MEDICAID EXPANSION ADVOCACY STRATEGIES: A COALITION FOR WHOLE HEALTH WEBINAR

Transcription

1 MEDICAID EXPANSION ADVOCACY STRATEGIES: A COALITION FOR WHOLE HEALTH WEBINAR Tuesday, November 27, :00-4:30 Eastern Presenters: Paul Gionfriddo, Our Health Policy Matters Cindy Zeldin, Georgians for a Healthy Future Leonardo Cuello, National Health Law Program *If at any point during the event you lose audio over your computer, please call the below number. Phone #: Access Code:

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3 Part One: Post-election Overview of Medicaid Expansion. Background on Medicaid expansion rejection and the potential rejecting states. Effects of expansion rejection on people, providers, and states. Part Two: Experiences from the Georgia Frontline (Cindy). Part Three: Key Points for Focusing Advocacy Efforts in the Reluctant States. 3

4 POST ELECTION OVERVIEW OF THE MEDICAID EXPANSION Part One

5 ACA is no longer at risk of repeal; will be implemented on or near the beginning of states moving forward with exchanges; 16 states deferring to feds. Deadline: 2/14/ states still holding the line against Medicaid expansion; investment/return projections starting to come in. 5

6 (in Billions of Dollars) CBO Estimate, March % ($73 Billion) increase $1 Trillion Return State Cost - No Expansion State Cost with Expansion New Federal Dollars 6

7 No to Medicaid Expansion: Florida, Georgia, South Carolina, Texas, Louisiana, Mississippi, Oklahoma Leaning Against: Iowa, Nebraska, Nevada, New Jersey, Maine No to State Exchanges: Wisconsin, Maine, Oklahoma, Texas, Alabama, Nebraska, Alaska, New Hampshire, South Carolina, Georgia, Missouri, Kansas, Wyoming, North Dakota, South Dakota, Louisiana Asking for more time: Idaho, New Jersey, Florida 7

8 In addition to giving up a lot of new money, because SCOTUS called it a new program: New Medicaid Basic Benefits package, behavioral health parity and prescription drug coverage provisions are at risk. Current eligibility groups and benefits stay in place (or could contract). Current enrollment processes remain in place. They keep current reimbursement levels. 8

9 People: Who will be harmed if states don t expand? Providers: Which providers stand to lose the most? States: How will expansion change the rules of existing Medicaid programs? 9

10 Medicaid/CHIP Exchange Uninsured 10

11 These changes are entirely the result of states rejecting Medicaid expansion Medicaid/CHIP Exchange Uninsured 11

12 Most of the new enrollment projected to occur under the ACA s Medicaid expansion is expected to be among childless adults and parents who are not already covered under their state s eligibility rules. Source: CBO Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision, July

13 People with serious mental illnesses earn roughly half ($23,000) of the amount earned by those without. (American Journal of Psychiatry, 2008) That income would typically qualify someone for Medicaid expansion. Without expansion, those below 100% of poverty will not be eligible for any exchange subsidies. Between 100% and 133% of poverty, people will have to pay 2% of income toward premiums. 13

14 Logical Constituencies 14

15 ACA cuts $10 billion in Medicare and Medicaid Disproportionate Share Hospital (DSH) payments as of Hospitals will still lose DSH payments in states that don t expand Medicaid. Nursing homes lose $$$ for long term care. Community health centers will lose $$$ for integrated care to meet health and behavioral health needs. Behavioral health programs lose $$$ to replace $4.6 billion cut by states between 2009 and

16 Four categories: adults, children, parents, pregnant women. Uniform eligibility requirements using tax-based definition of income (Modified AGI). Must adopt a methodology for ID ing newly eligible people. Streamlined online eligibility interfaced electronically with Federal Data Services hub. 16

17 Source: FL Attorney General Pam Bondi, Supreme Court Brief, 2012 $574,000,000 Florida s Projected Cost of Expansion? $351,000,000 Currently Medicaid Eligible, But Not Enrolled Newly Eligible Because of ACA 17

18 EXPERIENCES FROM THE GEORGIA FRONTLINE CINDY ZELDIN Part Two

19 Health Reform & Medicaid Cindy Zeldin Executive Director, Georgians for a Healthy Future

20 The Big Picture, The Big Opportunity: Covering the Uninsured Overall, in Georgia: Nearly two million uninsured; one-fifth of the population and onefourth of working-age adults Georgia consistently ranks in the top 10 among the states in number and percentage of uninsured Overall distribution of the uninsured in Georgia by income: <100% FPL. 45% 9% % FPL 12% 11% % FPL 23% 45% % FPL. 11% 23% 400% FPL+ 8%...9% Source: CPS data, 2-year average (Kaiser State Health Facts) 12%

21 ACA: Overall Approach to Coverage Everyone is eligible for something (citizens and most legal immigrants) Maintain employment-based health insurance system Expand Medicaid for low-income individuals and families Restructure the individual and small group health insurance marketplace through exchanges and new regulations Individual mandate

22 Why Does Coverage Matter? Access to the health care system Financial protection against high medical costs Overwhelming evidence that insurance facilitates better access to care and better health outcomes; increases productivity; saves lives Amenable to public policy intervention

23 Why Expand Medicaid? People with low-incomes disproportionately lack access to job-based health insurance (nationally, 28% of predominately low-wage firms offer v. 77% of predominately high-wage firms)* Purchasing a private, individual policy is cost-prohibitive for people with very low incomes Medicaid is an existing program; many states have used it as a vehicle to expand coverage for low-income families over the past 20 years * Source: Kaiser Family Foundation Employer Health Benefits 2012 Survey

24 Why Expand Medicaid, cont d? Improves health access and outcomes: Oregon health insurance experiment: Medicaid more likely to have a usual source of care and to get preventive care than their uninsured counterparts (Source: National Bureau of Economic Research) New England Journal of Medicine study: states that expanded Medicaid saw lower mortality rates than neighboring states that did not, after controlling for a range of factors (Source: New England Journal of Medicine) Reduces the burden of uncompensated care Federal funds coming into the health care economy have a stimulative effect: economic impact of $72 billion ($16 in impact from federal dollars for every $1 in state funds) (Source: AJC, University of Georgia) * Source: Kaiser Family Foundation Employer Health Benefits 2012 Survey

25 Who would be newly eligible for Medicaid? Creates a new eligibility category for Medicaid based solely on income Eligible individuals include those with incomes up to 138% FPL ($15,028 for an individual or $25,571 for a family of 3), Medicaideligible regardless of category Estimated 645, ,000 new Medicaid enrollees by 2019 (mostly childless adults) in Georgia Estimated 40% increase in enrollment in Georgia, as compared to an estimated increase of 27% nationally (Source: KFF)

26 Medicaid Expansion, cont d Expansion initially financed with 100% federal dollars ( ) and then scales down such that by 2020 and thereafter the expansion population is 90% federally financed Increased enrollment will lead to a 28.9% increase in federal spending and 2.7% increase in state spending relative to baseline (Source: KFF) Temporary increase in Medicaid reimbursement rates for primary care providers to parity with Medicare rates (federally financed) from

27 What did SCOTUS say about Medicaid? The carrot is constitutional, but not the stick It is overly coercive to withhold all of a state s Medicaid funds for failing to expand to 138% FPL The Medicaid expansion stands but HHS can only enforce it by withholding funds for the expansion population if a state does not adopt it, making it effectively optional for states

28 What are the implications for coverage? Congress authorized tax credits for the purchase of private health insurance through the exchange only for people with incomes above the poverty level If states expand Medicaid, they retain the spirit of the ACA; everyone has a pathway to coverage If a state chooses not to expand Medicaid, inequities within states and disparities across states will ensue

29 This sets up a Coverage Gap Source: Center for American Progress

30 Cover Georgia Good for consumers, good for health care system, good for the economy Can improve access to health care; can help ameliorate disparities Georgia taxpayers pay federal income taxes, and this money will go to other states if it doesn t come back to Georgia No deadline for states to join and states can withdraw from the expansion if it isn t working for them

31 Questions & Follow Up Contact me at: or

32 KEY POINTS FOR FOCUSING ADVOCACY EFFORTS IN RELUCTANT STATES Part Three

33 Full Expansion expansion to 138% of poverty. No expansion leaves current program in place. Partial Expansion: Expansion for some groups only, such as SSI recipients, veterans, people with certain conditions, etc. Expansion to less than 133% of poverty. Legal experts disagree about whether partial expansion will be found constitutional! 33

34 Rejecting States #25 Mississippi #40 Louisiana #43 South Carolina #44 Oklahoma #48 Georgia #49 Florida #50 Texas No-Brainer States #5 Vermont #8 Connecticut #11 Maryland #13 Minnesota #14 California #22 Washington #23 Massachusetts Source: Kaiser State Health Facts, 2009 Data 34

35 Rejecting States #32 Texas #33 Oklahoma #34 South Carolina #35 Louisiana #42 Mississippi #43 Florida #50 Georgia No-Brainer States #2 Connecticut #3 Minnesota #14 Maryland #16 Massachusetts #22 Vermont #36 Washington #49 California 35

36 1. This is a marathon, not a sprint. 2. Remember the rule of Expansion allies are key. 4. Partial victories are better than none. 5. To organize, use media you control. 36

37 There is nothing magical about any given date. Even though exchange blue prints are due in December, and details in February, nothing is a done deal until 2014 or beyond. However, beginning in 2014, states begin to lose out on three years of 100% federal funding and unless Congress changes the rules, they will never get this back! 37

38 Whatever a state says it will cost it to expand, it will cost at least nine times that amount to reject. Florida: Not spending $351 million annually on Medicaid expansion beginning in 2020 costs at least $3.2 billion of annual Federal match. Louisiana: Not spending an average of $700 million annually on Medicaid expansion over the next decade costs it an average of $9.3 billion annually during the same time frame. Texas: Not spending $4.4 billion annually because of expansion as of 2020 costs $39.6 billion in annual Federal funding. Note: State spending estimates come from SCOTUS Brief, January

39 Public hospitals, nursing homes, and community health centers have just as big a stake in expansion as do people with behavioral health conditions and behavioral health providers and advocates. All hospitals, and home and community-based service providers and all the people paying for long term care are natural allies. 39

40 Choose your battles: In general, a federal exchange will be better than a state-operated exchange in a reluctant state. In a state that would reject Medicaid expansion, partial expansion is better than no expansion. The key message for policymakers if high costs will be incurred by a given group whether or not Medicaid is expanded, then cover this group and let the feds absorb almost all the cost. 40

41 Health beat reporters have generally been eliminated by local media. Replace them with your own messages and stories using Facebook, Twitter, , LinkedIn, and electronic newsletters. Use these frequently. Once is not enough. Don t forget your own voice. Use it to make your stories authentic and personal. 41

42 Thank you! 42

43 MEDICAID EXPANSION ADVOCACY STRATEGIES: A COALITION FOR WHOLE HEALTH WEBINAR Today s webinar recording and slides will be posted online at and