl through Chapter 58. SCHIP just gives us more federal dollars, and a smaller state matching requirement.
*Did you know that the insurers are the same health insurance companies that are available to the private sector?* It's no wonder the insurance companies support this bill!
RESPONSE: Depends on the state. Not true in Massachusetts, where SCHIP/MassHealth is offered in two ways: 1. Fee for service without a managed care entity; or 2. Managed care but not through the same insurance companies available to the private sector — here it is four Medicaid managed care companies: Boston Medical Center's Health Net, Cambridge Health Alliance's Network Health, Neighborhood Health Plan, and Fallon Health Plan. It's true the last two are also available in the private market — they are much smaller in enrollment compared with the former two.
Other states do make more use of traditional private companies, though across the nation, for profit insurers are creating and expanding specialized Medicaid programs.
Did you know that the senate version calls for a doubling of the allocation in 2008 followed by 5 years of 16.5% annual increases? That doesn't include the increase at the state level. Conceivably, in 5 years, we could be spending 30% more on public health insurance and have very few gains to show for it because there are no quality or enrollment controls in place.
RESPONSE: The reason for the large increases is to capture a large share of children now eligible and unenrolled in SCHIP programs. There are about 6 million in SCHIP today. There are 10 million uninsured kids; 6 million of those 10 are, today, eligible for SCHIP coverage and unenrolled. Many states are reluctant to go after them because of the limited funding. By infusing more dollars into the program, the estimate is SCHIP will take on an additional net 4 million kids, growing to 10 million within five years. That's why the increases are so large.