medicaid overview - council of state governments
TRANSCRIPT
Medicaid Overview
Robin Rudowitz, Associate Director, Kaiser Commission on Medicaid and the Uninsured
The Henry J. Kaiser Family Foundation
Council of State Governments / Medicaid Leadership Policy Academy
Washington, DC
September 21, 2016
Figure 1
Medicaid’s Origins
Mandatory services and populations for participating
states with options for broader coverage
Means-tested, with focus on welfare population: -single parents with dependent children -aged, blind, and disabled
Federal State
Entitlement
• Enacted in 1965 as title XIX of the Social Security Act • Means-tested; originally focused on the public assistance population
Eligible Individuals are entitled to a defined set
of benefits
States are entitled to federal matching
funds
Sets core requirements on
eligibility and benefits
Flexibility to administer the program within
federal guidelines partnership
Figure 2
Medicaid plays a central role in our health care system.
Health Insurance Coverage
State Capacity for Health Coverage
MEDICAID
Support for Health Care System and Safety-Net
Assistance to Medicare Beneficiaries
Long-Term Care Assistance
Figure 3
Children 48%
Children 21%
Adults 27%
Adults 15%
Elderly 9%
Elderly 21%
Disabled 15%
Disabled 42%
EnrolleesTotal = 68.0 Million
ExpendituresTotal = $397.6 Billion
SOURCE: KCMU/Urban Institute estimates based on data from FY 2011 MSIS and CMS-64. MSIS FY 2010 data were used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT, but adjusted to 2011 CMS-64.
Medicaid spending is mostly for the elderly and people with disabilities.
Figure 4
97%*
84%
14%
87%*
71%
27%
98%
85%
15%
90%
71%
26%
75%*
56%*
7%*
47%*
37%*
8%*
Usual Sourceof Care
Well-ChildCheckup
SpecialistVisit
Usual Sourceof Care
General DoctorVisit
SpecialistVisit
Medicaid ESI Uninsured
NOTES: Access measures reflect experience in past 12 months. Respondents who said usual source of care was the emergency room are not counted as having a usual source of care. *Difference from ESI is statistically significant (p<.05) SOURCE: KCMU analysis of 2014 NHIS data.
Medicaid and private insurance provide similar access to care – the uninsured fare far less well.
Children Nonelderly Adults
Figure 5
NOTE: FMAP percentages are rounded to the nearest tenth of a percentage point. These FMAPs reflect the state’s regular FMAP in effect Oct. 1, 2016-Sept. 30, 2017; they do not reflect the 100% FMAP for persons newly eligible in states that adopted the ACA Medicaid expansion. SOURCE: The Kaiser Family Foundation State Health Facts. Data Source: 80 Fed. Reg. 73779 – 73782 (Nov. 5, 2015) accessed September 8, 2016, http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/.
Medicaid costs are shared by the states and the federal government based on each state’s federal matching rate.
WA
OR
WY
UT
TX
SD
OK
ND
NM
NV NE
MT
LA
KS
ID
HI
CO
CA
AR AZ
AK
WI
WV VA
TN SC
OH
NC MO
MS
MN
MI
KY
IA
IN IL
GA
FL
AL
VT
PA
NY
NJ
NH
MA
ME
DC
CT
DE
RI
MD
50.1-59.9 percent (12 states)
50 percent (14 states)
60.0-66.9 percent (13 states)
67.0-74.2 percent (12 states, including DC)
FFY 2017 FMAP
Figure 6
25.6% 18.4%
50.4%
19.8% 35.4%
9.8%
54.5% 46.2% 39.8%
Total State Spending$1.74 Trillion
State General Funds$705.7 Billion
Federal Funds$529.9 Billion
Medicaid Elementary & Secondary Education Other
SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on the NASBO’s November 2015 State Expenditure Report (data for Actual FY 2014.)
Medicaid is a budget item and a revenue item in state budgets.
Figure 7
4.7%
6.8%
8.7%
10.4%
12.7%
8.5% 7.7%
6.4%
1.3%
3.8%
5.8% 7.6%
6.6%
9.7%
-4.0%
6.9%
9.6%
13.9%
6.9%
-1.9%
0.4%
3.2%
7.5%
9.3%
5.6% 4.3%
3.2%
0.2% -0.5%
3.1%
7.8% 7.2%
4.8%
2.3%
1.5%
8.3%
13.8%
4.0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016Proj.
Medicaid Total Spending Medicaid EnrollmentAnnual Percentage Changes, 1998 - 2016
NOTE: Percentage changes from June to June of each year. Data for FY 2016 are projections based on enacted budgets. SOURCE: Historic Medicaid enrollment growth rates are as reported in Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. Historic Medicaid spending growth rates are derived from KCMU Analysis of CMS Form 64 Data. FY 2014-2016 data are derived from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015.
Economic conditions and policy changes drive growth in Medicaid enrollment and total spending.
Figure 8
NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,424 for an individual and $27,724 for a family of three in 2015.
The ACA Medicaid expansion fills historic gaps in coverage.
Figure 9
All states were required to modernize Medicaid application and enrollment processes.
ACA Vision PAST
Real-time determination
Data Hub
$
#
Dear __, You are eligible for…
Apply in person Multiple options to apply
Provide paper documentation
Electronic verification
Wait for eligibility determination
Medicaid CHIP
Marketplace
No Wrong Door to Coverage
Figure 10
NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, IA, IN, MI, MT, and NH have approved Section 1115 waivers. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated July 7, 2016. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
32 states (including DC) had adopted the ACA Medicaid Expansion as of September 2016.
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT*
MO
MS
MN
MI*
MA
MD
ME
LA
KY KS
IA*
IN* IL
ID
HI
GA
FL
DC
DE
CT
CO
CA
AR* AZ
AK
AL
Adopted (32 States including DC)
Not Adopting At This Time (19 States)
Figure 11
297%
213%
138% 138%
214% 199%
44%
0%
Children Pregnant Women Parents Childless Adults
Adopted the Medicaid Expansion (32 states) Not Adopting the Expansion at this Time (19 states)
NOTE: These medians are based on Medicaid expansion decisions made by January 28, 2016, including Louisiana's decision to expand. Eligibility levels are based on 2015 federal poverty levels (FPLs) for a family of three for children, pregnant women, and parents, and for an individual for childless adults. In 2015,the FPL was $20,090 for a family of three and $11,770 for an individual. Thresholds include the standard five percentage point of the federal poverty level (FPL) disregard. SOURCE: Based on results from a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2016.
Median Medicaid/CHIP Income Eligibility Thresholds, January 2016
($59,667)
($42,791)
($27,724)
($8,839)
($16,242)
($0)
($42,992) ($39,979)
Figure 12
NOTES: Numbers may not sum to subtotals or 100% due to rounding. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. SOURCE: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.
About half of the remaining uninsured are eligible for financial assistance but not enrolled in coverage.
Medicaid Eligible Adult 18%
Medicaid/CHIP Eligible Child
10%
Tax Credit Eligible 22%
In the Coverage Gap
9%
Ineligible for Coverage Due to
Immigration Status 15%
Ineligible for Financial Assistance
due to ESI Offer 15%
Ineligible for Financial Assistance
due to Income 12%
Total = 32.3 Million Nonelderly Uninsured
Eligible for Financial
Assistance 49%
Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015
Figure 13
Work Status of Adults in the Coverage Gap
No worker 38%
Part-time worker
21%
Full-time worker
41%
Notes: Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.
48% 55%
6%
14%
46% 17%
8%
6%
Most people left without coverage options are in working families.
Family work status :
Total = 2.9 Million in the Coverage Gap
Firm size and industry among those working:
<50 employees
50-99 employees
100+ employees
Agriculture/ Service
Education/ Health
Professional/ Public Admin
Manufacturing/Infrastructure
Other
Total = 1.5 Million Workers in the Coverage Gap
Figure 14
Studies point to positive results from the Medicaid expansion.
+ State Economic Activity
+ Provider Revenue + Access to Care
- Uninsured
- Uncompensated Care Costs - State-funded health
programs (e.g. Corrections)
State Savings
Federal + State Funds
+
- Jobs and Revenues
SOURCES: The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review, KCMU, June 2016;
Figure 15
SOURCE: Medicaid Managed Care Enrollment and Program Characteristics, CMS, Spring 2016. Data as of July 1, 2014.
Over half of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs.
WY
WI
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA
OR
OK
OH
ND
NC
NY
NM
NJ
NH
NV NE
MT
MO
MS
MN
MI
MA
MD
ME
LA
KY KS
IA
IN IL
ID
HI
GA
FL
DC
DE
CT
CO
CA
AR AZ
AK
AL
U.S. Overall = 61% 26-50% (5 states) 51-75% (13 states, including DC)
76-100% (16 states)
0% (11 states)
1-25% (6 states)
As of July 1, 2014
Figure 16
13
21
27
46
13
19
28
46
Managed CareExpansions to New
Groups
Managed Care QualityInitiatives
Emerging Delivery SystemInitiatives
HCBS Expansions
FY 2015 FY 2016
NOTE: Managed Care Expansions to New Groups refers to expansions to new groups, new regions, increasing the use of mandatory enrollment, and new RBMC programs. Other Delivery System Initiatives include new or expanded initiatives related to PCMH, Health Homes, ACOs, Episodes of Care, DSRIP and initiatives focused on dual eligible beneficiaries. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015.
Medicaid programs continue to add and expand payment and delivery system reforms in FYs 2015 and 2016.
Figure 17
States are using an array of Medicaid delivery system models.
Kentucky
Medicaid Managed Care
(Behavioral health and dental integrated)
Washington
Medicaid Managed Care
Separate Behavioral Health Organizations, plan to integrate statewide by 2020
Accountable Communities of Health (ACH) Waiver - focus on social determinants
Dental Fee-for-service
Colorado
Accountable Care Collaboratives (ACC) with Regional Care Collaborative
Organizations (RCCOs)
Separate Behavioral Health Organizations, plan to integrate RCCOs and BHOs to Regional Accountable Entities (RAEs)
New Dental Benefit – Cap $1000
Connecticut
Managed Fee-for-Service through Administrative Services Organizations
Intensive Care Management (ICM)
Behavioral Health Homes
Dental ASO Contracts
Figure 18
Medicaid Priorities
ACA Implementation
Cost Control Payment and
Delivery System Reform
Systems and Administration
Population Health and
Social Determinants
of Health
Medicaid directors reported many key priorities.
Figure 19
Source: Faces of Medicaid. http://kff.org/medicaid/video/faces-of-medicaid/
There are many “Faces of Medicaid”.
Figure 20
For more information on the Medicaid program and health reform, visit…
www.kff.org