the future of medicaid
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The Future of Medicaid. Diane Rowland, Sc.D. Executive Vice President, Henry J. Kaiser Family Foundation and Executive Director, Kaiser Commission on Medicaid and the Uninsured for National Congress on Health Reform Washington, DC September 23, 2008. Medicaid Today. - PowerPoint PPT PresentationTRANSCRIPT
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 1
The Future of Medicaid
Diane Rowland, Sc.D.Executive Vice President,
Henry J. Kaiser Family Foundationand
Executive Director, Kaiser Commission on Medicaid and the Uninsured
for
National Congress on Health ReformWashington, DC
September 23, 2008
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 2
Medicaid Today
Health Insurance Coverage
29 million children & 15 million adults in low-income families; 14 million elderly
and persons with disabilities
State Capacity for Health Coverage
43% of federal funds to states
MEDICAID
Support for Health Care System and Safety-net
16% of national spending on health services and supplies
Assistance to Medicare Beneficiaries
8.8 million aged and disabled — 21% of Medicare
beneficiaries
Long-Term Care Assistance
1 million nursing home residents; 41% of long-term
care services
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 3
IL
Percent of Nonelderly Residents Covered by Medicaid, by State, 2005-2006
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
SOURCE: Urban Institute and KCMU analysis of the March 2006 and 2007 Current Population Survey. Two-year pooled estimates for states and the US (2005-2006).
TX
FL
AL
10-12% (15 states)
13-15% (17 states)
< 10% (7 states)
US Average = 13%
NE
>15% (12 states including DC)
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 4
Medicaid’s Role for Selected Populations
Note: “Poor” is defined as living below the federal poverty level, which was $17,600 for a family of 3 in 2008. SOURCE: KCMU, KFF, and Urban Institute estimates; Birth data: NGA, MCH Update.
65%
44%
20%
51%
23%
41%
40%
27%
20%
21%
Nursing Home Residents
People Living with HIV/AIDS
People with Severe Disabilities
Medicare Beneficiaries
Births (Pregnant Women)
Low-Income Adults
Low-Income Children
All Children
Near Poor
Poor
Percent with Medicaid Coverage:
Families
Aged & Disabled
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 5
16% 17%
43%
9%13%
Total HealthServices and
Supplies
Hospital Care ProfessionalServices
Nursing HomeCare
PrescriptionDrugs
NOTE: Does not include spending on SCHIPSOURCE: A Catlin et al, “National Health Spending in 2006: A Year of Change for Prescription Drugs,” Health Affairs 27(1)14-29, January/February 2008. Based on National Health Care Expenditure Data, CMS, Office of the Actuary.
Total National
Spending(billions)
$1,966 $648 $660 $125 $217
Medicaid as a share of national health care spending:
Medicaid in the Health System, 2006
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 6
Enrollees Expenditures on benefits
Medicaid Enrollees and Expendituresby Enrollment Group, 2005
Children 18%
Elderly28%
Disabled42%
Adults 12%Children50%
Elderly10%
Disabled14%
Adults26%
Total = 59 million Total = $275 billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 7
Medicaid Payments Per Enrolleeby Acute and Long-Term Care, 2005
Children Adults Disabled Elderly
Long-Term Care
Acute Care
$1,617$2,102
$13,524
$11,839
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 8
Health Insurance Coverage of Children and Nonelderly Adults, 2006
Uninsured12%
Medicaid28%
Other Private4%
Employer56%
Uninsured20%
Medicaid11%
Other Private6%
Employer63%
Children Adults under 65
Total: 78.2 million Total: 181.8 million
Note Medicaid also includes S-CHIP, other state programs, Medicare, and military-related coverage. SOURCE: KCMU and Urban Institute estimates based on March 2007 Current Population Survey.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 9
IL
Uninsured Rates Among the Low-Income Nonelderly 2005-2006
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
SOURCE: Urban Institute and KCMU analysis of the March 2006 and March 2007 Current Population Survey. Two-year pooled estimates for states and the US (2005-2006).
TX
FL
AL
28-33% (17 states)
≥ 34% (17 states)
< 28% (17 states including DC)US Average = 33%
NE
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 10
18%
28%
17%
39%
43%
61%
26%
49%
17%
40%
17%
39%
46%
34%
44%
17%
22%
43%
Medicaid/Other Public Employer/Other Private Uninsured
Poor
Near-Poor
(<100% Poverty)
(100-199% Poverty)
Poor
Near-Poor
Poor
Near-Poor
Children
Parents
Adults without Children
NOTE: Medicaid also includes SCHIP and other state programs, Medicare and military-related coverage. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.
Medicaid’s Role for Low-Income Adults and Children, 2006
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 11
30%
92%
55%
4%
15%
4%
Poor Workers Higher Income Workers
Covered by Own orSpouse's Employer
Declined offer from Ownor Spouse's Employer
Not offered through Ownor Spouse's Employer
Access to Employer-Based Coverage by Family Income, 2005
SOURCE: Garrett B. and Clemens-Cope. Changes in Employer-Sponsored Health Insurance Coverage: 2001-2005. Kaiser Commission on Medicaid and the Uninsured report. June 2006
(Family Income <100% FPL)
(Family Income 400%+ FPL)
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 12
$2,137$3,785
$4,819
$8,825
$3,281$1,619$694$334
2000 2007 2000 2007
Employer Contribution
Worker Contribution
Average Annual Premium Costs for Covered Workers, 2000 and 2007
Note: Family coverage is defined as health coverage for a family of four. Data represents average for all types of plans.SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007.
$2,471
$6,438
$4,479
$12,106
Single Coverage Family Coverage
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 13
Children’s Eligibility for Medicaid/SCHIP by Income, January 2008
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
*The Federal Poverty Line (FPL) for a family of 3 in 2008 is $17,600 per year.**IL and NY use state funds to cover children above 200% FPL.***Since January 2008, SC, WI, and LA have implemented expansions.
TX
IL
FL
AL
< 200% FPL (9 states)
251-350% FPL (11 states including DC)
200% FPL (23 states)
201-250% FPL (8 states)U.S. Median Eligibility = 200% FPL
SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2008.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 14
Medicaid Eligibility for Working Parents by Income, January 2008
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
*The Federal Poverty Line (FPL) for a family of three in 2008 is $17,600 per year.** Maryland plans to expand eligibility for parents to 116% FPL in 2008.SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2008.
TX
IL
FL
AL
50- 99% FPL (21 states)< 50% FPL (13 states)
100-150% FPL (8 states)US Median Eligibility = 63% FPL151-275% FPL (9 states including DC)
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 15
1%4%
2%4%
12%
37%
13%
2% 2%2%4%
17%
4%7%
12%
23%
30%
17%
No UsualPlace of Care
PostponedSeeking CareDue to Cost
Needed Carebut Did Not
Get it Due toCost
Last MDContact >2Years Ago
Unmet DentalNeed
Last DentalVisit >2 Years
Ago
Employer/Other Private Medicaid/Other Public Uninsured
Children’s Access to Care, by Health Insurance Status, 2006
NOTE: MD contact includes MD or any health care professional, including time spent in a hospital. Data is for all children under age 18, except for dental visit and unmet dental need, which are for children age 2-17. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All estimates are age-adjusted.SOURCE: KCMU analysis of National Center for Health Statistics, CDC. 2007. Summary of Health Statistics for U.S. Children: NHIS, 2006.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 16
Barriers to Health Care Among Nonelderly Adults, by Insurance Status, 2006
4%
3%
6%
10%
14%
9%
11%
10%
23%
23%
26%
54%
Could Not AffordPrescription Drug
Needed Care butDid Not Get It
Postponed SeekingCare because of
Cost
No Regular Sourceof Care
Uninsured
Medicaid/Other Public
Private
NOTE: Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. SOURCE: KCMU analysis of 2006 NHIS data.
Percent of adults (age 19 – 64) reporting in past 12 months:
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 17
Medicaid Enrollees are Poorer and Sicker Than The Low-Income Privately Insured Population
61%
48%49%
16% 15%
27%
0%
25%
50%
75%
100%
Percent of Enrolled Adults:
Poor Health Conditions that limit work
Fair or Poor Health
SOURCE: Coughlin et. al, “Assessing Access to Care Under Medicaid: Evidence for the National and Thirteen States,” Health Affairs 24(4):1073-1083. Based on a 2002 NSAF analysis for Kaiser Commission on Medicaid and the Uninsured.
Medicaid Low-Income andPrivately Insured
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 18
Per Capita Spending For Medicaid Enrollees vs.Low-Income Privately-Insured
$1,752
$749
$2,253
$1,098
Medicaid
Low-Income Privately-Insured
Adults Children
SOURCE: Hadley and Holahan, “Is Health Care Spending Higher under Medicaid or Private Insurance? “ Inquiry, Winter 2003/2004.
Samples adjusted for health differences
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 19
Medicaid Financing of Safety-Net Providers
Medicare20%
State/Local Subsidies
14%
Self Pay/Other
7%
Commerical24%
Medicaid35%
Total = $29 billion
SOURCE: America’s Public Hospitals and Health Systems, 2004, National Association of Public Hospitals and Health Systems, October 2006. KCMU Analysis of 2006 UDS Data from HRSA.
Federal Grants
22%
Self Pay7%
State/Local13%
Private7%
Medicare6%
Medicaid37%
Other9%
Total = $8.1 billion
Public Hospital Net Revenues by Payer, 2004
Health Center Revenues by Payer, 2006
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 20
Medicaid as a Building Block for Health Reform
• The basis for affordable coverage for low-income families
• Key source of financing
• Serves key roles outside larger health reform including:
– Financing long-term services and supports
– Serving and managing complex populations
– Supporting safety net providers
– Emergency services for immigrants
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 21
VA
Federal Medical Assistance Percentages (FMAP), FY 2008
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
WV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
SOURCE: Federal Register, November 30, 3006 (Vol. 71, No. 230) pp. 69208-69211, at http://aspe.hhs.gov/health/fmap08.htm
TX
IL
FL
AL
71+ percent (6 states)
50 percent (13 states)
62 to <71 percent (16 states including DC)
51 to <61 percent (16 states)
VA
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 22
The Nonelderly Uninsured,by Age and Income Groups, 2006
Other Children6%
Low-IncomeParents
17%
Low-IncomeAdults without
Children34%
Low-IncomeChildren
14%
Other Parents8%
Total = 46.5 million uninsured
Low-income includes those with family incomes less than 200% FPL.SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.
Other Adultswithout Children
21%
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 23
States Moving Forward with Initiatives to Address the Uninsured
42
3438
States with Plans to ExpandCoverage
States Using Medicaid toSupport Financing
States Using Medicaid toSupport Enrollment
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2007.
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 24
Use of Medicaid to Expand Coverage
• Reach eligible, but not enrolled children
• Raise eligibility levels for parents
• Expand waivers or allow coverage for childless adults
• Provide premium subsidies for low-income workers that are financed with Medicaid funds
• Help finance safety net services / community-based care
• Provide broad-based coverage for people with disabilities
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 25
Challenges facing Medicaid within Broader Health Care System
• Financing– Federal deficit estimated at $482 billion for FY 2009
– State fiscal capacity (over half states face budget shortfall in FY 2009)
• Health care costs
– Health care spending growing about 2.5 percentage points faster than GDP
• Physician supply
– DHHS 2006 report projected shortfall of approximately 55,000 physicians in 2020
• Technology– Needed federal support in adoption of health IT
• Quality of care
– Geographic variation in treatment patterns