Public
Policy Center > Community
Program > Mini-Policy
Forum Briefs
Children without
Health Insurance in Hawaii
Health Insurance and Children
in Hawai'i: November
12, 2003 Health Policy Forum
Of the estimated 27,000
children in Hawai'i who are currently without health insurance,
approximately 14,000 are eligible for free medical assistance
through the public health insurance program QUEST, according
to the University of Hawai'i Social Science Research Institute.
If income eligibility levels were raised to 300% of
the Federal Poverty Level (FPL), an additional 2,500 children
could be covered. The Honolulu Advertiser reported
on October 29, 2003, ã120,000 people in Hawai'i do not have
health insurance, and about 22% are children despite the July
2000 expansion of Med-Quest.ä It was with these figures
in mind that a panel of health insurance experts from the
public and private sectors were gathered to discuss the issue
of uninsured children in Hawai'i, and what can be done to
remedy the current health insurance crisis that thousands
of children currently face.
Panel participants:
Pearl Tsuji - QUEST
Paul Tom ö private
sector
Frank Chong ö Senior
Health Policy Consultant, Aloha Care
James Chen ö Waianae
Comprehensive Health Center
Panel participants
were given the following questions to concentrate on during
their address:
Private sector:
- How do
employers provide for employees' children?
- Do employers
encourage employees to provide for their children?
- Are parents
saving money by not paying the premium to add children
as dependents?
- Should
there be legislation that mandates employers to cover employees'
children and forces employees to enroll in
the program?
Public/Government-sponsored
Insurance
- S-CHIP/Med-Quest/Medicaid
- Eligibility
- Funding
- Program
Administration
- Is there
a safety net?
- Community
Health Centers
How can
we get more children insured in Hawai'i?
- Barriers
to Remove
- Strategies
What have we
learned as possible policy success stories or strategies
to help shape future efforts to get all children insured?
The
opening speaker, Pearl Tsuji ,
works for DHS ,
Med-QUEST in
the Kapolei area, and is the public sector representative
at the forum. She spoke
on the topics of Medicaid, S-Chip, and Quest eligibility
and
program information. Medicaid:
Speaker Tsuji stated
that Medicaid is a joint program between the state and the
federal government, which is responsible for children/families/individuals
who are eligible for Medicaid backing. Medicaid falls
under Federal Title XIX, and receives $.58 back from the federal
government for each $1 the state pays.
Medicaid
Eligibility:
185% of the FPL is
used to determine Medicaid eligibility for children under
1 year old. For children between 1-5 years (inclusive),
133% of the FPL is used to determine eligibility. For
children between 5-18 years old (inclusive), 100% of the
FPL
is used to determine eligibility. Medicaid is used as
a ãpayer of last resort.ä Speaker Tsuji noted that
children can be insured and still qualify for Medicaid
coverage under the appropriate eligibility guidelines.
S-CHIP:
(State Children's Health
Insurance Program) is Title XXI under the federal government.
Speaker Tsuji said that (they) don't promote the program
as a separate program, rather it is promoted as medical
assistance
to enhance funding opportunities. For S-CHIP the state
receives $.71 back from the government on every $1 the state
spends.
S-CHIP Eligibility:
Incomes
levels cannot exceed 200% of the FPL. S-CHIP does not
cover those who are already insured elsewhere.
Speaker Tsuji
also added that all Federal programs are mandated by the
same
basic criteria:
- Need
to be a resident of Hawai'i
- Need
to have entered the U.S. on or before August
22, 1996
- OR in the U.S. for at least five years
- Must apply for Social Security #
Finally
(to reiterate), Federal Programs DO look at income, however,
there are no asset tests.
QUEST :
Quest
is a state funded medical assistance program for children,
designed specifically for those children who do not qualify
for other programs (for those who are not aged, blind, or
disabled). Hawai'i uses a special Federal exemption
to have this sort of program. A significant aspect
of this program, however, is that individual people with Employer
Covered Health Insurance are NOT eligible for QUEST although
their children and other family members are still eligible
for coverage (unless they are already covered under private
health insurance). Eligibility does have income requirements,
which must be below 185%, 133%, and 100% (depending on age)
of FPL although assets are not included. The application
date determines when a case is approved for the program÷applications
must be signed and received, paper work information must
be
integrated
Currently
there is a waitlist for adults trying to get into the QUEST
program. The cap for adults is 125,000, who are not
aged or blind but there is no wait (no limit) for children.
Paul
Tom, of Benefits Plan Consultants Hawai'i, Inc. (BPCH)
represented
the private sector in the Health Insurance Forum. He
spoke on the Health Insurance Pre-Paid Health Care Act of
1974 criteria.
Public
and Private Sectors:
Speaker
Tom began by stating that whatever was not covered by the
public sector is ultimately covered through or by the private
sector. In addition, he stated that current health costs
are
driven by state and federal taxation.
According
to Tom, there are currently two types of private insurances
available:
- First Class: Employer sponsored
insurance is offered as a benefit through employment;
the larger
group
they employ, the smaller the cost to the employer
- Second Class: Individual
purchased insurance through an insurance company
Health
Insurance Pre-Paid Health Care Act of 1974:
After
1974, employers no longer had the option to offer health
insurance to employees. Hawai'i is the only state with pre-paid
health
care law. The law states that all employers working more
than 20 hours per week for four or more consecutive weeks
must
have health insurance either with the employer or with another
carrier. This is not a voluntary option for the employer
or the employee. The law states that employers must
pay the bulk of the insurance premiums: 1.5% of an
employees wage can be used towards the cost, but it cannot
exceed 50% of the healthcare premium. Employers may
choose to offer two different plans or a combination thereof:
Section 7-A:
- This
plan is based on whichever HMO plan currently
has the highest enrollment in Hawai'i.
This plan is considered the ãgold-standardä plan.
This is an innovative idea because the
population decides on the plan, not a committee,
board, or congress.
- Preferred
Provider Plan tends to be the most used
in Hawai'i. (e.g.
Kaiser Plan: $10 co-payment, 100% for
x-rays/labs and hospital costs)
- If
an employer offers this plan, they are NOT mandated
to provide coverage for dependents, however.
- In Hawai'i,
95% of employers have 20 employees or less. A ãlargeä business
is considered 1,000 employees or more (e.g. Hawaiian
Airlines, Kaiser
Permanente, etc.
Section
7-B:
- The ãfloor plan,ä offering
to lowest benefits
- Law
requires that if an employer offers this plan
they must offer it to dependents and the employer will
pay at
least
50% of the dependent cost.
- Larger
employers tend to prefer this plan
- E.g. $200
deductible, 80/20 benefit, $2,000/year out-of-packet
Employees
can sponsor more than one plan or a combination of plans,
however the employer only has to pay at the lower costing
plan if they sponsor more than one plan.
Eligibility:
- Employee
must be working 20 or more hours per week, for four
or more consecutive weeks
- Is
spouse is working and another plan is offered by
his or her employer, s/he must accept that coverage and
are
considered
ineligible for dependent coverage under spouse's insurance.
- This
law does not cover contractors or people who are self-employed.
- This
law applies to private sector business, but does
not cover federal, state, or county employees.
(This
purportedly saves the government money by not have to use
taxpayer money to pay for health insurance premiums).
Rev.
Frank Chong is a senior health policy consultant with AlohaCare.
He is former Executive Director of the Waikiki Community
Health Center and has been active in health and human services
in the Honolulu area since the early 1980s. He discussed
the history of the health care/health insurance system in
Hawai'i and what issues individuals and community health
centers
face.
Speaker
Chong opened his remarks with a brief history of Health Care
system in Hawai'i:
- Missionaries
arrived in 1820's
- First
plantations were established in the 1830's. Plantation
owners saw a need to ensure and maintain the health
of the
workers by providing some sort of health care.
- Most
plantations had infirmaries, while some hired
salaried physicians.
- Department
of Health dates back to the Kingdom: around
1830's-1840's Hawai'i already had
a very sophisticated health
care system
- This
system was in place until about 1940, when advanced
in organized labor prompted a shift from health care to
health
insurance.
- Many/most
infirmaries disappeared as the plantations closed
down
- Most
Oahu hospitals have a particular ethnic base
which is very unique
- Between
1920-1974 there were rapid changes in Hawai'i's
health care system
- Following
WWII, the hospital, technology and medicine industries
exploded
- 1974: Health
care policy enacted to recognize that employers
have a responsibility to contribute to the health
of their workers.
Recent/Current
issues:
- Uninsured - Ten
years ago in Hawai'i the number of uninsured was about
5% of the populations. Today,
it is about 10% and rising.
- Costs
of health care and insurance are rapidly rising.
- President
Clinton initiated an unsuccessful push toward health
care reform by attempting to implement a national
health care
system. Now that our nation is in a health care
crisis, perhaps these efforts will gain greater acceptance.
At
Waikiki Community Health Center, a number of policy issues
and question arose:
- Is
insurance the best way to cover the uninsured 10% who
fall through the cracks?
- Medicaid
works well for those who are very poor and meet
the eligibility requirements,..
- How
far can the government go to taking care of
otherwise unqualified people (e.g. charity care)?
- Community
Health Centers are designed to meet the needs
of uninsured/underinsured populations, but
how can we maintain them economically and
support them legislatively?
Speaker
Chong noted that about half of our state's 100,000 uninsured
could conceivably qualify for one of the existing programs
if they knew about them and applied.
James
Chen has been involved with the Waianae Coast Comprehensive
Health Center for the past 12 years as their chief financial
officer. Speaker Chen discussed ãsafety net providersä (community
health centers), changes in Medicaid policy, and discrepancies
between service - application - children.
In
1994, a Demonstration project moved Medicaid from a ãfee for
serviceä system to a managed care system, whereby the state
pays a certain amount per patient, per month. This
amount often does not cover the real costs of health care.
Prior to 1994, ãsafety net providersä would receive
federal reimbursement. After the 1994 Demonstration
project, an unintended consequence developed that some people
now have had to switch to private providers and the community
health centers have taken a financial hit.
Effects
of Medicaid Policy
The
changes in policy regarding Medicaid ultimately effects community
health centers:
- Providing
services to Medicaid population is very costly
- Grant money,
as well as federal, state, and private money, is now
going toward
the coverage of Medicaid services·another
unintended consequence of recent legislation.
- The
unintended consequences are eroding the ability of
community health centers to provide services.
- New immigrants must wait five years to receive any
Medicaid services ö so, they are forced to seek health
care from community health centers, public hospitals
and emergency
rooms.
- Since
Medicaid doesn't cover the full spectrum of services,
community health centers are negatively impacted financially,
in providing these services.
Side
notes:
- Changes in employer-based
contributions won't improve the situation for the uninsured/underinsured÷the majority of these
folks aren't working. Therefore, they too, depend
on safety net providers for health care.
- Each
community health center serves it's own distinct
geographical community.
- Most
community health centers offer sliding scale fees.
Speaker
Chen notes that 50% of the children treated at Waianae
Community
Health Center are uninsured, and this should not be the case. All children should be covered under at least one of
the state's programs, but they must apply first. Unfortunately,
the application process often interferes with the retroactive
case reimbursement that supposedly applies
to the date of the application, not the approval date.).
Finally,
Speakers Chong and Chen challenge us as community members
to:
- Think
creatively
- Think
ahead. What will the intended consequences
be of a given policy or procedure?
- What
are our priorities? Do we really want everyone
insured, or do we want better health care for all?
- What
about holistic health: mental health, social
health, and physical health?
- Look outside your regular frame of reference ÷what do other
countries do? How have they handled Health Care issues
and policy? National Health Care?
- In
terms of policy, THNK OUTSIDE THE BOX !
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