THE FLORIDA KIDCARE PROGRAM, A STATE CHILDREN S HEALTH INSURANCE PROGRAM: An Analysis of Options

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1 Florida KidCare Program Page 1 FLORIDA STATE UNIVERSITY THE FLORIDA KIDCARE PROGRAM, A STATE CHILDREN S HEALTH INSURANCE PROGRAM: An Analysis of Options AN ACTION REPORT SUBMITTED TO THE FACULTY OF THE COLLEGE OF SOCIAL SCIENCES IN CANDIDACY FOR THE DEGREE OF MASTER OF PUBLIC ADMINISTRATION RUBIN O D. ASKEW SCHOOL OF PUBLIC ADMINISTRATION AND POLICY BY: LAURA ANN KNICKELBEIN (850) lknickelbein@hotmail.com TALLAHASSEE, FLORIDA APRIL 2005

2 Florida KidCare Program Page 2 Laura Knickelbein 165 Crenshaw Drive, Apartment 10 Tallahassee, Florida (850) Letter of Transmittal April 29, 2005 Governor Jeb Bush The Governor s Mansion 700 North Adams Street Tallahassee, Florida Dear Governor Bush: Thank you for allowing me to submit this report for your review and consideration, The Florida KidCare Program, A State Children s Health Insurance Program: An Analysis of Options. This report is the byproduct of intensive research and analysis conducted throughout the spring 2005 semester. The issue of uninsured citizens in the United States and in the state of Florida, especially children, has become increasingly serious. This report describes in detail the history of the state s health insurance program for children, which includes an extensive review of literature on this issue, and makes recommendations as to the best way for Florida to handle this growing problem. The report also examines alternatives for increasing the number of children enrolled in the KidCare Program. Sincerely, Laura Ann Knickelbein, MSW, MPA

3 Florida KidCare Program Page 3 Acknowledgements I would like this time to thank the following people for their contribution to this research. Some of the many contributors include: Governor Jeb Bush and his administrative staff; Alan Levine, Secretary of the Agency for Health Care Administration and his staff in the Office of Medicaid Services; Senator Ron Klein; Senator Durell Peaden Jr. and his legislative staff; Senator Gary Siplin and his legislative staff; Senator Mike Fasano; Representative Loranne Ausley, and Representative Kenneth Littlefield. A special thanks to Dr. Lance DeHaven-Smith, for your guidance, insights, and suggestions for helping make this report what it is.

4 Florida KidCare Program Page 4 TABLE OF CONTENTS i. Title Page 1 ii. Letter of Transmittal 2 iii. Acknowledgements 3 iv. Table of Contents 4 v. Executive Summary 6 vi. Problem Statement 8 vii. Background 11 viii. Literature Review 18 ix. Research Methodology 20 x. Evaluative Criteria 20 xi. Management Policy Options 22 xii. Option 1- Current Status 22 xiii. Option 2- Expand Eligibility 26 xiv. Option 3- Universal Health Care for Children 29 xv. Recommendation for Action 31 xvi. Conclusion 32 xvii. References 33 xviii. Appendix A 35 xix. Appendix B 38 xxi. Appendix C 40 xxii. Appendix D 42

5 Florida KidCare Program Page 5 xxiii. Appendix E 47 xxiv. Appendix F 50

6 Florida KidCare Program Page 6 Executive Summary In recent years, the number of children without access to health insurance has grown in the United States and Florida. Many parents in the United States do not have access to employer-based health insurance programs and cannot afford health insurance coverage on their own. This is particularly the case with disadvantaged populations such as the poor and the near poor. One reason for the increase in uninsured children is the growing cost of health care services and health care insurance. The federal and state government has a responsibility to address this problem. The federal government has implemented a variety of financial assistance programs, including Medicaid and the State Children s Health Insurance Program. In Florida, health insurance is provided to eligible residents through Medicare, Medicaid, and the KidCare program. Nonetheless, some residents remain uninsured because they earn too much to be eligible for government assistance, and yet not enough to afford private insurance for themselves and their families. This paper explores the Florida KidCare Program and examines the alternatives for increasing the number of Florida children who have access to health care. The research will address the following questions: Is the Florida KidCare Program an effective and efficient way to administer the state children s health insurance program to low-income children? Is the Florida KidCare Program meeting the unmet health care and health insurance needs of low-income children in Florida? A review of the options is the best way to make sure that the citizens of the United States and in particular the residents of Florida have the ability and the access to health care insurance coverage and health care services. Without affordable health

7 Florida KidCare Program Page 7 insurance coverage, the cost of medical services will continue to rise, which will most likely have a negative impact on these families and a nation as a whole. This will result an increase in the number of people using local emergency rooms to obtain primary care and/ or preventive services, because they can not afford to go to the doctors until it is too late or it has a negative impact on their daily lives. Without affordable health care coverage the impact could be monumental on citizens, the health care industry, and federal and state governments. The options were reviewed by focusing on the background and professional literature associated with the state children s health insurance program, previous annual evaluations of the Florida KidCare Program and interviews with a variety of stakeholders associated with the KidCare Program. The alternatives that were considered included: keeping the KidCare Program the way it is currently; expanding the eligibility to all children in Florida whose families incomes are at or below 200 percent of the poverty level or threshold (FPL); and offering universal health care coverage to all children in the State of Florida on a sliding fee scale. Several factors were considered in assessing these options: the statistics on the uninsured adults and children in Florida and nationally; the effectiveness and efficiency of the KidCare Program; the perceptions of KidCare among various stakeholders; and the potential impacts of each options for the citizens of Florida and the children who are enrolled and/or are eligible for the KidCare Program. Primary emphasis was given to ways that the Florida KidCare Program could be adjusted to increase access to health care services and insurance.

8 Florida KidCare Program Page 8 Problem Statement Before Medicaid was enacted in 1965, there was a growing concern about the number of children who lack access to health care in the United States. The history of aid to low income children in the United States really began with the passing of Medicaid in 1965, which allowed states to work with the federal government to provide assistance to low-income families so their children would be able to access health care. Medicaid was designed to help those low-income families receive health care insurance for their children as long as they meet the certain criteria (US Census, 2003). However, even with the passing of Medicaid legislation, there was a growing trend in the number of uninsured children. The underlying issue became what the federal and state government could do to help alleviate this problem. Since Medicaid was enacted up until the early 1990 s, there was a significant increase in the number of people using local emergency rooms for preventive measures and to see the doctor when they were ill. Florida experienced high utilization rates among the poor along with the rising cost of health care. The Florida Legislature passed legislation in 1990 to create the Healthy Kids Corporation to work with health professionals and those who could not afford private insurance (Healthy Kids, 2004). This program provided health care to those individuals who qualified, and coverage was part of the managed care movement that relied on Health Maintenance Organizations (HMO s) (Healthy Kids, 2004). The state has also been concerned about welfare dependency among this population, which is why they have created certain eligibility requirements for both Medicaid and the KidCare Program.

9 Florida KidCare Program Page 9 The Federal government passed legislation in 1997, to help those who could not afford health insurance for their children (US Census Bureau, 2003). The legislation was part of Title XXI of the Social Security Act of 1997, which created the State Children s Health Insurance Program (SCHIP) (US Census Bureau, 2003). At this time, the impact of 1996 s welfare reform legislation was starting to be felt by low-income families, who were receiving services and benefits under the Medicaid Program (Gruber, 1997). Even with the SCHIP and Medicaid, there was an increase in the number of uninsured children; there were a number of factors that led to this increase. Some of those factors associated with children being uninsured are: parents losing Medicaid benefits for their children; can no longer afford insurance; have no access to employer-based health care; and/or parents earn too much income to qualify for assistance (Gruber, 1997). According to the Department of Health and Human Services (2000), between 1995 and 1997, there were 444,000 children in Florida who were uninsured, however, this was before the SCHIP legislation was enacted and the creation of the Florida KidCare Program (US HHS, 2000). According to the 2003 US Census Bureau (2003), there were an estimated 45.0 million people, or 15.6 % of the US population, who did not have any type of medical or health care insurance (US Census Bureau, 2003). There were 8.4 million children who were uninsured or have no type of medical insurance coverage (US Census Bureau, 2003). According to the Kaiser Foundation in 2003, there were 9,134,360 persons (12%) of the U.S. population under the age of 18 that were uninsured compared to 646,390 (16%) of Florida s population under the age of 18 was uninsured (Kaiser, 2005). Florida s uninsured population is significantly above the national average.

10 Florida KidCare Program Page 10 Title XIX of the Social Security Act allows individual states to determine if they wanted to provide SCHIP as part of their statewide Medicaid program or have it placed as a separate entity or expand their a stand-alone entity if already in place (US Census, 2003). Florida chose to make their SCHIP program a stand-alone entity known as the Florida KidCare Program along with expanding their current Medicaid Program (AHCA, 2004). The KidCare Program is a program that provides health insurance coverage to low-income children who do not have access to health care coverage, or that their parents cannot afford the health care coverage through their employer; and/ or on their own (AHCA, 2004). Florida actually has a combination program between Medicaid and SCHIP, thus meaning, children who apply to the KidCare Program and are determined to eligible for Medicaid are enrolled in the Medicaid Program component of the KidCare Program (CMS, 2003). Florida s program is not considered to be part of the Medicaid Program, however, one component of the program does accept Medicaid eligible children (AHCA, 2004). The KidCare program is different from the Medicaid Program in terms of how they receive funding and how much the federal government matches the states contribution (AHCA, 2004). According to the Agency for Health Care Administration (2004), in August of 2003, there were 1, 501,373 children in the state of Florida who were enrolled in the Florida KidCare Program (AHCA, 2004). In Florida, there currently is a different eligibility criterion for the KidCare Program depending on what component of the program they are applying for (AHCA, 2004). The KidCare Program consists of four different components (AHCA, 2004). The four components of KidCare are: MediKids,

11 Florida KidCare Program Page 11 Healthy Kids, Children s Medical Services (CMS), and Medicaid for Kids (AHCA, 2004). Problem Definition Is the Florida KidCare Program an effective and efficient way to administer the state children s health insurance program to low-income children? Is the Florida KidCare Program meeting the unmet needs of low-income children in Florida in regards to access to health insurance coverage and access to services within the state? In Florida, Medicaid uses the HMO or managed care approach for their program along with the KidCare Program (AHCA, 2004). In certain ways, Florida has been at the forefront of privatization in terms of Medicaid Reform, so people, along with some key stakeholders, believe that SCHIP and the KidCare Program are some of the ways in which the state can try to regulate the cost of health care, especially in terms of utilization rates, eligibility, and services that are provided to those individuals in their programs. Importance of the Problem Disadvantaged populations have many barriers that may impact their ability to have their basic needs met. The federal and state governments have developed a variety of policies to address these barriers. One such federal policy was the implementation of the state children s health insurance program (SCHIP). SCHIP is a managed care/medicaid process that provides health insurance for low-income children who would not have access to health care coverage otherwise (AHCA, 2003). Background and Literature Review Background Information:

12 Florida KidCare Program Page 12 Medicaid The Medicaid Program was established in 1965, along with the establishment of the Medicare Program. The Medicare Program was established as a program to provide health insurance to older Americans and/or those whose were diagnosed as being permanently disabled (CMS, 2004). Meanwhile, the Medicaid Program was implemented to provide services to low income women and their children and support to the states to provide access to health care coverage and health care services to lowincome children and their mother (CMS, 2004). In 2000, more than 1.1 million children in Florida were covered under Medicaid (Families USA, 2005). Since the establishment of the Medicaid program, there have been many changes that have impacted the scope of the program and how it is administered by the states. One such change was the way the states receive their allocations from the federal government. In 2000, the United States implemented a block grant to pay for the states Medicaid Program. The block grant now allows the states to administer funds to their Medicaid Program with little administrative oversight from the federal government. Medicaid is a state and federal match partnership; in Florida the match for Medicaid is 71 cents per one dollar spent, meaning for every dollar the state pays, the federal government matches that by 71 cents (CMS, 2004). Under the Block grants for Medicaid there is a cap on how much the state can spend (CMS, 2004). There are a variety of optional programs within the Medicaid Program that have been used to increase coverage of uninsured in the U.S. such as the various waiver programs for different at-risk populations, and the use of HMO plans to provide coverage to those enrolled in Medicaid. Florida has led the way in implementing strategies to

13 Florida KidCare Program Page 13 increase the coverage and benefits provided to those residents enrolled in the program (AHCA, 2003). There have been a variety of ways that Florida has gone about controlling the costs of providing these services, such as: community based care; HMO plans to provide coverage; cost sharing the monthly premiums with the participant; HIFA (Health Insurance Flexibility and Accountability) Waivers and 1119 Waivers; establishing a sliding fee not above 5% of the participants month income for preventive care and immunizations; and limiting the criteria for the program (AHCA, 2003). The state has done an adequate job at controlling the cost of health care for uninsured children; however, there has been an increase in the cost of providing care to the elderly population in the state (AHCA, 2003). The elderly and the cost of their coverage make up most of the cost associated with the Medicaid Program in Florida (AHCA, 2003). According to two reports by the AHCA (2004), the cost for children in Florida in regards to their health care needs consumed about 17.65% of the Medicaid Budget for the state fiscal year (SFY) compared to the 30.84% of the budget that was consumed by the elderly for their health care needs (AHCA, 2004). In , Florida s Medicaid program enrollees consisted of 53.30% of the enrollees who were children compared to the 13.38% of enrollees that were elderly (AHCA, 2004). AHCA reported that the cost of long term care in Florida consumed approximately $ 3,203,302,895 during SFY , which was paid by the Medicaid Program (AHCA, 2004). State Children s Health Insurance Program The federal government enacted Title XXI of the Social Security Act of This act created the State Children s Health Insurance Program (SCHIP) (Centers for

14 Florida KidCare Program Page 14 Medicare and Medicaid Services, 2003). SCHIP was established to provide access to health care coverage to low-income children who do not qualify for the Medicaid program (Centers for Medicare and Medicaid Services, 2003). SCHIP was also established as part of the balanced budget act of 1997 (Centers for Medicare and Medicaid Services, 2003). The establishment of the state children s health insurance program can be found as part of public law. SCHIP is founded in Public Law Sub-title J (Centers for Medicare and Medicaid Services, 2003). According to the Agency for Health Care Administration, the SCHIP program was established to provide low or no-cost health insurance for children from birth to 18 who are not currently covered by any other type of health insurance (AHCA, 2004, p.1). SCHIP is open to all children who meet the eligibility criteria established by the state and those that are federally mandated. Children do not need to qualify for the Medicaid program in order to be enrolled in SCHIP. Florida KidCare Program The Florida KidCare Program was established through the passage of state legislation in The KidCare Program includes four subcomponents: MediKids, Healthy Kids, Children s Medical Services (CMS), and Medicaid for Kids (AHCA, 2004). MediKids is a Medicaid look-like a program component that covers children ages 1-4 and also covers children birth to one year old who are below 200% FPL (AHCA, 2004). Medicaid for Kids is the program component that covers children who are eligible for Medicaid and are between the ages of birth to 18 (AHCA, 2004). Medicaid covers infants up to one year old from % FPL; children one to five at or below 133% FPL; children and adolescents from 6 to 14 years old at or below 100%

15 Florida KidCare Program Page 15 FPL, and children between the ages of at or below 100% FPL (AHCA, 2004). According to AHCA (2004), The Children s Medical Services component covers children from birth to 18 who have special behavioral or physical health needs or ongoing medical conditions (AHCA, 2004, p.1). Florida Healthy Kids is the component that covers children ages 5 to 18 (AHCA, 2004). Healthy kids serves three groups of children: 1. Those children who are under 200% FPL and are Title XIX eligible; 2. Those children who are under 200% FPL and are not Title XIX eligible, and 3. Those children who are above 200% FPL, in which the parents pays the full premium for the child. The approximate average cost of a self-pay premium per child is $ 112. Program Name MediKids Healthy Kids Children s Medical Services (CMS) Eligibility 1. Children ages 1-4 who are at or below 200% FPL and 2. Children birth to one year old who are below 200% FPL 1. Those children who are under 200% FPL and are Title XIX eligible; 2. Those children who are under 200% FPL and are not Title XIX eligible, and 3. Those children who are above 200% FPL, in which the parents pays the full premium for the child. 1. Children from birth to 18 who have special behavioral or physical health needs or ongoing medical conditions Number of Enrollees June , ,370 10,138

16 Florida KidCare Program Page 16 Medicaid 1. Covers infants up to one year old from % FPL; 2. Children one to five at or below 133% FPL; 3. Children and adolescents from 6 to 14 years old at or below 100% FPL, and 4. Children between the ages of at or below 100% FPL Non- Title XIX enrollees: 22,378 (Full Self-pay) Medicaid without expansion 1,196,842 The Florida Healthy Kids Corporation administers and monitors the program s effectiveness along with enrollment statistics, with annual evaluations (AHCA, 2004). The Florida Healthy Kids Corporation is a nonprofit that was established in 1990 by the Florida Legislature to look at the needs of uninsured children in Florida and establish a program that would help serve that population (OPPAGA, 2002). The KidCare Program and the Healthy Kids Corporation were established by amendments to Florida Statute (FS), Chapter 409 (Florida, 2003). The eligibility requirements for the Florida KidCare Program were established in FS, Chapter (Florida, 2003). The KidCare Program is evaluated annually by the Office of Program Policy Analysis and Government Accountability (OPPAGA) and the Institute for Child Health Policy located at the University of Florida, these reports are published online and can also be requested by the public. Statistics Associated with the Uninsured and KidCare Program Participants: According to the US Census Bureau (2003), in 2003, an estimated 45.0 million people in the United States or 15.6 % of the US population did not have medical or health insurance (US Census Bureau, 2003). In 2003, in the United States, there were 8.4 million children who do not have any type of medical insurance coverage (US Census Bureau, 2003). According to the Kaiser Foundation in 2003, there was 9,134,360 or 12%

17 Florida KidCare Program Page 17 of the U.S. population under the age of 18 that were uninsured. In January 2004, there were over 1.5 million children enrolled in the Florida KidCare Program (AHCA, 2004). There are some very important themes that were identified in the research when looking at the data for the uninsured in the United States and Florida. Some of those themes were: above average rates of uninsured in Florida; uninsured and socioeconomic status, and the main factor associated with being uninsured. 1. Florida has an above average number of residents and children who are uninsured. A recent study conducted by the Kaiser Foundation (2005) found 646,390 children or 16% of Florida s population under the age of 18 was uninsured (Kaiser, 2005). 2. The uninsured are generally poor or near poor. The Governor s Task Force on Access to Affordable Health Insurance (2004), found 64% of Floridians who are uninsured live at or below 200% FPL (family of four is $ 37,700) (Task Force on Access to Affordable Health Insurance, 2004). 3. The main reason that Floridians lack healthcare coverage is accessibility. The Governor s Task Force on Access to Affordable Health Insurance (2004), found 55% of those Floridians that do not have insurance, state the reason is due to the lack of affordability of the insurance available, according to the Task Force on Access to Affordable Health Insurance (Task Force on Access to Affordable Health Insurance, 2004).

18 Florida KidCare Program Page 18 Literature Review A variety of studies have focused on the uninsured in the United States and in Florida. Most of the studies have used national survey data. One of the national surveys that was used is the US Census Bureau data collected through the current population studies (CPS) (US Census, 2003). The state of Florida also uses information gather through in-person and telephone surveys of the KidCare Program participants (AHCA, 2004). These surveys measure the participants and their families perceptions of the program in regards to access, accountability, cost and enrollment status of the participants in the program (AHCA, 2004). The following sources were used to support the claims and the historical background of the State Children s Health Insurance Program: articles from the JSTOR database at Florida State University; articles from the Inform database at Florida State University; information from the Kaiser foundation website; information from the Urban Institute; information from the US Department of Health and Human Services; and information from Florida s Agency for Health Care Administration. A lot of research has been conducted on the history of Medicaid and the impact that this program has on children s access to health care. Meanwhile, the Urban Institute has done most of the research on the historical impact that SCHIP has had on uninsured children in the United States. Several of the authors agree that the Medicaid Program is going to be facing a serious impact in regards to how the program is financed and how many people they will be able to serve if states continue to face severe budget cuts (Gruber, 1997; Altman, 1983; Currie & Thomas, 1995).

19 Florida KidCare Program Page 19 Some of the themes that were common among the professional and academic research was: the rising cost of Medicaid; utilization rates; benefits from Medicaid; present and future financial burdens on the states, and the burden on the current system by the populations that are currently enrolled in the program. A couple of stakeholders of the Florida KidCare Program agreed that more needs to be done to provide health care insurance coverage and access to care for children in the state who have no other means of obtaining these services and coverage. They also agreed that politics in this state have played a role in what alternatives and approaches the legislature uses to address these problems. Two of the stakeholders agreed that uninsured children are an issue, but with the current regime in the legislature and the governor s office, this issue is not a primary focus. A majority of the major stakeholders agree that the various political parities need to work together to help provide coverage to those who are still uninsured, however, there is a divide on how this should be done. Three of the five stakeholders who hold public office agree that we need to increase the number of children being served, however they would like to see the federal government increase its contribution to states instead of cutting its federal allocation for the various programs. Two stakeholders, one who currently receiving services and one who is no longer enrolled in the program, have both voiced concern over the reduction of services, enrollment periods, and the tightening of eligibility into the SCHIP and Medicaid Programs. The literature states that Medicaid and the SCHIP is very beneficial and reduces cost shifting, but nonetheless the number of uninsured is growing. Florida s KidCare Program has been an effective and efficient way to provide health care coverage to low-

20 Florida KidCare Program Page 20 income children. According to the American Public Health Association (2004), the State Children s Health Insurance Program has been successful, providing healthcare to over 5.3 million children ever enrolled in 2002 in all 50 states, the District of Columbia, and five territories (American Public Health Association, 2004, p.3). The problem still remains that the number of children who are uninsured is growing and more needs to be done to expand coverage. Education and outreach should still be a top priority no matter what option is being considered. Even an excellent plan will remain ineffective without public knowledge and full utilization. Research Methodology and Evaluative Criteria Data Collection: This research was collected from the following: previous program evaluations conducted annually on the Florida KidCare Program; Governor Jeb Bush s Task Force for Affordable Health Care Research; previously conducted reports from the Florida Office of Program Analysis and Government Accountability Office and interviews conducted with various stakeholders of the Florida KidCare Program. IDENTIFICATION, DEFINTION, AND DATA SOURCES OF EVALUATIVE CRITERIA TO BE USED IN ANALYZING POLICY OPTIONS: The Policy recommendation options were evaluated based on the following: economic feasibility, political feasibility, accessibility, potential effectiveness, and potential efficiency. Economic feasibility for this research has been determined to mean the extent to which it is affordable given the current tax structure, federal match, cost of implementation, administrative cost, and projected state revenues. Political feasibility

21 Florida KidCare Program Page 21 means the likelihood that the option would garner sufficient support in the Florida Legislature and the Governor s office to be enacted. Accessibility refers to whether or not the options allow for the greatest number of people to benefit from the option. Potential effectiveness is the extent to which additional uninsured children would receive coverage. Potential efficiency is the relative cost per child for coverage with comparable benefits. LIMITATIONS STUDY CONSTRAINTS The research has several limitations or constraints associated with this report. Some of the limitations are: time constraints; small sample of interviews with the major stakeholders of the KidCare Program; budgetary issues that could impact the program in the future along with past issues such as the creation of the waiting list; open enrollment periods which may impact the number of children who have access to services during this time period; stricter eligibility requirements which may impact the children currently enrolled in the program, knowledge of the program, and the availability of services to children in Florida who are from low income families; and finally monetary contributions being available through the state legislature to admit more children to the KidCare Program. Some changes that have occurred have been: the creation and elimination of a waiting list for the program having two month long open enrollment periods yearly, developing stricter eligibility requirements for the program, and access to services. Some future changes that may impact the program are: Medicaid Reform, revision of services that will be available, increase in cost sharing for coverage due to financial crisis within the state, and access to services.

22 Florida KidCare Program Page 22 Management Policy Options The following policy options were determined to be the best solutions to the problem of providing access to health care coverage and access to health care services for low-income children in the state of Florida: 1.) Keep the Florida KidCare Program the way it is currently, 2.) Increase the eligibility for the program to include all children, no matter their age, up to 200% of the Federal poverty line (FPL), and 3.) Ensure all children in the state of Florida have universal health care coverage provided through a sliding fee scale based on parent s ability to pay. Option 1: Current Program The KidCare Program went through some major changes in The state legislature eliminated the waitlist for the program and increased or tightened the eligibility requirements for enrollment and subsequent renewal periods. Florida also decided that it would only admit children into the program two times a year and only if money was available to do so. These changes have already started to cause problems. Some parents have complained to officials that there was too much paperwork required during the renewal period for documenting parental income. The Legislature responded by requiring only the W2 form or other forms, which demonstrate income and taxes. In recent months, the Florida Legislature had to focus its efforts on increasing the number of children being served since there was a drop in those enrolled. Since elimination of the waiting list and stricter eligibility requirements, there has been a decrease in the number of children enrolled in KidCare Program. According to the Florida KidCare Coordinating Council,

23 Florida KidCare Program Page 23 in April 2004 there were 336,689 children enrolled before the elimination of the waiting list compared to 270,717 in December 2004 (Florida KidCare Coordinating Council, 2005). The Florida Coordinating Council (2005) state that there were two main factors associated with the decrease in the number of children enrolled in KidCare were: the tighter eligibility requirements and the smaller open enrollment period (Florida KidCare Coordinating Council, 2005). Tighter eligibility requirements restricted the number of children that were eligible for the program during the renewal period and these children were not eligible for Medicaid (Florida KidCare Coordinating Council, 2005). The problem with the open enrollment period is that most parents either forgot or were not aware of the open enrollment, thus they missed the opportunity for their children to participate in the program and must now wait for the next enrollment period (Florida KidCare Coordinating Council, 2005). Four of the Stakeholders point out that the tightening in eligibility has caused some families to be dropped from the program. They recommend that the program have a continuous enrollment period; bring eligibility back to where it was; increase education and public outreach; and stop cutting services to those who are the most vulnerable. One stakeholder was concerned that capitation on the program would limit the amount of money that Florida can draw down in regards to federal dollars, thus allowing more children access to health care. A majority of the key stakeholders were worried that the changes passed during the 2004 legislative session would decrease the access to health care services, increase the number of emergency rooms visits due to lack of access to care, and increase the potential for costs to be shifted to those with insurance.

24 Florida KidCare Program Page 24 Economic Feasibility In terms of economic feasibility, this option appears to cost the least. The cost would be determined only if the legislature determines there is enough money to enroll more children in the program. One concern is that if the state does not have enough money to have an open enrollment program, there will be a greater overall cost when considering the use of emergency room services. According to Leon County (2005), at the end of September 2003, Tallahassee Memorial hospital provided $52 million in uncompensated care and to Capital Regional Medical Center provided $14 million in uncompensated care, totaling approximately $66 million in Leon County, FL alone (Leon County, 2005). If every county provides approximately $ 60 million in uncompensated care a year, Florida s 67 counties are delivering approximately $4,020,000,000 annually. Evidence has been shown through the various local governments in the state that there has been an increase in the number of people using their local emergency rooms to receive their health care, especially those who are uninsured. Elimination of the waiting list may give the illusion that all the uninsured children who are eligible for the program have applied. However, this may not be the case because the parents may not remember that it is time to apply, or the parents may not realize that they are eligible for the program. There needs to be more done to keep the public informed about the program and when the open enrollment periods are going to be. In January 2005, this writer noticed that not a lot of notice was given before the actual enrollment period began. The administrators of the program need to be aware that it takes time for families to gather the requisite information to apply to the program and also how long it takes them to receive mail from the various regions of the state, as these

25 Florida KidCare Program Page 25 factors this could also have an impact. This writer also noticed that one of the requirements during the enrollment period was to have their most recent tax forms available to prove their income; however the problem is that most people do not receive their tax forms from their employers before the end of January, and, if the parents wait, they miss the enrollment period. This can also be a problem if the parents cannot locate all their tax information from the previous or current year. More needs to be done such as allowing the parents to apply and send an approximate income level or give them till the end of February to send that information, this would help to decrease the number of people who would apply but don t have all the necessary information. Political Feasibility The political environment of Florida has changed over the last couple of years. The Republican Party has control of both chambers of legislature along with the governor s office. Although it views uninsured children as a problem in the state, according to a couple stakeholders, they are not the focus of the party. In the current political environment in Florida, this option is somewhat politically feasible. Currently in Florida, there has been an increase in the public awareness in regards to the number of children who do not have health care insurance. Child Advocacy groups, various social service agencies and organizations, hospitals, and physicians have all began to speak out about the unmeet health care needs of this population and the impact on health care costs. In 1997, the Florida Legislature passed legislation to help this population. The current legislature needs to look at the program and make the necessary requirements that would ensure that these children have access to affordable health care insurance and services. In 2004, KidCare was a hot topic because of the number of children that were

26 Florida KidCare Program Page 26 on the waiting list, however, even with the governor and the Legislature funding the program to let those approximately 90,000 children gain access to the program there is still a number of children in Florida who have no access to health care insurance. This option is slightly lower in regards to politically feasible than the expanding eligibility. Accessibility Currently residents are having a hard time accessing the KidCare Program mainly due to two overwhelming barriers: the new open enrollment periods and the tighter eligibility requirements. Under the current program administration, there are major gaps in the coverage of uninsured children in Florida. In order to increase accessibility, more public education and outreach needs to be done. If parents are aware that this program option is available to them, they are more likely to seek information about the program, thus increasing the possibility of trying to enroll their children. There are families in Florida who have uninsured children, but are not aware that the program exists and/or have been misinformed. Many families who were waiting on the list for the KidCare Program were actually eligible for Medicaid but no one bothered to inform them they were eligible and there have also been cases where families go to the local Medicaid office to apply and are told that they are not eligible and are not informed that this program exists. This might be due to the staff being overwhelmed by high caseloads and/ or not having professional staff that are aware of the community resources that are available to help serve these populations. This is the least accessible option. Option 2: Expanding the Program s Eligibility One way to serve more uninsured children in the state is to increase the eligibility to 200% of FPL. This way there is a set standard among all age groups, thus meaning

27 Florida KidCare Program Page 27 that all age groups have the same set of standards in regards to the eligibility criteria for KidCare. This will allow the state to cover more uninsured children. By doing so, the impact will be less in the long run because you are reducing the probability that families will wait till the child is really sick and then will seek help and health care services at the local emergency room. This action will have greater positive impact on all the citizens because the children in the program will have access to preventive medicine and care before it becomes more expensive issue to treat. Recent Studies have shown that when people have limited access to care and/or are uninsured they are more than likely to wait until they are really sick and/or seek medical attention at local emergency rooms (Kaiser, 2004). Economic Feasibility This option would cost more than keeping the program the way it currently is, but would cost less than universal health care. This option would increase the amount of funding needed to run the KidCare Program because more children would be eligible for the program and more administrative cost associated with their participation. However, by increasing the program, there would be more children who would be eligible for health care insurance coverage and would no longer be falling through the safety net. By increasing the eligibility requirement, the number of children enrolled in KidCare would increase, thus resulting in approximately another 100, ,000 insured children in Florida (Ullman et al, 2003). This would increase the number enrollees by a third (33%) to a half (50%)of its current number of enrollees. According to one stakeholder, the cost would be partially absorbed by an increase in monthly premiums from $15 to $20 per month. The cost of care would be given to providers providing those services.

28 Florida KidCare Program Page 28 Political Feasibility This option would probably face some resistance, but initially both parties would accept in the long run because it would cost the state less than overhauling the whole program and/or offering universal health care. Democrats would like to see universal health care for children in Florida if not for the whole nation, however, in the current political environment that type of legislation would face stiff opposition. Recently there has been an increase in pressure to make sure the government can afford the cost of adding more people to their program. During the 2005 Legislative Session, there has been an increase in the focus on the need for the KidCare program in Florida. Currently there is legislation that is moving through both chambers of the Legislature to increase the time to verify the information in the application for the program and to have a continuous open enrollment period; however, there has been no legislation that speaks to expanding the eligibility requirements for the program (Florida Senate, 2005). In the past two months, there has been an increased push towards Medicaid Reform in the state. Several of the stakeholders have voiced concern that reforming Medicaid could have a major impact on the number of uninsured children in the state. They voiced the need to reform services and the way the program is implement for other populations the Medicaid program serves. There is a political divide in how the state should implement the KidCare Program. However, some agree that more children need to be covered by the program. The argument meant is over how to serve as many children as they can while trying to control the cost. This option is the most politically feasible option at this time.

29 Florida KidCare Program Page 29 Accessibility This option would increase the number of children the program could serve. Increasing public education and outreach throughout the state would contribute to the number of children who could be enrolled in the program. If parents were aware that this program option is available to them, they are more likely to seek more information about the program, thus increasing the possibility of them trying to enroll their children in the program. Bilingual applications and caseworkers would also increase the number of children from various ethnic groups to become involved with the program. This would decrease the number of children who are currently slipping through the cracks. More children would be covered, and in the long run would end up saving the state money. By increasing the eligibility requirements to 200% FPL for all the age groups and all the program components, the program would be able to serve more children who are currently uninsured in the state. There would be fewer children that would slip through the safety net. This option has a higher accessibility rate than the current status of the program. Option 3: Universal Health Care for Florida s Children Universal Health Care for Florida s Children is an option that in the long run will have the most impact because all children would have access to health care insurance coverage and health care services no matter what their parent s level of income is. Some legislators have sponsored a bill that would provide for universal health care for children in the state; however, the cost associated with the care would be based on a sliding fee. In 1993, the focus of the federal executive branch was to pass legislation, which would

30 Florida KidCare Program Page 30 have provided universal health care to all residents in the United States, however it did not pass in either the political or public arenas (CMS, 2004). Economic Feasibility The economic impact of this alternative option is the most costly but in the long run would end up lowering the overall cost of health care by encouraging preventive care. This approach would allow all children to have health care insurance and access to care no matter what there parents income. It would be important to provide this alternative based on a sliding fee scale so that the state would not have to pay for all the costs associated with this option. In the 1990 s, Florida tried to pass universal health care for children, but did not succeed due to the prospect of funding the program though increased taxes (Freedman, S. et al, 1993). The cost associated with providing universal coverage to children in Florida was $ 1,000 per child per month (Freedman, S. et al, 1993). The example can be computed for a total that Florida would be looking at in regards to insuring all children in Florida. In January 2003, the cost would have been $1000 times 12 months times 3,646,340 children, which equals $ 43,756,080,000. Below 100% FPL, it would have cost $244,796,000, and $583,580,000 for children 100% and above the FPL, which parents would help to pay (Freedman, S. et al, 1993). This option is the least economically feasible. Political Feasibility It is important to realize that most in the Democratic Party would be behind this approach if they can control the cost associated with the program. Most in the Republican Party would go along with this option but would want to control cost, enrollment and how services are provided, especially in Florida. However, the cost of

31 Florida KidCare Program Page 31 providing such care outweighs the various political positions. This may have more of an impact on the Republican Party due to a competing interests in companies, and lack of focus on social welfare and meeting the unmet needs of the citizens within the state, especially those in oppressed populations. It is important to realize that neither party is going to promote this option because there is no support for this type of legislation currently. Currently, there is one bill in the Florida Senate that was dealing with this issue the bill has been held up in committee since March and does not look like it will make it through. Three of the key stakeholders in office have verified that there is no political support for this type of legislation at this time. This is least politically feasible option. Accessibility Universal Health care for children would allow all residents in Florida access to affordable health insurance and health care services. This option has the best accessibility rates associated with it because it would allow the most children access to the KidCare Program. However, the public education should also be implemented and increased with this option too. Recommendation for Action Policy Option Evaluative Policy Option # 1: Keep KidCare Program as it currently is Policy Option # 2: Expand KidCare Eligibility to include % Policy Option# 3: Universal Health Care for all Children in Florida Criteria FPL Economic Feasibility Political Feasibility Accessibility Total

32 Florida KidCare Program Page 32 The Recommendation for Action was evaluated using the evaluative criteria. The options were evaluated using a scale of 1 to 5, 5 being the highest, and 1 being the lowest. There was a possibility of obtaining a score of 15. Based on the analysis of data and personal face-to-face interviews with key stakeholders and from support gathered through professional literature, the best recommendation for alleviate or reduce the problem of uninsured children in Florida is to adopt policy option # 2, expanding the KidCare Program s Eligibility. This option received a score of 13 out of 15, compared to option # 1, which scored a 10 out of 15, and option # 3, which scored a 7 on the scale of 15. Conclusion In Conclusion, the recommendation that would be most politically and economically feasible while allowing for the most participation would be option # 2, which called for expanding the current eligibility of the KidCare Program to serve children from 100% of the Federal Poverty Level to 200% of the Federal Poverty Level. This option would reduce the number of children that would not have medical insurance or access to health care in Florida. There are many options available to the government to ensure that members of vulnerable populations have the necessary coverage needed be future, productive citizens. This option would allow the government to control the cost of health care in the state because they would be increasing the amount of children being served by the KidCare Program. By children being able to access health care services, they will be more likely to obtain care that is reasonably priced compared to the cost of receiving preventive care through local emergency rooms.

33 Florida KidCare Program Page 33 References AHCA, Information about the Florida KidCare Program. Retrieved from the Internet on 2/10/05 from AHCA, Enrollment Trends in Medicaid and KidCare Reports retrieved from on the Internet on 4/15/05. Altman,D., Health Care and the Poor, Annals of the American Academy of Political and Social Science, Vol.468, Health Care Policy in America (July 1983), , retrieved from Florida State University, J-STOR Database on 2/7/05 American Public Health Association, Access to Care, retrieved from the Internet on 2/28/05 from Centers for Medicare and Medicaid Services, State Children s Health Insurance Program, retrieved from the Internet on 2/10/05 from Centers for Medicare and Medicaid Services (CMS), History of Medicaid and Medicare in the United States, retrieved from the Internet on 1/27/05 at Currie, J. & Thomas, D., Medical Care for children: Public Insurance, Private Insurance, and Racial Differences in Utilization, The Journal of Human Resources, Vol.30, Number 1 (Winter1995), retrieved from Florida State University s J-STOR Database on 1/31/05 Families USA, Florida Medicaid: Medicaid Cuts are Bad Medicine, retrieved from the internet on 2/28/05 from Florida, The 2003 Florida State Statutes, retrieved from the Internet on 1/31/05 from Florida KidCare Coordinating Council, Recommendations and Update on the KidCare Program for retrieved from on April 2, Florida Senate, Information retrieved about various bills for the 2005 Legislative Session retrieved from on 4/14/05. Freedman, S., Siderits, P., Gallagher, T., & Cook, D., 1993.No New State Tax: Universal Health Coverage for Children in Florida retrieved from Florida State University s ABI/INFORM Database on 1/27/05.

34 Florida KidCare Program Page 34 Gruber, J., Policy Watch; Medicaid and Uninsured Women and Children, The Journal of Economic Perspectives, Vol.11, Number 4 (Autumn 1997), retrieved from Florida State University s J-STOR Database on 2/7/05 Leon County, Information and Presentation material on update on health care in Leon County, retrieved from the Internet on 4/14/05 from Task Force on Access to Affordable Health Insurance, Final report of Governor s Jeb Bush s Task Force on Access to Affordable Health Insurance, 2004, Tallahassee, Florida Ullman, F., Bruen, B. & Holahan, J., The State Children s Insurance Program: A Look at the Numbers, Position Paper Number 4, retrieved from the Internet on 2/7/05 from US Census Bureau, Current Population Surveys, retrieved from the Internet on 2/10/05 from

35 Florida KidCare Program Page 35 Appendix A: Stakeholder Questions for In-person Interviews

36 Florida KidCare Program Page 36 QUESTIONS ABOUT THE FLORIDA KIDCARE PROGRAM: STAKEHOLDERS PERCEPTIONS 1. Are you aware of the Florida KidCare Program? 2. Do you know if the Florida KidCare Program is a stand-alone State Children s Insurance Program (SCHIP), a partnership between Medicaid and SCHIP or a Medicaid Program? 3. Are the aware that federal legislation (in part the passing of the Social Security in 1997) established SCHIP to provide affordable health care coverage to lowincome children in the United States? 4. How many children in Florida do you think are uninsured because their parents cannot afford insurance or do not have access to employer-based health care plans? 5. Do you think that the issue of uninsured citizens in the US and in Florida is a problem? 6. Do you think that the issue of uninsured children in Florida is a problem? 7. Do you think that the number of uninsured children in Florida is growing trend? 8. Do you think that the KidCare Program has done a good job at providing healthcare insurance to income children in Florida?

37 Florida KidCare Program Page How do you think the 2004 KidCare Legislation passed by the Florida Legislature will impact children in the state? 10. If they could change the KidCare Program what would they change? 11. Do they think KidCare should be kept the way it currently is, to increase eligibility to 200% FPL for all age groups, or adopt universal health care for all children in Florida? 12. Based on the previous answer, how do you think cost, political affiliation, accessibility, and effectiveness will impact the program and its participants? 13. What is the cost associated with the program as it currently is? 14. What would it cost to include all of the programs to cover children from FPL? 15. What would it cost of to offer universal health care coverage to all children in the state? 16. Is there anything else I should know about this program?

38 Florida KidCare Program Page 38 Appendix B: Distribution of Children 18 and under by Insurance Status for

39 Florida KidCare Program Page 39 Distribution of Children 18 and Under by Insurance Status, state data , U.S Distribution of Children 18 and Under by Insurance Status, state data , U.S Click here to jump to the 50 State Comparison for this topic. FL # FL % US # US % Employer 2,178, ,048, Individual 245, ,350,910 4 Medicaid 1,060, ,842, Medicare 6, ,930 0 Uninsured 646, ,134, Total 4,138, ,597, Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on pooled March 2003 and 2004 Current Population Surveys. Total US numbers are based on March 2004 estimates.

40 Florida KidCare Program Page 40 Appendix C: U.S. and Florida Insured and Uninsured Women (Age 19 to 65) and Children (Age 0-18),

41 Florida KidCare Program Page 41 U.S. and Florida Insured and Uninsured Women (Age 19 to 65) and Children (Age 0-18), U.S. and Florida Insured and Uninsured Women (Age 19 to 65) and Children (Age 0-18), (5,6) Sources: Urban Institute and Kaiser Commission on Medicaid - Uninsured estimates based on pooled March 2000 and 2001 Current Population Surveys. atehealthfacts.kff.org : Ethnicity and Race of Florida Children is from the Agency for Health Care Administration, Florida Health Insurance Study: Volume 1 The Telephone Survey oridahealthst at.com/rga_r eports.shtml

42 Florida KidCare Program Page 42 Appendix D: Florida KidCare Enrollment Trends December 2000-February 2005

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47 Florida KidCare Program Page 47 Appendix E: Charts from Institute for Child Health Policy

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50 Florida KidCare Program Page 50 Appendix F: Information from the Florida KidCare Coordinating Council Information from the Florida KidCare Coordinating Council

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