 |
The State Child Health Insurance Plan (SCHIP) and
|
EXECUTIVE SUMMARY
1. The new State Child Health Insurance Program (SCHIP) provides a tool for addressing several critical health needs of American Indian and Alaskan Native children. The WGA Task Force, which includes tribal officials, Indian Health Service and state agencies, makes recommendations herein that can be customized to the needs of individual states.
2. The WGA Task Force encourages the states to explore innovative options for implementing SCHIP that best match the program with the needs of the population to be served.
3. The WGA Task Force encourages the states to employ early and consistent consultation with tribes in developing their SCHIP programs.
4. The WGA Task Force encourages the governors to have state child health policy directors work with the area tribes and the Task Force in establishing local partnerships and developing flexible approaches to service delivery under SCHIP.
5. Members of the WGA Task Force recommend to their respective organizations/tribes not to reduce current funding for Indian child health but rather to use the SCHIP to provide services not previously covered. States are encouraged to structure their program in such a way as to minimize public and private sector opportunities to supplant existing child health care dollars.
6. The WGA Task Force recommends that measurable goals be identified at the state and/or tribal level to evaluate the health status outcomes of the children served through SCHIP funds.
7. The WGA Task Force recommends that the governors communicate to the Secretary of Health and Human Services and to the appropriate members of Congress the following points in order to assure the success of the SCHIP:
1) request HCFA to fast track the state plans developed in consultation with area tribes by reducing the level of exacting detail that is expected;
2) request the Secretary endorse local efforts for tribal consultation and innovative approaches to addressing the health needs of American Indian and Alaska Native children without predefined Federal procedures;
3) ensure that the budget of the Indian Health Service is not decreased in response to states' targeting the health of Indian children through SCHIP.
INTRODUCTION
In December 1996, the Western Governors' Association (WGA) adopted Resolution 96-024, entitled "Indian Health Care", sponsored by Utah Governor Michael Leavitt. As directed by the resolution, WGA created a Task Force comprised of state public health officials, representatives of American Indian and Alaska Native tribes, federal Indian Health Service officials, federal Health Care Financing officials, and other interested parties. (Appendix A) The resolution called on the task force to identify key health problems that could be effectively targeted to improve the health of Indian children. Under the leadership of the Utah Department of Health, the Task Force met twice in Salt Lake City and held several teleconference work sessions.
Investigations and analysis by the Task Force produced data clearly documenting a number of personal health areas where American Indian and Alaska Native children suffer greater morbidity and mortality than the general population (Appendix B). As the Task Force worked to develop recommendations on intervention strategies for the governors, Congress passed The Balanced Budget Act of 1997, P.L. 105-33, which includes provisions establishing SCHIP under new Title XXI of the Social Security Act. This new state-federal partnership is intended to expand health insurance coverage of low-income children by providing states with federal matching funds. A total of $20.25 billion in federal matching funds is authorized for the 1998-2002 period. The Task Force felt the most helpful recommendations it could make to the Governors would be to address how each state's implementation of the new Title XXI program could combine the goal of addressing Indian children's health concern as part of that important initiative. This conclusion was reinforced by several sections of Title XXI that pertain to Indian children specifically including Section 2102(b)3D which requires Title XXI state plans to describe the method to "ensure the provision of child health assistance to targeted low-income children in the State who are Indians...."
This report makes a number of recommendations for implementing SCHIP with respect to Indian children. It also provides three SCHIP implementation models and assesses their strengths and weaknesses. However, it should be recognized that SCHIP is only one tool for addressing the critical health needs of American Indian and Alaska Native children, and that SCHIP provides a unique opportunity for states to customize a health program to meet their individual needs.
STATE CHILD HEALTH INSURANCE PROGRAM (SCHIP)
SCHIP is targeted at uninsured children who live in families with income below twice the poverty line. Generally, states can use SCHIP funds to provide coverage through health insurance that meets specific standards for benefits and cost-sharing, or through their Medicaid programs or through a combination of both. States may also purchase a health benefits plan that is provided by a community-based health delivery system, or may purchase family coverage under a group health plan as long as it is cost effective to do so.
Each state will be allotted funds from the total appropriated amounts based on a combination of the number of low-income children and low-income, uninsured children in the state. Federal matching funds will be disbursed quarterly to each state with an approved SCHIP plan. Each state will receive a certain percentage (the enhanced federal matching percentage) of the total amounts paid for child health assistance equal to the Medicaid matching percentage for each state increased by about 30 percent. Health Care Financing Administration SCHIP allotments in fiscal year 1998 for each of the 18 WGA states and three WGA territories appear at Appendix C.
AMERICAN INDIAN AND ALASKA NATIVE CHILDREN AND THE SCHIP
Title XXI requires state plans seeking SCHIP resources to set forth details regarding the provision of child health assistance to targeted low-income children in the state who are American Indian. It also requires consultation with the tribes in the development of the state plan. While considering the range of options available under the SCHIP legislation, states must first recognize that in and of itself, providing insurance coverage under SCHIP may not significantly improve the health of Indian children. In addition, the scope of services usually provided in state Medicaid programs and benchmark health insurance plans may not be the most effective ones to address the major health problems of American Indian and Alaska Native children.
RECOMMENDATION NUMBER ONE: States should explore innovative options for implementing SCHIP that best match the program with the needs of the population to be served.
The SCHIP offers a unique but time limited opportunity for states to develop creative methods to provide health services to Indian children. Whether a state chooses a Medicaid expansion approach, an independent program approach or some combination of these, the Task Force believes western governors should insure that strategies for reaching Indian children in each state are tied to solutions that have a high probability of improving health outcomes. Given the greater number of restrictions placed on Medicaid program expansions by the Health Care Financing Administration, channeling SCHIP money into current Medicaid programs will present states with the need to negotiate with HCFA specific state plan provisions to address SCHIP.
Three model frameworks for consideration by states for implementing SCHIP are set forth below. A description of models A and B is attached in Appendix D.
A. Targeted benefits model - States opt to create a benchmark plan-based program that provides for the creation of unique benefits and administrative activities that allows the distinctive health problems of American Indian children to be addressed.
B. Comprehensive child health model - States create a comprehensive child health improvement program that draws on the resources of SCHIP, Medicaid, MCH Block Grant, WIC, IDEA, Family Preservation, and other child health funding and provides for customized and comprehensive service options for children and families of at-risk populations.
C. Enhanced Medicaid model - States opt to expand Medicaid in a manner that attends to the unique health problems of American Indian children. This could take the form of additional, enhanced services or a parallel benchmark plan-based program, similar to model A above, with a benefits package and administrative budget that more adequately address the needs of these children.
IMPLEMENTING SCHIP THROUGH PARTNERSHIPS
RECOMMENDATION NUMBER TWO: States should employ early and consistent consultation with tribes in developing their SCHIP programs.
The SCHIP requirement for tribal consultation does not reduce the flexibility of a state. Instead it encourages the development of needed partnerships. Through partnerships with tribes, barriers to improved health can be identified and solutions developed to assist states in maximizing the potential of the SCHIP funds. The requirement for the inclusion of services to American Indian/Alaskan Native children should not be interpreted as a shift in trust responsibility, but rather as an opportunity for collaboration.
RECOMMENDATION NUMBER THREE: Governors should have child health policy directors work with area tribes to establish local partnerships and develop flexible approaches to service delivery under SCHIP.
Given the unique makeup of the WGA Task Force, the potential exits for partnerships between all stakeholders with a common identified goal of removing the barriers to improved health for Indian children. State child health policy directors can be instrumental in assuring broad representation from across state agencies involved in child health issues. Governors should ensure that these individuals are key players in the development of the tribal component of SCHIP.
RECOMMENDATION NUMBER FOUR: States should not reduce current Indian health funding, but rather they should use SCHIP to provide services not currently covered. States also should structure their program in such a way as to minimize the likelihood of supplanting public or private child health care dollars.
The possibility exists for current health programs, at the private, state, or federal level, to shift funding away from services that have been provided in the past but that could now be provided under SCHIP. SCHIP dollars should be used in addition to public and private health care dollars currently spent on children without insurance coverage. It should not supplant the existing public health programs or the charity care contributions of the private sector. The potential flexibility of SCHIP funds could assist the tribal and IHS health programs to expand the scope of preventive services with funds saved through the use of SCHIP funds.
RECOMMENDATION NUMBER FIVE: States should identify measurable goals at the state and/or tribal level to evaluate the health status outcomes of the children served through SCHIP funds.
It is important for any new program to establish measurable goals that allow for ongoing evaluation. This will assist the states in long term effective management of SCHIP funds and other child health initiatives. In addition, for those states choosing a non-Medicaid model, a meaningful evaluation component will demonstrate the ability to effectively address local issues through increased flexibility.
ADDITIONAL ACTION ON SCHIP
RECOMMENDATION NUMBER SIX: The governors should communicate to the Secretary of Health and Human Services and to the appropriate members of Congress the following points in order to assure the success of the SCHIP:
1) Request the Health Care Financing Administration to "fast track" approval of state plans developed in consultation with area tribes by reducing the level of exacting detail that is expected;
2) Request the Secretary endorse local efforts for tribal consultation and innovative approaches to addressing the health needs of American Indian children without predefined Federal procedures;
3) Ensure that the budget of the Indian Health Service is not decreased in response to states' targeting the health of Indian children through the SCHIP.