Robin Rudowitz, Associate Director, Kaiser Commission on Medicaid and the Uninsured The Henry J. Kaiser Family Foundation

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1 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

2 Figure 1 Medicaid s Origins Enacted in 1965 as title XIX of the Social Security Act Means-tested; originally focused on the public assistance population Entitlement Eligible Individuals are entitled to a defined set of benefits States are entitled to federal matching funds Means-tested, with focus on Mandatory services and Federal State welfare population: populations for participating Sets core Flexibility to -single parents with dependent requirements on states administer with options the for children eligibility and broader program coverage within partnership -aged, blind, and disabled benefits federal guidelines

3 Figure 2 Medicaid plays a central role in our health care system. Health Insurance Coverage Assistance to Medicare Beneficiaries Long-Term Care Assistance MEDICAID Support for Health Care System and Safety-Net State Capacity for Health Coverage

4 Figure 3 Medicaid spending is mostly for the elderly and people with disabilities. Disabled 15% Elderly 9% Disabled 42% Adults 27% Elderly 21% Children 48% Adults 15% Children 21% Enrollees Total = 68.0 Million Expenditures Total = $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.

5 Figure 4 Medicaid and private insurance provide similar access to care the uninsured fare far less well. 97%* 98% 84% 85% Medicaid ESI Uninsured 90% 87%* 75%* 71% 71% 56%* 47%* 37%* 27% 26% 14% 15% 7%* 8%* Usual Source of Care Well-Child Checkup Specialist Visit Usual Source of Care General Doctor Visit Specialist Visit Children Nonelderly Adults 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.

6 Figure 5 Medicaid costs are shared by the states and the federal government based on each state s federal matching rate. AK WA OR NV CA ID UT AZ HI MT WY CO NM ND SD NE KS OK TX MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV GA FFY 2017 FMAP PA SC VA NC FL VT NY ME NH MA RI CT NJ DE MD DC 50 percent (14 states) percent (12 states) percent (13 states) percent (12 states, including DC) 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 (Nov. 5, 2015) accessed September 8, 2016,

7 Figure 6 Medicaid is a budget item and a revenue item in state budgets. Medicaid Elementary & Secondary Education Other 54.5% 46.2% 39.8% 9.8% 19.8% 35.4% 25.6% 18.4% 50.4% Total State Spending $1.74 Trillion State General Funds $705.7 Billion Federal Funds $529.9 Billion SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on the NASBO s November 2015 State Expenditure Report (data for Actual FY 2014.)

8 Figure 7 Economic conditions and policy changes drive growth in Medicaid enrollment and total spending. Annual Percentage Changes, Medicaid Total Spending 12.7% 10.4% 9.3% 8.7% 8.5% 7.5% 7.7% 6.8% 6.4% 5.6% 4.7% 4.3% 3.2% 3.2% -1.9% 0.4% 1.3% 9.7% 5.8% 7.6% 4.8% 3.8% 6.6% 0.2% -0.5% 3.1% Medicaid Enrollment 7.8% 7.2% 2.3% 6.9% 1.5% -4.0% 9.6% 13.9% 8.3% 13.8% Proj. 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 Historic Medicaid spending growth rates are derived from KCMU Analysis of CMS Form 64 Data. FY data are derived from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October % 4.0%

9 Figure 8 The ACA Medicaid expansion fills historic gaps in coverage. 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.

10 Figure 9 All states were required to modernize Medicaid application and enrollment processes. 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

11 Figure states (including DC) had adopted the ACA Medicaid Expansion as of September WA OR NV CA ID AZ UT MT* WY CO NM ND SD NE KS OK MN WI* IA* IL MO AR* MS VT NY MI* PA OH IN* WV VA KY NC TN SC AL GA ME NH* MA CT RI NJ DE MD DC TX LA AK HI FL Adopted (32 States including DC) 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, Not Adopting At This Time (19 States)

12 Figure 11 Median Medicaid/CHIP Income Eligibility Thresholds, January 2016 Adopted the Medicaid Expansion (32 states) Not Adopting the Expansion at this Time (19 states) 297% ($59,667) 214% ($42,992) 213% ($42,791) 199% ($39,979) 138% 138% ($27,724) ($16,242) 44% ($8,839) 0% ($0) Children Pregnant Women Parents Childless Adults 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.

13 Figure 12 About half of the remaining uninsured are eligible for financial assistance but not enrolled in coverage. Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015 Ineligible for Financial Assistance due to Income 12% Ineligible for Financial Assistance due to ESI Offer 15% Medicaid Eligible Adult 18% Medicaid/CHIP Eligible Child 10% Eligible for Financial Assistance 49% Ineligible for Coverage Due to Immigration Status 15% Tax Credit Eligible In the 22% Coverage Gap 9% Total = 32.3 Million Nonelderly Uninsured 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.

14 Figure 13 Most people left without coverage options are in working families. Work Status of Adults in the Coverage Gap Family work status : Firm size and industry among those working: 100+ employees 6% 8% 46% 17% Other Manufacturing /Infrastructure Education/ Health Full-time worker 41% No worker 38% employees 6% 14% Professional/ Public Admin Part-time worker 21% <50 employees 48% 55% Agriculture/ Service Total = 2.9 Million in the Coverage Gap Total = 1.5 Million Workers in the Coverage Gap 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.

15 Figure 14 Studies point to positive results from the Medicaid expansion. - Uninsured + Federal + State Funds + Provider Revenue + Access to Care State Savings - Uncompensated Care Costs - State-funded health programs (e.g. Corrections) + State Economic Activity - Jobs and Revenues SOURCES: The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review, KCMU, June 2016;

16 Figure 15 Over half of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs. CA AK OR WA NV ID AZ UT MT WY NM HI CO ND SD NE KS TX U.S. Overall = 61% As of July 1, 2014 OK MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV GA SC PA FL VT VA NC NY ME NH CT RI NJ DE MD DC 0% (11 states) 1-25% (6 states) 26-50% (5 states) 51-75% (13 states, including DC) % (16 states) MA SOURCE: Medicaid Managed Care Enrollment and Program Characteristics, CMS, Spring Data as of July 1, 2014.

17 Figure 16 Medicaid programs continue to add and expand payment and delivery system reforms in FYs 2015 and FY 2015 FY Managed Care Expansions to New Groups Managed Care Quality Initiatives Emerging Delivery System Initiatives HCBS Expansions 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.

18 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

19 Figure 18 Medicaid directors reported many key priorities. Medicaid Priorities ACA Implementation Cost Control Payment and Delivery System Reform Systems and Administration Population Health and Social Determinants of Health

20 Figure 19 There are many Faces of Medicaid. Source: Faces of Medicaid.

21 Figure 20 For more information on the Medicaid program and health reform, visit