CFED Assets & Opportunity Scorecard
Access to Health Insurance
Health insurance is one way to protect a family’s assets. It mitigates the cost to a family for expenses resulting from a medical emergency or the treatment of a chronic illness – expenses that might otherwise require a family to spend long-term savings, sell assets or go into debt. Health insurance, including dental coverage, also encourages people to seek preventive care and treatment for injuries and illnesses, minimizing the impact a medical condition would otherwise have on an individual’s ability to earn income. However, rising health care costs and gaps in health insurance coverage mean that many individuals and families are one serious illness or accident away from financial instability and a loss of assets. States should increase access to health insurance by increasing income eligibility for public health insurance programs, such as Medicaid and other state-funded programs, as well as by streamlining the enrollment and renewal process. States should also ensure that basic preventive and restorative dental care are covered through Medicaid.
CFED evaluated the strength of each state’s policies that support access to health insurance against the four criteria described in the Elements of a Strong Policy tab. The table below shows which criteria each state met.
CFED uses the following icons to denote the strength of state policies:
Strength of State Policies: Access to Health Insurance
|State||Are parents up to at least 200% FPL eligible? 1||Are childless adults up to at least 200% FPL eligible? 1||Has the state implemented at least 4 of 7 simplified procedures for both CHIP and Medicaid for children and parents? 2||Does the state's Medicaid program cover basic dental care for adults? 3||Rating|
|Alabama||No (24%)||No Coverage||Yes (Medicaid 6, CHIP 4)||No Coverage|
|Alaska||No (81%)||No Coverage||Yes (Medicaid 4, CHIP 4) 4||Yes (Comprehensive)|
|Arizona||No (106%)||No (110%, closed) 5||No (Medicaid 6, CHIP 3)||No (Emergency)|
|Arkansas||Yes (200%) 6||Yes (200%) 6||No (Medicaid 5, CHIP 3)||Yes (Limited)|
|California||Yes (200%)||Yes (200%)||No (Medicaid 3, CHIP 4)||No Coverage|
|Colorado||No (106%)||No Coverage||Yes (Medicaid 7, CHIP 5)||No (Emergency)|
|Connecticut||No (191%) 7||No (72%) 7||Yes (Medicaid 6, CHIP 5)||Yes (Comprehensive)|
|Delaware||No (119%)||No (110%)||No (Medicaid 6, CHIP 3)||No Coverage|
|District of Columbia||Yes (206%)||Yes (211%)||No (Medicaid 6, CHIP 2)||Yes (Limited)|
|Florida||No (58%)||No Coverage||Yes (Medicaid 4, CHIP 4) 4||No (Emergency)|
|Georgia||No (49%)||No Coverage||No (Medicaid 2, CHIP 4)||No (Emergency)|
|Hawaii||Yes (200%)||Yes (200%)||No (Medicaid 4, CHIP 3)||No (Emergency)|
|Idaho||No (185%)||No (185%)||Yes (Medicaid 4, CHIP 5)||Yes (Limited)|
|Illinois||Yes (200%)||No Coverage||Yes (Medicaid 5, CHIP 6)||No (Emergency)|
|Indiana||Yes (206%)||Yes (210%, closed) 8||No (Medicaid 3, CHIP 3)||Yes (Limited)|
|Iowa||Yes (250%)||Yes (250%)||Yes (Medicaid 4, CHIP 6) 4||Yes (Comprehensive)|
|Kansas||No (32%)||No Coverage||Yes (Medicaid 4, CHIP 6)||No (Emergency)|
|Kentucky||No (59%)||No Coverage||No (Medicaid 3, CHIP 4)||Yes (Limited)|
|Louisiana||No (25%)||No Coverage||Yes (Medicaid 6, CHIP 5)||No (Dentures & Pregnant Women) 9|
|Maine||Yes (300%)||Yes (300%)||Yes (Medicaid 4, CHIP 5)||No (Emergency)|
|Maryland||No (116%)||No (128%)||Yes (Medicaid 6, CHIP 4)||No Coverage|
|Massachusetts||Yes (300%)||Yes (300%)||Yes (Medicaid 6, CHIP 4)||Yes (Limited)|
|Michigan||No (63%)||No (45%, closed) 5||Yes (Medicaid 4, CHIP 6) 4||Yes (Limited)|
|Minnesota||Yes (275%)||Yes (250%)||No (Medicaid 4, CHIP 2)||Yes (Limited)|
|Mississippi||No (44%)||No Coverage||No (Medicaid 5, CHIP 3)||No (Emergency)|
|Missouri||No (36%)||No Coverage||No (Medicaid 5, CHIP 2)||No (Emergency)|
|Montana||No (55%)||No Coverage||Yes (Medicaid 5, CHIP 6)||No (Emergency)|
|Nebraska||No (57%)||No Coverage||No (Medicaid 5, CHIP 2)||Yes (Limited)|
|Nevada||No (87%)||No Coverage||No (Medicaid 3, CHIP 2)||No (Palliative) 10|
|New Hampshire||No (49%)||No Coverage||No (Medicaid 2, CHIP 3)||No (Emergency)|
|New Jersey||Yes (200%, closed) 5||No (23%) 11||Yes (Medicaid 5, CHIP 5)||Yes (Limited)|
|New Mexico||Yes (408%, closed) 5||Yes (414%, closed) 5||Yes (Medicaid 6, CHIP 5)||Yes (Comprehensive)|
|New York||No (150%)||No (100%)||Yes (Medicaid 5, CHIP 5)||Yes (Comprehensive)|
|North Carolina||No (49%)||No Coverage||No (Medicaid 3, CHIP 5)||Yes (Comprehensive)|
|North Dakota||No (59%)||No Coverage||Yes (Medicaid 5, CHIP 4)||Yes (Comprehensive)|
|Ohio||No (90%)||No Coverage||Yes (Medicaid 7, CHIP 4)||Yes (Comprehensive)|
|Oklahoma||Yes (200%) 12||Yes (200%) 12||No (Medicare 6, CHIP 3)||No Coverage|
|Oregon||Yes (201%)||Yes (201%)||Yes (Medicaid 5, CHIP 5)||Yes (Comprehensive) 13|
|Pennsylvania||No (46%)||No Coverage||No (Medicaid 7, CHIP 3)||Yes (Limited)|
|Rhode Island||No (181%)||No Coverage||No (Medicare 5, CHIP 2)||Yes (Comprehensive)|
|South Carolina||No (91%)||No Coverage||No (Medicaid 5, CHIP 2)||No (Emergency)|
|South Dakota||No (52%)||No Coverage||No (Medicaid 5, CHIP 3)||Yes (Comprehensive)|
|Tennessee||Yes ($55,000/yr, closed) 14||Yes ($55,000/yr, closed) 14||No (Medicare 1, CHIP 1)||No Coverage|
|Texas||No (26%)||No Coverage||No (Medicare 3, CHIP 2)||No (Emergency)|
|Utah||No (150%)||No (150%)||No (Medicaid 6, CHIP 2)||No Coverage|
|Vermont||Yes (300%)||Yes (300%)||No (Medicaid 5, CHIP 3)||Yes (Limited)|
|Virginia||No (31%)||No Coverage||No (Medicaid 6, CHIP 3)||Yes (Limited) 4|
|Washington||Yes (200%)||Yes (200%)||No (Medicare 3, CHIP 4)||No Coverage|
|West Virginia||No (32%)||No Coverage||Yes (Medicaid 6, CHIP 5)||No (Emergency)|
|Wisconsin||Yes (200%)||Yes (200%, closed) 5||Yes (Medicaid 7, CHIP 4)||Yes (Comprehensive)|
|Wyoming||No (51%)||No Coverage||Yes (Medicaid 7, CHIP 4)||Yes (Limited)|
1. Martha Heberlein, et al., Performing Under Pressure: Annual Findings of a 50-State Survey on Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012 (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2012), Table 4.
2. Ibid., Tables 7, 8, 9, 11, 12, 13 and 14. For the full list of simplification procedures a state could implement, please see footnotes 5 and 6 from "Elements of A Strong Policy."
3. "Medicaid Compendium Update," American Dental Association, July 2012, www.ada.org/2123.aspx. Information is provided only on states' main Medicaid program and does not address benefits in other Medicaid program components.
4. The state's rating has changed compared to previous editions of the Scorecard due to changes in the way data in the underlying sources was collected or categorized, not as a result of policy change.
5. Enrollment in this state's program is currently closed.
6. To qualify for the ARHealthNetworks program, adults must have income below 200% of the FPL and work for a qualifying, participating employer. In 2011, the state expanded eligibility to self-employed adults who qualify for the program.
7. Connecticut has a state-funded program, the Charter Oak Program. However, the state stopped subsidizing premiums for new enrollees as of June 2010, but adults can buy into the program at the full monthly cost of $446 if they do not qualify for the CT Pre-Existing Condition Insurance Plan.
8. Enrollment in the Healthy Indiana program is closed, but during 2011, the state opened the waiting list in an effort to add members up to the cap.
9. In Louisiana, dental coverage is only offered for dentures, denture relines, and denture repairs. Pregnant women eleigible for Medicaid are covered for extended benefits.
10. Palliative care is a form of care intended to relieve pain without attempting to cure the disease or condition.
11. New Jersey's eligibility levels shown for childless adults apply to individuals who are "employable," as defined by the program. Those considered "unemployable" have a lower eligibility threshold.
12. To qualify for Oklahoma's Insure Oklahoma program, adults must have incomes below 200% of the FPL and also be self-employed, unemployed but looking for work, working disabled, a full-time college student or work for a small employer.
13. Dental coverage in Oregon is only available to adults in the Oregon Health Plan Plus, while those on the Oregon Health Plan Standard receive coverage for emergency services.
14. The CoverTennessee program offers coverage to adults who earn up to $55,000 a year and also work for a qualified business, are self-employed or recently unemployed. Enrollment in the program is closed.
WHAT STATES CAN DO
States have a number of tools at their disposal to increase access to health insurance. They can expand income eligibility for Medicaid and other state-funded programs, particularly for parents and childless adults.1 States can implement the PPACA requirement to cover all nonelderly adults up to 133% FPL prior to the 2014 deadline and even expand coverage beyond the federal requirement. States can also facilitate enrollment and renewal of coverage in CHIP and Medicaid by simplifying procedures. Finally, states can provide basic preventive and restorative dental care through Medicaid.
As states make important decisions about implementation of the PPACA, it is important for policymakers to consider the impact of those decisions on their low-income residents. Expanding income eligibility for Medicaid would make millions of currently uninsured adults eligible for the program.2 Simplifying procedures for enrollment and retention into Medicaid and CHIP ensures more low-income families have access to the health coverage they need, while protecting dental benefits for Medicaid beneficiaries decreases out-of-pocket expenses for financially vulnerable families. As states overhaul their health care systems, policymakers can implement reforms that contain costs and expand coverage to their low-income residents.
WHAT STATES HAVE DONE
Overall, 18 states offer coverage to parents with incomes up to at least 200% of the federal poverty line either through Medicaid, a Medicaid waiver, or state-funded program, while 16 offer coverage to childless adults with incomes up to at least 200% of the poverty line. Twenty-nine states have implemented four of seven simplified procedures for children,3 and 41 states have implemented four of seven simplified procedures for parents applying for Medicaid, although only 24 states have done both. Twenty-six states provide adult dental coverage beyond emergency services through Medicaid.
1 Through the creation of CHIP and the expansion of Medicaid eligibility for children, most children have attained health insurance coverage, even if their parents have not.
2 How Will the Medicaid Expansion for Adults Impact Eligibility and Coverage?, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2012), http://www.kff.org/medicaid/upload/8338.pdf.
3 The CHIPRA performance bonuses are available to states that implement 5 of 8 simplified procedures. However, data on one of the eight procedures – premium assistance options – was not available. Therefore states received credit if they implemented 4 of 7 simplified procedures for children.
ELEMENTS OF A STRONG POLICY
CFED considers a state’s health insurance coverage policy strong if it meets the following criteria:1
1. Are parents with incomes up to at least 200% of the FPL eligible for coverage under Medicaid or other state-funded programs? Approximately 67% of nonelderly uninsured parents have incomes below 200% FPL.2 States should expand coverage to this population to reduce the number of uninsured. In addition, while most states have separate eligibility standards for children and for parents, it is well documented that increased coverage of parents leads to increased health care coverage among children.3 By creating a family eligibility standard, states simplify the process of enrollment for working parents and create a seamless public insurance system for the entire family.
2. Are childless adults with incomes up to at least 200% of the FPL eligible for Medicaid or other state funded programs? Although the majority of uninsured Americans are adults without children, Medicaid has not traditionally covered these individuals.4 Starting in 2014, PPACA requires states to expand Medicaid coverage to nonelderly individuals with incomes up to 133% of FPL, including childless adults. However, this expansion still excludes a vulnerable portion of low-income childless adults between 133% and 200% of FPL. States should extend coverage to childless adults up to the 200% threshold through state-funded programs or Medicaid waivers.
3. Has the state simplified procedures to maximize enrollment and retention in CHIP and Medicaid for children and parents? Simplified procedures increase enrollment and retention of eligible individuals in Medicaid and CHIP. Recognizing the value of simplification, the 2009 CHIP reauthorization offered states performance bonuses to implement procedures such as not requiring an in-person interview to enroll in the program and creating joint applications for CHIP and Medicaid. States should adopt simplification procedures for both CHIP5 and Medicaid for children and parents.6
4. Does the state’s Medicaid program cover basic dental care for adults? In addition to having an impact on overall health and the health of their children directly and indirectly,7 adult oral and dental health can be an integral factor in employability, job retention, and income/savings protection. Dental problems, such as tooth loss, can affect employability,8 while pain and infection can play a role in job retention and productivity.9 Delaying treatment due to lack of coverage often leads to more costly and complex treatments down the road.10 Ideally states should provide both preventive and restorative adult dental care for their residents; however, even coverage of basic dental services in the state’s Medicaid program that goes beyond emergency care for all adults is an important step for states to take.
To see how each state’s policy stacks up against these criteria, see the State Data tab above.
1 CFED acknowledges the expert assistance of Judy Solomon of the Center on Budget and Policy Priorities, Enrique Marinez-Vidal and Isabel Friedenzohn of AcademyHealth and Meg Booth of the Children’s Dental Health Project.
2 Current Population Survey, s.v. “Annual Social and Economic Supplement, 2011” U.S. Census Bureau. Calculated by CFED using the CPS Table Creator, http://www.census.gov/cps/data/cpstablecreator.html.
3 “Five Good Reasons for States to Expand Family Coverage,” Families USA, April 2000, http://familiesusa2.org/assets/pdfs/5_good_reasonsf09b.pdf.
4 Some states have offered childless adults coverage via Medicaid waivers or state-funded programs.
5 Simplification procedures eligible for the CHIP performance bonus include (1) 12-month-continuous coverage, (2) no asset tests, (3) no face-to-face interview, (4) joint application for Medicaid and CHIP, (5) administrative renewals, which allows states to renew eligibility based on information available to them from other program records or databases, (6) presumptive eligibility, which allows certain health care providers to make preliminary eligibility decisions in order for individuals to receive care while they complete the application, (7) express lane eligibility, which allows states to use eligibility for other public programs to determine that a child satisfies one or more components of eligibility for Medicaid or CHIP, and (8) premium assistance option. “Medicaid Performance Bonus “5 of 8” Requirements,” Kaiser Commission on Medicaid and the Uninsured and Georgetown University Health Policy Initiative Center for Children and Families, April 2009,http://ccf.georgetown.edu/index/cms-filesystem-action?file=ccf publications/federal schip policy/chip tip 5 of 8 final.pdf.
6 Simplified procedures for parents applying for Medicaid include (1) no face-to-face interviews, (2) no asset tests, (3) attempt to administratively verify income. (4) online application process including online submission, electronic signatures, and enhanced functionality for online account, (5) use of Social Security Administration data match to verify citizenship, (6) 12-month frequency of renewal, and (7) a simplified family application.
7 Dana Hughes and Joel Diringer, “Eliminating Medi-Cal Adult Dental: Costs and Consequences,” Dental Health Foundation and California Primary Care Association, June 2009, http://www.calohac.com/resources/documents/OHAC_Adultdentalcutbrief32009final.pdf.
8 Carol Pryor and Michael Monopoli, Eliminating Adult Dental Coverage in Medicaid: An Analysis of the Massachusetts Experience, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2005).
9 Mary McGinn-Shapiro, Medicaid Coverage of Adult Dental Services, (Washington, DC: National Academy for State Health Policy, 2008), http://www.nashp.org/sites/default/files/Adult Dental Monitor.pdf.
10 Leonard Cohen, Richard Manski and Frank Hooper, “Does the Elimination of Medicaid Reimbursement Affect the Frequency of Emergency Department Dental Visits?” The Journal of the American Dental Association 127, (1996), p. 605-609.
MAKING THE CASE
Strategies for a Successful Campaign
To expand access to quality health care in the current political environment, state advocates should defend the PPACA and push for quick implementation of key reforms. To garner support for reform, advocates should:1
1. Identify key constituencies and partners who benefit from reform. Think of the populations that will benefit from reforms, which include small business owners, the chronically ill, young adults and seniors. Consider partnering with relevant groups such as local small business groups, diagnosis specific advocacy organizations, senior organizations or college groups.
2. Hold public events to educate key constituencies about new benefits. Examples include: an event at a local senior center to explain what health reform means to older adults, or distributing information at a university’s job fair for young adults who will continue to be covered under their parent’s insurance post-graduation.
3. Collect stories. Collect testimonies of people who have benefited from Medicaid. Real life stories shift the discussion away from politics and toward taking care of people. The Kaiser Family Foundation’s Faces of Medicaid report series and Utah Health Policy Project’s Storybank provide numerous examples of stories that show the face of Medicaid beneficiaries, including children, seniors and people with disabilities.
4. Engage the media. Engaging the media helps spread the message to a larger audience. Notifying the media prior to public events, writing letters to the editor and op-eds to the local newspaper, and maintaining a presence on blogs and social networking sites are all ways to raise attention about the benefits of reform and the importance of expanding coverage.
5. Develop implementation priority agendas. States can pursue a number of opportunities made available through PPACA, and advocates should help the state identify which opportunities will most benefit its residents. Developing an implementation priority agenda will help states prepare for the steps they must take to comply with the law as well as any grants or pilot programs in which they may want to participate.
6. Participate in decision-making bodies. A variety of new and existing boards and commissions are making key decisions as PPACA is implemented across states. It is crucial that consumer advocates proactively seek the chance to participate in these conversations.
Key Messaging to Defend Medicare
In addition to promoting implementation of key reforms, states should defend Medicaid from cuts in the current budgetary climate. Key messages in support of Medicaid include:2
1. Medicaid increases access to care, decreases debt and improves health.3 A recent study found that Medicaid increased health care utilization rates, decreased liabilities and out-of-pocket costs and increased well-being. Using Oregon’s lottery system to compare Medicaid recipients to nonMedicaid recipients, the study found:
- Those with insurance coverage were 30% more likely to use a hospital, 15% more likely to take prescription drugs and 21% more likely to have an outpatient visit.
- The insured group was also 25% less likely to have unpaid medical bills sent to a collection agency and 20% less likely to have any out-of-pocket costs.
- The Medicaid group was more likely to screen negative for depression and report good health and overall happiness in the past six months.
2. Medicaid benefits members of the community. Medicaid benefits more than the patients it serves. Medicaid supports health care providers, including physicians, nurses, community health centers, mental health providers and hospitals. Medicaid also benefits employers and even those who are insured – without Medicaid, premiums would increase because costs of covering the uninsured would shift to the private market. Finally, Medicaid benefits the community as a whole by limiting the negative effects of high rates of uninsured, such as emergency room overcrowding and losses in productivity.
3. The majority of Americans support Medicaid, even during periods of budget deficits. According to a 2005 survey by the Kaiser Family Foundation, 74% of adults said Medicaid is a “very important” government program. The survey found that although almost two-thirds of the public thought their state’s budget was either in crisis or had major problems, half said they “strongly” opposed and another 22% “somewhat” opposed cutting back on their state’s Medicaid program to balance the budget.
4. Medicaid leverages federal dollars and limits costs of emergency care. The federal government matches state investment in Medicaid, at a minimum of a 1:1 ratio, which means that states that cut their Medicaid programs will lose federal dollars. In addition to forfeiting matching funds, the cost of covering emergency health care for a greater number of uninsured people will increase, and these costs will be shifted to the state and private businesses.
5. There are alternatives to cuts. States can maximize Medicaid revenue by charging providers a fee, which was the case in Colorado, or increasing tobacco taxes in order to leverage additional federal dollars, as was the scenario in Arkansas. States can also reform payment and delivery systems to reduce costs by increasing use of generic drugs, eliminating payments for preventable errors like hospital-acquired infections and implementing patient-centered medical homes. Finally, states can implement public health campaigns to reduce tobacco use, prevent HIV transmission and increase vaccinations.
1 This section is adapted from: “State Implementation of National Health Care Reform: Strategies for Public Outreach,” Community Catalyst, May 2010, http://www.communitycatalyst.org/doc_store/publications/Strategies_for_Public_Outreach.pdf. (Accessed August 2011).
2 With the exception of message #1, this section has been adapted from: “Defending Medicaid in Hard Times: A Guide for State Advocates,” Community Catalyst, http://www.communitycatalyst.org/resources/defending_medicaid. (Accessed August 2011).
3 Amy Finkelstein, et al., The Oregon Health Insurance Experiment: Evidence from the First Year, (Cambridge, MA: National Bureau of Economic Research, 2011).
For each edition of the Assets & Opportunity Scorecard since 2007, CFED has worked with experts in the field to capture detailed stories of noteworthy state policy changes—both policy victories and instructive defeats. These case studies appear in the Resource Guides for each policy priority.
Expanding Medicaid in Colorado (published October 2011)
In 2009, the Colorado General Assembly passed House Bill 09-1293, the Colorado Health Care Affordability Act. The Act created a Hospital Provider Fee that generates enough revenue to increase payments to hospitals for providing care to Medicaid and indigent populations, as well as revenue to implement significant expansions of the Medicaid and CHIP programs. Click here to read more.
The Return of Adult Dental in Michigan (published October 2011)
In June 2009, the Michigan Oral Health Coalition – a coalition focused on improving the oral health of Michigan residents through partnerships with providers, educators, legislators, policymakers and the community – launched an advocacy campaign to reinstate Medicaid adult dental services eliminated earlier that year. Click here to read more.
Progress and Challenges in Texas (published September 2009)
Texas enacted CHIP legislation in 1999 and, despite this late start, experienced robust early enrollment. More than 500,000 children were soon covered in its separate state CHIP program… The success of these policies in reaching eligible uninsured children has not been welcomed by all lawmakers in Texas’s socially conservative, low-tax, low public service political context. During the 2003 recession, lawmakers cut CHIP continuous eligibility from 12 months to six, resulting in enrollment dropping by 40%. Click here to read more.
Expanding Coverage in Massachusetts (updated September 2009)
In 2006, Massachusetts enacted a far-reaching health care reform plan that expanded access to health insurance for the uninsured. The plan includes significant expansions in subsidized public coverage for low-income families and childless adults. The reform succeeded in reducing the number of uninsured in Massachusetts – as of 2008, only 2.6% of the population was uninsured. The decline in the uninsured population in the state accounted for 22% of the total drop in nonelderly uninsured nationally. Click here to read more.
For a two-page overview of access to health insurance, download CFED’s Policy Brief.
For an in-depth compendium of analysis, research, and resources on access to health insurance, download CFED’s Resource Guide.