Medicaid & vulnerable populations. Harold Pollack, PhD School of Social Service Administration University of Chicago September 8, 2014

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1 Medicaid & vulnerable populations Harold Pollack, PhD School of Social Service Administration University of Chicago September 8, 2014

2 Preparing to talk about ACA after botched launch of healthcare.gov

3 All things considered, ACA proceeding reasonably well Eight million selected marketplace plan. Seven million more insured through Medicaid. Five million outside new marketplaces. Millions of young adults age signed up on parents plans Cost growth is much lower than predicted at passage. Premiums on new marketplaces are below 2010 projections Heath care quality indicators are trending favorably. Hospital readmission In-hospital infection rates.

4 Then came ACA (OK slight exaggeration)

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7 Even this graph was made more optimistic last month.

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10 MH/SUD Coverage in ACA (once the Messiah comes & states take up Medicaid expansion) Individuals Currently Holding Individual Coverage Individuals Currently with Coverage under Small Group Plans New Coverage for M/SUD Care Expanded M/SUD Care Coverage Total Uninsured Total

11 Medicaid expansion doing the really heavy lifting At least in states that are embracing it.

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13 Percentage-Point Increase in Insurance Coverage for Adults by State Decision to Expand Medicaid ** In Medicaid expansion states In Medicaid nonexpansion states 8.8 ** 9.8 ** 8.1 ** 6.1 ** 1.7 * ** 4.2 ** ** ** 4.2 ** 3.4 ** ** 6.5 ** All Adults At or below 138% of FPL % of FPL 400% or more of FPL White, non- Hispanic Nonwhite, non- Hispanic Hispanic Female Male Family income Age Race and ethnicity Gender

14 Distribution of Uninsured Adults Ages by State Medicaid Expansion Status 14 June 2014 September % 39.4% 49.7% 50.3% States expanding Medicaid States not expanding Medicaid

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17 Some Challenges: Illinois Medicaid We spend too little on most Medicaid recipients, and possibly spend too much/to ineffectively on a very costly concentrated group. Top 3.2% of recipients often disabled account for half of total program costs. Average expenditure more than $30,000/yr. Bottom 72% of recipients account for 10% of total program costs. Average expenditure: Less than $600/yr. Illinois national leadership in child coverage quite economical. From both a cost-effectiveness and a care quality perspective, we need to focus more effectively and more humanely on the most costly and complex individuals.

18 0% 3% 6% 9% 12% 15% 18% 21% 24% 27% 30% 33% 36% 39% 42% 45% 48% 51% 54% 57% 60% 63% 66% 69% 72% 75% 78% 81% 84% 87% 90% 93% 96% 99% 100% Percent of total Medicaid expenditure Illinois Medicaid expenditures % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% $300,000 $280,000 $260,000 $240,000 $220,000 $200,000 $180,000 $160,000 $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 Average expenditure ($/year) cumulative cost

19 Need greater attention to improving health status of Medicaid recipients Expanded coverage (e.g. in Oregon Health Insurance Experiment) improves care access and mental health. Very little evidence that we are improving health behaviors. Example: Smoking slightly higher among Oregon Medicaid lottery winners than in the control group. Little movement in diet, obesity, and other measures from expanded health insurance coverage. People have much better access to basic medications. But significant issues of medical management and adherence.

20 Need greater attention to psychosocial determinants of health One hospital stay averages in the neighborhood of $20,000. Housing for a year averages in the neighborhood of $9,000. For both adults and children, medical resources are far more available than are social services or other supports often of great impact on individual health. Basic needs such as adult dental care left unaddressed in Medicaid.

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22 Using Medicaid/exchanges more effectively for population health Medicaid will be responsible for large and growing proportion of adults and children in many low-income communities. Once ACA fully implemented, Kentucky Medicaid expected to cover 30% of state non-elderly population w/more in exchanges. Uninsurance rate in KY has just dropped 42% in six months. Broadening Medicaid s population health vision then makes sense for host of cancer prevention strategies in school nutrition, activity, criminal justice system, alcohol and other drugs.

23 Medicaid unprepared for its de facto monopsony role Replaces/supplants many previous programs. Ryan White CARE Act for HIV Medicaid formulary concerns Correctional care Hepatitis C issues Rena knows more about than I do. MH/SA services Safety-net substance abuse treatment clients now Medicaid eligible. Systems unprepared for Medicaid Medicaid s gaps such as IMD exclusion now more significant for more people.

24 Thank You