Among the key reasons states maintained or expanded those initiatives despite the downturn was a federal requirement that states at least retain their 2008 eligibility standards and enrollment efforts in order to receive some of the $87 billion in supplemental federal funding for those programs offered through the American Recovery and Reinvestment Act of 2009.
“Increased federal assistance through ARRA bolstered the states' efforts,” said Tricia Brooks, senior fellow at Georgetown University Health Policy Institute, which co-authored the survey, speaking at a discussion of the results at the Kaiser Family Foundation on Jan. 11.
Innovative state-level initiatives also expanded the reach of the safety-net programs. One example was a new type of recruitment program launched in Howard County, Md., that was expanded statewide recently, even as that state also expanded income eligibility.
The recruitment approach moved beyond the standard letter sent home from school with the children of low-income parents to an active search for income-qualifying families through the state comptroller's office. The result was about 243,000 newly enrolled beneficiaries—about half of them children—added to the state's Medicaid program since 2008, according to Dr. Peter Beilenson, health officer of Howard County.
The program helped the state cut the number of residents who are eligible but do not apply for the program's benefits, Beilenson said. “Because the whole system is so complex, most people don't know where to go to get coverage.”
Such efforts by states along with an influx of federal funding have produced historic enrollments in both the SCHIP and Medicaid programs nationwide. Medicaid grew at its fastest rate since its launch in the 1960s in the 12 months before December 2009, according to the latest data from the Kaiser Commission.
The only states that reduced their eligibility and enrollment efforts last year—Arizona and New Jersey—approved those changes before enactment of the stimulus law.
Specific access expansions included changes by 13 states in 2010 that allowed more children to qualify for coverage under either Medicaid or SCHIP, according to the survey. Those 2010 expansions included the Kansas legislature's approval of funding to increase eligibility for the SCHIP program from 200% to 250% of the federal poverty level.
The expanded coverage may help ease the burden on Kansas hospitals, which must provide uncompensated care to residents without any type of insurance. “These programs are doing a better job with improving access to care if (the beneficiaries) can get to the primary-care physicians they need instead of overwhelming the emergency rooms,” said Cindy Samuelson, a spokeswoman for the Kansas Hospital Association.
Another 23 states and the District of Columbia also raised the maximum family income for qualifying children to at least 250% of the federal poverty level ($45,775 for a family of three in 2010). Additionally, 14 states streamlined enrollment and renewal procedures to lower access barriers and allow more children and adults to qualify, according to the survey. Those changes included the new use of electronically available Social Security Administration data by 29 states to determine eligibility for either program.
Conversely, less access and eligibility growth was seen in the states last year for the parents of qualifying children. The report found 33 states do not cover parents with household incomes of up to 100% of the federal poverty level ($18,310 for a family of three in 2010).
“In the absence of further expansions, these restrictive eligibility levels will leave most uninsured, low-income parents without an affordable coverage option until the health reform expansion goes into effect in 2014,” the Kaiser report noted.
The expanded access and recruitment efforts in many state Medicaid and SCHIP programs last year are expected to face some opposition this year as the stimulus law payments are scheduled to end in June and resurgent congressional Republicans are unlikely to provide another such funding package. That will leave many states facing new budget shortfalls, and some will consider cuts from their sizable public health programs, according to healthcare experts (See story, at left).
“There will certainly be some people who lose coverage,” said Dr. Georges Benjamin, executive director of the American Public Health Association.
But states may also resist slashing their safety-net programs since doing so could cost them significant federal matching funds beyond the stimulus law. For instance, matching programs authorized through the Children's Health Insurance Program Reauthorization Act of 2009 awarded a total of $206 million to 15 states in 2010.
“There will be some cuts but clever states will figure out they can double their money because reimbursement rates are so high and they can upgrade their IT systems for the same reason,” Benjamin said.