National Health Policy

Ms. Rosenbaum began her presentation with an overview of cost-sharing regulations for SCHIP programs. Medicaid SCHIP expansion States must follow general Medicaid cost-sharing rules (unless they have an 1115 waiver). States that opt to implement a State-designed SCHIP program that covers families with incomes below 150 percent of the FPL can impose only “nominal” cost-sharing. For families with incomes above 150 percent, cost-sharing may vary based on income and family size, however, cost-sharing for all families is capped at 5 percent of the family’s annual income. Both income and family size can be defined by the State.

States charge premiums, enrollment fees, deductibles, coinsurance, and/or co-payments for different reasons. These features are used to increase family responsibility and accountability; control enrollment; deter inappropriate, unnecessary, or excessive care; promote appropriate care; and control the size of the State’s premium and the family’s share of the premium.

Cost-sharing can have an impact on enrollment in many ways. Ms. Rosenbaum cited research that found that even with small premiums (less than 5 percent) States should expect decreased participation and adverse affects on the probability and amount of care received. States should also have special provisions for children with medical costs that fall outside of the benefits included in the SCHIP program. These costs will be extra for the family, and if special provisions are made, will not fall inside the 5-percent limit. States may want to build into their SCHIP program a spend-down program or recognize medical expenses not covered under the SCHIP plan when calculating family income.

State respondents noted that cost-sharing in certain States is very political and varies significantly by State and income eligibility level. Some States that cover families at higher income eligibility levels have no cost-sharing, while others at low eligibility levels do. Cost-sharing is often determined by a State’s environment and cannot be compared across States.
Premium Subsidies for Employer-Sponsored Insurance and Family Coverage

Coordinating SCHIP funding with employer coverage has pros and cons and is mainly pursued by States only when there is legislative interest. Mr. Curtis sited many key problems States will face when pursuing this option. Mississippi and Massachusetts have HCFA-approved plans to subsidize premiums for children with access to employer-sponsored coverage (through a parent) and shared their models and experiences, although limited, with the workshop participants.

Mr. Curtis cited research that estimates that 33 to 37 percent of uninsured children have access to employer-based health insurance. The percent of “targeted low-income” children would be less, but it is still a significant number. Reasons States may want to consider coordinating with employer-based insurance (ESI) coverage are: to encourage, rather than “crowd-out,” employer financing of health care for dependents; to support work for low-income families; and to allow parents to cover their children under the same plan they are in. Reasons States may not want to coordinate with employer-based coverage include: the program is complicated to administer; it may exacerbate the appearance of inequity under SCHIP (i.e., assistance is only available to those who have not previously purchased coverage, and co-workers in similar or the same circumstances may not have access to the program); and it may increase the likelihood that crowd-out will occur (i.e., families may drop their dependent coverage to enroll their children into SCHIP through the subsidized employer-sponsored program if they can remain in the same health plan).

Mississippi’s SCHIP ESI program will be available to children in families with incomes up to 200 percent of the FPL. Ms. Hanna, during her presentation, gave reasons her State decided to create an employer-sponsored subsidy program. The State’s philosophy is that the program is a natural outgrowth of the emphasis on insurance vs. Medicaid; it is a step toward unsubsidized health insurance; and it will prevent crowd-out. Difficulties the State will face with its subsidized ESI program: a large proportion of small employers; no standardized health insurance market, and little data on the employer market (i.e., employer contribution levels, benefit package, etc.). To participate in the subsidized ESI program, both the family and employer must agree to participate, then the benefits are compared and coordinated, if necessary, and the subsidy must pass the cost-effectiveness test. The program faces many challenges, such as: gaining the interest of families and employers; meeting the needs of transient employees; implementing a process to deal with enrollment periods of health plans; and educating agencies, employers, families, providers, and others affected by the program.

Massachusetts’ SCHIP ESI program is also available to children in families with incomes up to 200 percent of the FPL and in some cases provides family coverage as well. The ESI program must meet the benefit benchmark, must be cost effective, and the employer must pay 50 percent of the cost of insurance. To meet the family coverage cost-effectiveness test, the State compares the cost to cover children under their direct coverage program with the employer-sponsored coverage. If the total premium minus the employer share costs the same or less than covering the children in the direct-coverage program, the State will buy the children in to their parents’ employer coverage. If the cost of buying the children in also covers the parent(s) as well, then the State can offer family coverage. This is most likely to occur when there are two or more children and the employer pays more than 50 percent of the insurance cost.

Before a State decides to subsidize ESI coverage or provide family coverage, it should study the present insurance market, contact carriers for information and work with them, and consult with health insurance experts. Operational difficulties are many and include designing processes to subsidize the employer premium, verifying that coverage meets the SCHIP standard, ensuring that families do not pay more than the 5-percent maximum, and making sure that co-payments are not charged for well-child visits.

Mr. Curtis gave a brief summary of why other States may want to subsidize ESI coverage. Under such a program, public and private dollars are mixed. Also, by keeping children in the ESI market, the risk pool is widened, which may in effect decrease the cost of ESI. Being up front and honest, Mr. Curtis states that subsidizing ESI is difficult.

It may not be realistic for some States to even consider it. Success will depend on State staffing capacity, the insurance and employer market, the level of income eligibility, and legislative support.

During the discussion after the presentations, HCFA stated that the regulations may have guidance on options to provide family coverage.
Annual Reports and Evaluations

Ms. MacTaggart stressed that, according to the Title XXI Statute, State SCHIP programs must report on insurance coverage, access to care, and use of services by completing and submitting the HCFA quarterly financial and statistical reports, annual reports, and year 2000 evaluation.

In quarterly reports, States are to report expenditure and enrollment information. Expenditures should be broken down by program: Medicaid, Medicaid SCHIP, and State-designed SCHIP. Enrollment information should be broken down by age, service delivery system, and household income.

The annual report, due January 1 of each year, should include progress in reducing the number of uncovered, low-income children and progress in meeting the identified State Plan strategic objectives and performance goals. (It was noted that not all States have submitted their 1999 annual report.)

The Year 2000 State Evaluation should include: an assessment of the effectiveness of the State plan in increasing the number of children with creditable health coverage and an assessment of the effectiveness of other private and public programs in the State. It should also include a description and analysis of: the characteristics of children and families; access to or coverage by other health insurance prior to and after eligibility; service area and time limits for coverage; quality (structure, process, and outcome and consumer experience); sources of non-Federal funds; coordination with other programs; trends that affect access, affordability, and quality of health care for children; a description of plans for improving availability; and recommendation for improving the program.

Ms. Riley presented a draft version of the evaluation framework. The framework, requested by SCHIP directors who attended a National Academy for State Health Policy (NASHP) meeting on SCHIP evaluation in December 1998, was developed by a workgroup of State, HCFA, American Public Health Service Association (APHSA), and National Governor’s Association (NGA) representatives to meet the needs of States and the Title XXI Statute requirements for the Year 2000 SCHIP Evaluation. The framework has been reviewed and commented on by SCHIP and Medicaid Directors, key congressional staff, and selected advocates. Comments were integrated into the draft framework. The purpose of the framework is to:
� Recognize the diversity of State approaches to Title XXI and allow States flexibility to highlight key accomplishments and progress of their Title XXI programs.
� Provide consistency across States in the structure, content, and format of the report.
� Build on data already collected by HCFA quarterly enrollment and expenditure reports.
� Enhance accessibility of information to stakeholders on the achievements under Title XXI.

A framework for annual reports was also developed by the same group. However, at this meeting, it was recommended to HCFA that the annual report due January 1, 2000, be replaced by the evaluation report that is due March 31, 2000. HCFA is consulting with counsel to resolve this matter. The evaluation workgroup is still meeting to finalize the evaluation framework. It should be finalized by late July.

Over the past 30 years, eight major randomized controlled trials of breast cancer screening – with mammography and/or clinical breast examination – have been conducted. Results from several trials have been updated during the past year, and initial results of three other trials have been reported. PURPOSE: The National Cancer Institute held an International Workshop on Screening for Breast Cancer in February 1993 to conduct a thorough and objective critical review of the world’s most recent clinical trial data on breast cancer screening, consider the new evidence, assess the current state of knowledge, and identify issues needing further research. METHODS: Investigators representing the eight randomized controlled trials of breast cancer screening in women aged 40-74 presented published and unpublished data. Evidence relating to the effectiveness of breast cancer screening in different age groups, especially women aged 40-49, was presented. RESULTS:

For women aged 40-49, randomized controlled trials consistently demonstrated no benefit from screening in the first 5-7 years after study entry. A meta-analysis of six trials found a relative risk of 1.08 (95% confidence interval = 0.85-1.39) after 7 years’ follow-up. After 10-12 years of follow-up, none of four trials have found a statistically significant benefit in mortality; a combined analysis of Swedish studies showed a statistically insignificant 13% decrease in mortality at 12 years. Only one trial (Health Insurance Plan) has data beyond 12 years of follow-up, and results show a 25% decrease in mortality at 10-18 years. Statistical significance of this result is disputed, however. In women aged 50-69, all studies show mortality reductions; three of four studies show reductions of about 30% at 10-12 years after study entry. Results from two of these trials were statistically significant. Too few women over age 70 have been included in studies for adequate analysis. CONCLUSIONS:

For women aged 40-49, randomized controlled trials of breast cancer screening show no benefit 5-7 years after entry. At 10-12 years, benefit is uncertain and, if present, marginal; thereafter, it is unknown. For women aged 50- 69, screening reduces breast cancer mortality by about a third. Currently available data for women age 70 or older are inadequate to judge the effectiveness of screening. IMPLICATIONS: Randomized trials have provided stronger scientific evidence regarding the effectiveness of screening for breast cancer than for any other cancer. However, much still needs to be learned. Periodic gatherings of scientists in the field should speed the process.

What Will We Know About SCHIP’s Success?
Mr. Weil opened this session stating that success is judged by those who hold you accountable (the public and elected officials), who are influenced by communities of interest, who often amplify their voices through the media. The implicit SCHIP premise is that providing insurance to a child equals better health outcomes. The insurance card leads to access, utilization, medical home, and security. To quantify the success of SCHIP, States can initially look at the number of enrolled and document their previous insurance status. Once the program has been implemented for some time, States can then look at utilization of services, continuity of coverage and source of care, consumer confidence in obtaining care, and quality of care. Qualitative success can be measured by administrative smoothness and simplicity and program design.

Dr. Holahan reported on findings from the Urban Institute’s 1997 Assessing the New Federalism survey, which provides a baseline of information for 13 States prior to SCHIP implementation. The survey examined how access to and use of health services varied for children by insurance status and income. Overall, uninsured children, from families both below and above 200 percent of the FPL had no usual source of care and used the emergency room more often than children with private or public insurance. Uninsured children were less likely to have at least one well-child visit per year and less likely to have at least one visit to the doctor a year. A significant number of parents of uninsured children were not confident that they could obtain needed care for their children, compared with parents of children with private or public insurance. The Urban Institute will continue to assess whether SCHIP: reduces the rate of uninsurance among the eligible population, leads to crowd-out of the private coverage, improves parents’ confidence that they can obtain needed health care for their family, increases the use of preventive care, and decreases unmet health care needs for low-income children.

Dr. Wolf recognized the problems States face when trying to evaluate the quality and performance of SCHIP: lack of good baseline data; inadequate data information systems for baseline, tracking, and comparisons; lack of measurement uniformity across States and across measurement systems; no mechanism for risk adjustment; and the possible fluctuation of insurance status of SCHIP kids, thereby limiting enrollment duration. This being said, Dr. Wolf gave examples of national/Federal data sources that may help assess SCHIP, which include: the Behavioral Risk Factors Surveillance Systems (BRFSS), Youth Risk Behavior Survey (YRBS), the National Health Interview Survey (NHIS), the Medical Expenditure Panel Survey (MEPS), and the Early Childhood Longitudinal Survey. However, each has limitations and may not actually be that helpful in measuring quality or performance in the short term on a State-by-State basis.

The three State respondents as well as workshop participants reiterated that the Federal tools do not address or meet the needs of States for evaluation (i.e., CAHPS�® is only available in English). Also, with the 10 percent administrative cap, State expenditures are limited, and States often cannot afford to conduct surveys to the extent they would like. Concerns were also voiced about cost effectiveness: Where do we draw the line between the cost of evaluating and the cost of providing care? Will States be required to spend more money on processes rather than on services?

Aging and health policy play an essential role in research, practice, and education. The John Heinz Senate Fellowship was created in memory of the late United States Senator John Heinz who spent much of his congressional career as an outspoken advocate for the rights of older Americans. This session will be presented by Heinz Fellows and former Heinz staff members from a variety of different disciplines to increase understanding of the role of policy in both aging research and practice, and to help aging professionals understand how to translate research, evidence, and best practices into sound aging policy.

Works Cited
Riley T. How will we know if SCHIP is working? Health Aff 1999 Mar/Apr;18(2):64-66.
Selden SM, Banthin JS, Cohen JW. Waiting in the wings: eligibility and enrollment in the State Children’s Health Insurance Program. Health Aff 1999 Mar/Apr;18(2):126-134.
National Academy for State Health Policy. Framework for Title XXI annual report. Portland (ME): The Academy, 1999 Apr.
National Academy for State Health Policy. Framework for State evaluation of Children’s Health Insurance Plan Under Title XXI of the Social Security Act. Portland (ME): The Academy, 1999 Apr.
Tollen LA. Subsidizing employer sponsored insurance under state children’s health insurance programs. Washington (DC): Institute for Health Policy Solutions, 1999 Feb.
Henneberry J, Hearne J. Using SCHIP funds for health insurance premium contributions: policy issues and operational challenges. Washington (DC): Institute for Health Policy Solutions, 1998 Oct.
MassHealth Family Assistance Program: case study of employer-based insurance subsidy program. Washington (DC): Institute for Health Policy Solution, 1999 Apr.
Hearne J. Coordination of children’s coverage expansions with employer-sponsored coverage. Washington (DC): Institute for Health Policy Solutions, 1998 Mar.
Merlis M. Employer coverage and the Children’s Health Insurance Program under the Balanced Budget Act of 1997: options for states. Washington (DC): Institute for Health Policy Solutions, 1997 Aug.
Rosenbaum S. Curriculum Vitae. Washington (DC): George Washington University, 1999 Feb.
Markus A, Rosenbaum S, Roby D. SCHIP, health insurance premiums and cost sharing: lessons from the literature. Washington (DC): George Washington University Medical Center, 1998 Oct. Health Resources and Services Administration Contract No.: 98-OA-140506.

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