Reflections on the Children’s Health Insurance Program

Cropped shot of an adorable young girl with her pediatricianBy Jennifer Ryan, Vice President

As the deadline for formally reauthorizing the state Children’s Health Insurance Program (CHIP) passed last Friday, I found myself remembering the origins of (S)CHIP, the collective effort that went into implementing the program, and the important role it plays for nearly nine million children today.  While there is hope this week that the House will adopt the Senate Finance Committee’s version of a reauthorization package, the fact that legislative action did not occur before CHIP technically expired has raised concern and uncertainty across the country.

My work on CHIP – originally called S-CHIP to emphasize the states’ autonomy in deciding how to structure and implement it – began in 1997 and has continued for two decades.  I had the privilege of serving on the team at the federal Department of Health and Human Services that was tasked with working with the states to implement CHIP in 1997-1998.  I worked alongside our firm’s founder, Peter Harbage, among other great public servants, to support a robust Steering Committee that represented a wide range of stakeholders across the Department. Everyone wanted to be a part of CHIP.

CHIP – The Golden Child

The early days of CHIP implementation were exciting and our work enjoyed a great deal of attention from the White House as well as from the bi-partisan group in Congress, led by Senators Orrin Hatch (R-UT) and the late Edward Kennedy (D-MA), all of whom felt a strong ownership interest in the program’s success.

There was bi-partisan excitement at the state level as well. Governors convened “Children’s Cabinets” and state-wide task forces dedicated to the design and branding of the new program and, even though CHIP was optional and required state matching funds, every state participated.  Alabama was the first state to have its CHIP plan approved. One of the nation’s longest serving and most dedicated CHIP Directors, Cathy Caldwell, notes that Alabama’s uninsurance rate among children has declined from 20% in 1997 to 2.4% today.

Nearly everyone agreed that putting out the “welcome mat” to get families to enroll in CHIP (and Medicaid) would be the key to its success. The Robert Wood Johnson Foundation provided nearly $150 million through its Covering Kids & Families outreach campaign to support community-based organizations in every state (in the 2009 CHIP reauthorization, Congress affirmed the importance of outreach by allocating $100 million in federal funding to what is now known as Connecting Kids to Coverage). In addition, states adopted policy strategies to simplify and streamline the enrollment process in order to make it easier for eligible children to get CHIP and Medicaid coverage. They shortened their applications, asked for less paperwork, and stopped requiring families to come into a welfare office for a “face-to-face” interview.  These policies are now the core operating standard across Medicaid, CHIP, and the Health Insurance Marketplaces.

The program has been an unequivocal success.  Today, 48 states and the District of Columbia provide coverage to children with family incomes up to at least 200% of the federal poverty level (FPL) through CHIP and Medicaid; 19 of those states cover children up to 300% of the FPL.  The uninsurance rate among low-income children has declined from 23% in 1997 to only 5% today. While CHIP is a relatively small source of coverage, costing only $14 billion per year to operate nationally, its importance is very real to the families who rely on it.

For Kyli

My cousin, Kyli, experienced failure to thrive at 11 weeks old and was eventually diagnosed with metabolic encephalopathy of unknown origin.  She suffered a myriad of complex developmental and health conditions that, a generation ago, would have meant she would not survive past infancy.  But Kyli’s fiercely dedicated, middle-class parents looked into New York’s Child Health Plus program in hopes of gaining access to the specialized services she would need. Because of her condition, Kyli eventually qualified for the Care at Home program – a Medicaid waiver program designed to enable children with disabilities to remain in the community. The coverage Kyli received gave her access to life-saving therapies and acute medical interventions (which occurred as often as seven or eight times a year). The program also provided assistive devices and personal supports, including home care nursing, that enabled Kyli’s parents to care for her at home.  Not only was Kyli’s quality of life improved – her parents would likely have been bankrupted if the program had not been there for them.

Kyli passed away on October 20, 2013 at the age of 11 1/2.  I’ll never forget that day, because I was back at the federal government in the Center for Medicaid and CHIP Services.  We were busy gearing up for the first open enrollment period for the Affordable Care Act and the launch of the Medicaid expansion, despite the government shutdown. I learned the news about Kyli over email while in a meeting about streamlining Medicaid eligibility and enrollment processes.  I have never been prouder or more humbled by the work of promoting access to comprehensive, affordable health coverage than I was that day.

Let’s let CHIP and Medicaid continue to do their job.