The Medicaid Landscape

Transcription

1 The Medicaid Landscape Robin Rudowitz Associate Director, Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation Council of State Governments Washington, DC June 18, 2014

2 Figure 1 Medicaid Basics

3 Figure 2 Medicaid is an integral part of the health system. Health Coverage Health Spending Employer- Sponsored Insurance 49% Uninsured 16% Medicaid 16% Medicare 13% Total = million Other Public 1% Private Non-Group 5% NOTE: Health spending total does not include administrative spending. SOURCE: Health insurance coverage: KCMU/Urban Institute analysis of 2011 data from 2012 ASEC Supplement to the CPS. Health expenditures: KFF calculations using 2011 NHE data from CMS, Office of the Actuary Private Health Insurance 35% Consumer Out-of- Pocket 13% Other Private Funds 8% Medicaid 16% Medicare 24% Total = $2.3 trillion Other Government Programs 4%

4 Figure 3 Medicaid has many roles in our health care system. Health Insurance Coverage 32 million children & 18 million adults in low-income families; 16 million elderly and persons with disabilities Assistance to Medicare Beneficiaries 9.6 million aged and disabled 20% of Medicare beneficiaries Long-Term Care Assistance 1.6 million institutional residents; 2.9 million community-based residents MEDICAID Support for Health Care System and Safety-net 16% of national health spending; 40% of long-term care spending State Capacity for Health Coverage For FY 2014, FMAPs range from %

5 Figure 4 Medicaid plays a critical role for selected populations. Percent with Medicaid Coverage Nonelderly Below 100% FPL Nonelderly Between 100% and 199% FPL Families All Children Children Below 100% FPL Parents Below 100% FPL Births (Pregnant Women) Elderly and People with Disabilities Medicare Beneficiaries Nonelderly Adults with Functional Limits People with HIV in Regular Care Nursing Home Residents 45% 27% 36% 40% 46% 0% 20% 16% 50% 63% 71% NOTE: FPL-- Federal Poverty Level. The FPL was $23,050 for a family of four in SOURCE: Kaiser Commission on Medicaid and the Uninsured (KCMU) and Urban Institute analysis of 2012 ASEC Supplement to the CPS; Birth data from Maternal and Child Health Update, National Governors Association, 2012; Medicare data from MCBS Cost and Use file, 2009; Functional Limitations from KCMU Analysis of 2012 NHIS data; Nursing Home Residents from 2011 OSCAR data.

6 Figure 5 The majority of Medicaid expenditures are for acute care. DSH 4.1% Long-Term Care 29.5% Mental Health 0.8% ICF/MR 3.3% Home Health and Personal Care 13.3% Nursing Facilities 12.1% Inpatient 13.4% Other Acute 9.6% Physician, Lab & X-ray 3.2% Outpatient/Clinic 6.3% Drugs 2.1% Acute Care 66.3% Payments to Medicare 3.5% Payments to MCOs 28.3% FY 2012 Total = $ billion NOTE: Excludes administrative spending, adjustments and payments to the territories. SOURCE: Urban Institute estimates based on FY 2012 data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured.

7 Figure 6 Medicaid spending is mostly for the elderly and people with disabilities. Disabled 15% Elderly 9% Disabled 42% Adults 27% Elderly 22% Children 49% Adults 15% Children 21% Enrollees Total = 66.4 Million Expenditures Total = $369.3 Billion SOURCE: KCMU/Urban Institute estimates based on data from FY 2010 MSIS and CMS-64. MSIS FY 2009 data were used for CO, ID, MO, NC, and WV, but adjusted to 2009 CMS-64.

8 Figure 7 Federal and state governments share Medicaid costs. AK CA OR WA NV ID Federal Medicaid Matching Rates, FFY 2014 AZ HI UT MT WY NOTE: FMAP percentages are rounded to the nearest tenth of a percentage point. These rates are in effect Oct. 1, 2013-Sept. 30, SOURCE: Federal Register, November 30, 2012 (Vol. 77, No. 231), pp , at NM CO ND SD NE KS TX OK MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV VA GA FFY 2014 FMAP PA SC NC FL VT NY ME NH MA RI CT NJ DE MD DC 50 percent (15 states) percent (12 states) percent (13 states) percent (11 states, including DC)

9 Figure 8 Medicaid is a budget item and a revenue item in state budgets. Medicaid Elementary & Secondary Education Other 56.4% 46.6% 45.0% 10.8% 19.9% 35.3% 44.2% 23.7% 18.1% Total State Spending $1.64 Trillion State General Funds $654.8 Billion Federal Funds $526.2 Billion SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on the NASBO s November 2013 State Expenditure Report (data for Actual FY 2012.)

10 Figure 9 Medicaid spending growth is primarily driven by changes in enrollment. 12.7% Spending Growth Enrollment Growth 10.4% 10.3% 9.3% 9.7% 8.7% 8.5% 8.8% 7.7% 7.8% 6.8% 7.2% 7.5% 6.4% 5.8% 7.6% 4.7% 6.6% 5.6% 3.8% 3.8% 3.2% 3.2% 4.3% 3.1% 4.4% 3.2% 1.3% 2.5% 0.4% 1.0% -1.9% 0.2% -0.5% Adopted NOTE: Enrollment percentage changes from June to June of each year. Spending growth percentages in state fiscal year. SOURCE: Medicaid Enrollment June 2012 Data Snapshot, KCMU, August Spending Data from KCMU Analysis of CMS Form 64 Data for Historic Medicaid Growth Rates. FY data based on KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2013.

11 Figure 10 Most beneficiaries receive care through some type of managed care arrangement. AK WA OR NV CA MT ND ID SD WY NE UT CO KS AZ NM OK TX HI U.S. Overall = 66.0% VT ME NH MN WI NY MA MI CT RI PA IA NJ OH DE IL IN MD WV VA MO KY DC NC TN AR SC MS AL GA LA FL 0% - 50% (10 states) 51% - 65% (16 states) 66% - 80% (20 states and DC) 80%+ (4 states) NOTE: Includes enrollment in HIO, Commercial MCO, Medicaid-only MCO, and PCCM. SOURCE: CMS Medicaid Managed Care Enrollment Report, July 2011.

12 Figure 11 Two-thirds of all states are expanding or focusing quality for Medicaid managed care Adopted Number of States Any of these Changes Expanded Service Areas Added Eligibility Groups Added Mandatory Enrollment Managed Long Term Care NOTE: States were asked to report new initiatives or expansions in these areas; this does not reflect ongoing state efforts in these areas. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2012 and September Other Managed Care Changes Quality Initiatives or Major Contract Changes

13 Figure 12 The majority of states are implementing new or expanding care coordination initiatives. 33 FY 2013 Adopted for FY Any Care Coordination Initiatives Health Homes PCMH ACOs Quality Initiatives 1 Other Care Coordination Initiatives NOTES: States reported new initiatives in these areas ; this does not reflect ongoing state efforts in these areas. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2013.

14 Figure 13 Medicaid and the Affordable Care Act

15 Figure 14 The goal of the ACA is to make coverage more available, more reliable, and more affordable. Universal Coverage Medicaid Coverage For Low-Income Individuals Individual Mandate Exchanges With Subsidies For Moderate Income Individuals Health Insurance Market Reforms Employer-Sponsored Coverage

16 Figure 15 The ACA builds on the traditional Medicaid program. Health Insurance Coverage for Certain Individuals Shared Financing States and Federal Govt. Assistance for Duals / Long-Term Care Minimum Floor for Health Insurance Coverage Up to 138% FPL Additional Federal Financing for Coverage New and Expanded Options HCBS for Long-Term Care / Coordination for Duals Support for Health Care System Delivery System Reforms NOTE: HCBS refers to home and community-based services.

17 Figure 16 The ACA Medicaid expansion fills current gaps in coverage. Medicaid Eligibility Today Limited to Specific Low-Income Groups Medicaid Eligibility in 2014 Extends to Adults 138% FPL* Elderly & Persons with Disabilities Extends to Adults 138% FPL* Pregnant Women Children Parents Adults *138% FPL = $15,856 for an individual and $26,951 for a family of three in 2013.

18 Figure 17 The ACA modernizes the Medicaid application and enrollment experience in all states. PAST Apply in person Multiple options to apply ACA Vision No Wrong Door to Coverage Provide paper documentation Electronic verification $ Data Hub # Medicaid CHIP Marketplace Wait for eligibility determination Real-time determination Dear, You are eligible for

19 Figure 18 The Medicaid expansion has coverage and fiscal implications for states. Reduction in the Number of Uninsured + Federal + State Funds Increased Provider Revenue Increased State Savings Uncompensated Care Costs State-funded health programs (e.g. Mental health) Increased State Economic Activity Jobs and Revenues

20 Figure 19 Current Status of State Medicaid Expansion Decisions, 2014 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI* IA* IL MO AR* MS MI* OH IN* KY TN AL VT NY PA* WV VA NC SC GA ME NH* MA CT RI NJ DE MD DC AK HI TX LA FL NOTES: Data as of June 10, *Medicaid expansion waivers: AR and IA have approved waivers; MI implemented through a waiver in Apr. 2014; NH passed legislation to implement in July 2014; IN and PA have pending waivers for Medicaid expansions. WI amended its Medicaid state plan and existing waiver to cover adults up to 100% FPL, but did not adopt the expansion. SOURCES: States implementing in 2014 and not moving forward at this time are based on data from CMS here. Open Debate based on KCMU analysis of current state activity related to the Medicaid expansion. Implementing Expansion in 2014 (27 States including DC) Open Debate (3 States) Not Moving Forward at this Time (21 States)

21 Figure 20 In states that do not expand Medicaid under the ACA, there will be large gaps in coverage available for adults. 0% FPL Childless Adults 47% FPL Parents Median Medicaid Eligibility Limits as of Jan NOTE: Applies to states that do not expand Medicaid. In most states not moving forward with the expansion, adults without children are ineligible for Medicaid.

22 Figure 21 Nationwide, 4.8 million uninsured nonelderly adults below poverty may fall into the coverage gap. Distribution By State: Distribution By Geographic Region: GA 8% FL 16% NC 7% PA 6% Other States Not Moving Forward 41% South 79% Midwest 11% Northeast 7% TX 22% West 4% Total = 4.8 Million in the Coverage Gap Notes: Excludes legal immigrants who have been in the country for five years or less and immigrants who are undocumented. The poverty level for a family of three in 2013 is $19,530. Totals may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and Current Population Survey. See technical appendices available at for more detail.

23 Figure 22 States implementing the Medicaid expansion are experiencing higher enrollment growth from Summer 2013 and April % 10.3% 3.3% All Reporting States (48 States) States With Medicaid Expansion in Effect as of April 2014 (24 Reporting States*) States Not Expanding Medicaid at this Time (23 Reporting States) *NH reported data but had not yet implemented its expansion. Note: Summer 2013 based on average monthly enrollment between July and September Enrollment data represent point-in-time, unduplicated total enrollment counts for enrollees receiving full benefit coverage for 48 states reporting for both time periods.(excludes CT, ME, and ND). Data are subject to certain state-specific caveats and limitations. Source: CMS, Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report, May 1, 2014, /medicaid-moving-forward-2014.html.

24 Figure 23 Compared to the uninsured, Medicaid coverage increases access to care. 97% 98% 82% 82% Medicaid ESI Uninsured 90% 87% 71% 71% 70% 53% 45% 36% 25% 26% 17% 12%* 9% 8% Usual Source of Care Well-Child Checkup Specialist Visit Usual Source of Care General Doctor Visit Specialist Visit Children NOTES: In past 12 months. Respondents who said usual source of care was the ER are not counted as having a usual source of care. All differences between the uninsured and the two insurance groups are statistically significant (p<0.05). * Difference from ESI is statistically significant (p<0.05). SOURCE: KCMU analysis of 2013 NHIS data. Nonelderly Adults

25 Figure 24 While uninsured, individuals could not afford needed care, resulting in significant negative impacts on their health and finances. I skipped medications. -Ruth I was supposed to go to the hospital, but I didn t. -Susan [I] basically worked with a broken hand for two months. - John [The pain] really made it hard some days to work - Stephanie

26 Figure 25 What to look for going forward: Will state decisions to implement the Medicaid expansion change? How well will new enrollment systems work and how well will systems be coordinated across health programs? How will the ACA affect Medicaid enrollment and the uninsured? What effect will the ACA have on state revenue and fiscal conditions? How will Medicaid payment and delivery systems continue to evolve? How will increased Medicaid coverage affect access to health care and services and ultimately health outcomes?