CHARTPACK. Medicaid and its Role in State/Federal Budgets & Health Reform

CHARTPACK Medicaid and its Role in State/Federal Budgets & Health Reform April 2013

Figure 1 #1: What is Medicaid and What Does it Do? Figure 2 Medicaid has many vital roles in our health care system. Health Insurance Coverage 31 million children & 16 million adults in low-income families; 16 million elderly and persons with disabilities Assistance to Medicare Beneficiaries 9.4 million aged and disabled 20% of Medicare beneficiaries Long-Term Care Assistance 1.6 million institutional residents; 2.8 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 2013, FMAPs range from 50 73.4% 1

Figure 3 Medicaid is a major source of health coverage and spending. Health Coverage Health Spending Employer- Sponsored Insurance 49% Uninsured 16% Medicaid 16% Medicare 13% Total = 307.9 million Other Public 1% Private Non-Group 5% Private Health Insurance 35% Other Private Funds 8% Consumer Out-of- Pocket 13% Medicaid 16% Medicare 24% Total = $2.3 trillion Other Government Programs 4% 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 Medicaid helps to fill gaps in private insurance coverage. Figure 4 Employer/Other Private Medicaid/Other Public Uninsured 32% 29% 15% 12% 5% 4% 48% 32% 73% 90% 20% 39% <100% FPL 100-199% FPL 200-399% FPL 400%+ FPL NOTE: FPL-- Federal Poverty Level. The FPL was $22,350 for a family of four in 2011. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS 2

Medicaid eligibility levels are more limited for adults than for children. 235% Figure 5 185% Minimum Medicaid Eligibility under Health Reform - 138% FPL ($24,344 for a family of 3 in 2012) 61% 37% Children Pregnant Women Working Parents Jobless Parents 0% Childless Adults SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013. Figure 6 All but 4 states set Medicaid/CHIP eligibility for children at 200% FPL or higher. CA OR WA NV ID UT AZ (CHIP closed) MT WY NM CO ND MN WI SD IA NE IL KS MO OK 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 FL HI < 200% FPL (4 states) 200-249% FPL (22 states) 250% or higher FPL (25 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. OK has a premium assistance program for select children up to 200% of the FPL. AZ s CHIP program is currently closed to new enrollment. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013. 3

Medicaid coverage for working parents is more limited. Figure 7 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN IA MO AR WI IL MS IN MI TN AL KY OH WV GA SC PA VT VA NC NY ME NH CT RI NJ DE MD DC MA TX LA AK FL HI < 50% FPL (16 states) 50% - 99% FPL (17 states) 100% FPL or Greater (18 states, including DC) NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. Several states also offer coverage with a benefit package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013. Only 9 states provide full Medicaid to childless adults. Figure 8 WA (closed) OR* (closed) CA AK NV ID UT* (closed) AZ (closed) MT WY CO (Closed) NM (closed) HI ND SD NE KS TX WI (closed) No Coverage (26 states) More Limited than Medicaid (16 states) Medicaid Benefits (9 states, including DC) Closed denotes enrollment closed to new applicants NOTE: Map identifies the broadest scope of coverage in the state. MN and VT also offer waiver coverage that is more limited than Medicaid. OR and UT also offer premium assistance with open enrollment. IL, LA, and MO offer coverage limited to adults residing in a single county or area. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013. OK MN IA MO* AR LA IL MS MI (closed) IN (closed) TN AL KY OH WV GA SC PA VT* VA NC FL NY ME (closed) NH MA RI CT NJ NJ DE MD DC 4

Medicaid is the largest source of funding for safety-net providers. Safety-Net Hospital Net Revenues by Payer, 2010 Figure 9 Health Center Revenues by Payer, 2011 Medicaid 35% Federal / State / Local Payments 11% Commercial 27% Federal 330 Grants 17% Medicare 6% Private 7% Medicaid 38% Medicare 21% Other Grants & Contracts 24% Other 4% Uninsured 2% Total = $47 Billion Other Public 2% Total = $12.7 Billion Uninsured/ Self Pay 6% SOURCES: Data for hospitals from America s Safety Net Hospitals and Health Systems, 2010, National Association of Public Hospitals and Health Systems, May 2012. Health center data from 2011 Uniform Data System (UDS), BPHC/HRSA/HHS. 9 Million dual eligible beneficiaries are covered by both Medicare and Medicaid. Figure 10 Medicare 37 Million Dual Eligibles 9 Million Medicaid 51 Million Total Medicare Beneficiaries, 2008: 46 million Total Medicaid Beneficiaries, 2008: 60 million SOURCE: Kaiser Family Foundation analysis of Medicare Current Beneficiary Survey, 2008, and KCMU and Urban Institute estimates based on data from the FY2008 MSIS. 5

Medicaid provides benefits to reflect the needs of the population it serves. Figure 11 Low-Income Families Individuals with Disabilities Elderly Individuals Pregnant Women: Pre-natal care and delivery costs Children: Routine and specialized care for childhood development (immunizations, dental, vision, speech therapy) Families: Affordable coverage to prepare for the unexpected (emergency dental, hospitalizations, antibiotics) Autistic Child: In-home therapy, speech/occupational therapy Cerebral Palsy: Assistance to gain independence (personal care, case management and assistive technology) HIV/AIDS: Physician services, prescription drugs Mental Illness: Prescription drugs, physicians services Medicare beneficiary: help paying for Medicare premiums and cost sharing Community Waiver Participant: community based care and personal care Nursing Home Resident: care paid by Medicaid since Medicare does not cover institutional care Six in ten dollars of Medicaid spending is for state expansion enrollees and optional services. Figure 12 Mandatory Services for Federal Core Enrollees 40% Mandatory Services for State Expansion Enrollees 27% Optional Services for Federal Core Enrollees 19% Optional Services for State Expansion Enrollees 14% Total = $311 billion NOTE: Total expenditures do not include disproportionate share hospital (DSH) payments, drug rebates, administrative costs, or accounting adjustments. Shares may not sum to 100% due to rounding. SOURCE: Urban Institute estimates based on FFY data from the 2007 MSIS and CMS 64. 6

Figure 13 Medicaid provides access to care that is comparable to private insurance and better than access for the uninsured. Employer/Other Private Medicaid/Other Public Uninsured 53% 28% 20% 30% 26% 2% 3% 2% 2% 1% 1% 11% 10% 10% 12% 7% 10% 4% No Usual Source of Care Postponed Seeking Care Due to Cost Went Without Needed Care Due to Cost No Usual Source of Care Postponed Seeking Care Due to Cost Went Without Needed Care Due to Cost Children Nonelderly Adults NOTES: In past 12 months. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All differences between the uninsured and the two insurance groups are statistically significant (p<0.05). SOURCE: KCMU analysis of 2011 NHIS data. Most Medicaid enrollees receive care through private managed care. Figure 14 AK WA MT OR ID WY NV UT CO CA AZ NM HI U.S. Overall = 65.9% ND SD NE KS TX OK MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV GA SC PA VT VA NC FL NY 0% - 50% (9 states) 51% - 65% (15 states) 66% - 80% (17 states and DC) 80%+ (9 states) ME NH MA CT RI NJ DE MD DC NOTE: Includes enrollment in MCOs and PCCMs. Most data as of October 2010. SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011. 7

#1: What is Medicaid and What Does it Do? Answers Figure 15 Medicaid is the nation s primary health insurance program for Americans with low incomes and significant health care needs. Medicaid increases access to care and limits out-of-pocket burdens for low-income people. Medicaid is the largest source of funding for safety-net providers and the dominant payer for long-term care. Medicaid also helps to make Medicare work for low-income elderly and disabled beneficiaries. Medicaid provides an entitlement to coverage for individuals eligible for the program. Medicaid also guarantees federal matching payments to states with no cap in order to meet program needs. States administer Medicaid within broad federal rules. Although Medicaid is publicly financed, the program purchases health services primarily in the private sector. Figure 16 #2: What does Medicaid cost and why? 8

Figure 17 Medicaid provides support for providers and services in the health care system. Medicaid as a share of national health care spending: 31% 16% 18% 8% 7% Total National Spending (billions) Total Health Services and Supplies Hospital Care Professional Services Nursing Home Care Prescription Drugs $2,279 $851 $723 $149 $263 NOTE: Includes neither spending on CHIP nor administrative spending. Definition of nursing facility care was revised from previous years and no longer includes residential care facilities for mental retardation, mental health or substance abuse. The nursing facility category includes continuing care retirement communities. SOURCE: CMS, Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2013. Data for 2011. The majority of Medicaid expenditures are for acute care. Figure 18 DSH 4.2% Long-Term Care 30.2% Mental Health 0.9% ICF/MR 3.3% Home Health and Personal Care 13.5% Nursing Facilities 12.5% Inpatient 14.6% Other Acute 9.3% Physician, Lab & X- ray 3.6% Outpatient/Clinic 6.8% Drugs 3.5% Acute Care 65.6% Payments to Medicare 3.6% Payments to MCOs 24.1% Total = $413.9 billion NOTE: Excludes administrative spending, adjustments and payments to the territories. SOURCE: Urban Institute estimates based on FY 2011 data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured. 9

Medicaid spending growth per capita was slower than private health care spending from 2007 to 2011. Spending Growth FFY 2007-2011 Figure 19 5.3% 3.5% 3.3% 2.3% 0.1% Medicaid LTC Per Enrollee Medicaid Services Per Enrollee Medicaid Acute Care Per Enrollee NHE Per Capita Private Health Insurance Per Enrollee NOTE: Acute Care includes payments to managed care plans. SOURCE: Medicaid estimates from Urban Institute analysis of data from the Medicaid Statistical Information System (MSIS), Medicaid Financial Management Reports (CMS Form 64), and Kaiser Commission and Health Management Associates data. NHE and private health insurance data from Centers for Medicare & Medicaid Services Office of the Actuary, National Health Statistics Group. Medicaid enrollment and spending growth is accelerated during economic downturns. Spending Growth 12.7% Enrollment Growth Figure 20 10.4% 9.3% 9.7% 8.7% 8.5% 7.7% 7.8% 6.8% 7.2% 7.5% 6.4% 5.8% 7.6%6.6% 4.7% 5.6% 3.8% 3.8% 3.2% 4.3% 3.1% 4.4% 3.2% 3.2% 1.3% 2.7% 2.0% 0.4% -1.9% 0.2% -0.5% Adopted 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 NOTE: Enrollment percentage changes from June to June of each year. Spending growth percentages in state fiscal year. SOURCE: Medicaid Enrollment June 2011 Data Snapshot, KCMU, June 2012. Spending Data from KCMU Analysis of CMS Form 64 Data for Historic Medicaid Growth Rates. FY 2012 and FY 2013 data based on KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2012. 10

The elderly and disabled account for the majority of Medicaid spending. Figure 21 Disabled 15% Elderly 10% Disabled 42% Adults 26% Elderly 23% Children 49% Adults 14% Children 20% Enrollees Total = 62.7 Milion Expenditures Total = $346.5 Billion NOTE: Percentages may not add up to 100 due to rounding. SOURCE: KCMU/Urban Institute estimates based on data from FFY 2009 MSIS and CMS-64, 2012. MSIS FFY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS-64. Disability and long-term care drive higher per-enrollee spending. Acute Care Long-Term Care $15,840 Figure 22 $6,275 $13,149 $9,748 $2,305 $65 $2,900 $2,240 $2,887 $13 $9,565 $3,401 Children Adults Disabled Elderly SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on FFY 2009 MSIS and CMS-64 data. MSIS FFY 2008 data was used for PA, UT, and WI, but adjusted to 2009 CMS-64. 11

Duals account for 38% of Medicaid spending. Figure 23 Medicaid Enrollment Adults 26% Children 49% Other Aged & Disabled 10% Dual Eligibles 15% Medicaid Spending Non-Dual Spending 62% Premiums 3% Medicare Acute 7% Other Acute 2% Long-Term Care 25% Dual Spending 38% Total = 62.7 Million Total = $358.5 Billion Prescribed Drugs 0.4% SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FFY 2009 MSIS and CMS-64 reports, 2012. 2008 MSIS data was used for PA, UT, and WI, because 2009 data were unavailable. Top 5% of enrollees accounted for more than half of Medicaid spending in FFY 2009. Figure 24 Top 5% Children 0.3% Adults 0.2% 5% Disabled 2.5% Elderly 2.0% Bottom 95% of Spenders Bottom 95% of Spenders Top 5% Children 3.7% Adults 1.9% Disabled 30.4% Elderly 18.6% 54% Enrollees Expenditures Total = 62.7 million Total = $346.5 billion SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012. MSIS FY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS-64. 12

#2: What does Medicaid cost and why? Answers Figure 25 Medicaid accounts for about one sixth of total health care spending in the country. On a per enrollee basis, Medicaid spending is growing more slowly than premiums for employer-sponsored insurance or national health care spending. However it is subject to same market pressures as other payers. Enrollment is the dominant driver in Medicaid spending, especially during periods of economic downturn. The elderly and disabled account for the majority of Medicaid spending. Medicaid spending is concentrated among a small number of beneficiaries with complex health care needs. States have a strong incentive to manage Medicaid cost growth. Figure 26 #3: What is Medicaid s role in state budgets? 13

Medicaid Costs are Shared by the States and the Federal Government Figure 27 AK CA OR WA NV HI ID AZ UT MT WY NM CO ND SD NE TX 50 percent (14 states) 50.1-59.9 percent (14 states) 60.0-66.9 percent (12 states) 67.0-74.0 percent (11 states, including DC) NOTE: FMAP percentages are rounded to the nearest tenth of a percentage point. These rates will be in effect Oct. 1, 2012 Sept. 30, 2013. SOURCE: Federal Register, November 30, 2011 (Vol 76, No. 230), pp 74061-74063, at http://www.gpo.gov/fdsys/pkg/fr- 2011-11-30/pdf/2011-30860.pdf. KS OK MN IA MO AR LA WI IL MS NY MI PA OH IN WV VA KY NC TN SC AL FFY 2013 FMAP GA FL VT ME NH MA RI CT NJ DE MD DC State Tax Revenue, 1989 2012 Figure 28 20% 15% 10% 15.9% 11.3% 5% 5.4% 3.3% 4.9% 0% 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012-5% -10% -9.4% -15% -20% -16.3% SOURCE: Percent change in quarterly state tax revenue, US Census Bureau. Updated October 2012. 14

Since the start of the recession about 10 million more enrolled in Medicaid. Figure 29 Total Monthly Enrollment (in Millions) 42.3 43.6 47.0 50.4 52.6 June 2007 2008 2009 2010 2011 NOTE: The orange bars denote the period since the most recession started, though it technically started in December 2007. SOURCE: Compiled by Health Management Associates from State Medicaid enrollment reports for the Kaiser Commission on Medicaid and the Uninsured. Figure 30 Drops in revenues had a larger impact on state budgets than increases in Medicaid spending during the recession. Decline in Medicaid Spending -$22 Billion Decline in State Revenues -$80 Billion NOTES: Measures the change in state own source revenues (taxes, miscellaneous revenues, and charges) between state fiscal years 2008 and 2010 compared the change in state spending on Medicaid between state fiscal years 2008 and 2010. Medicaid spending does not include administrative costs, accounting adjustments, or the U.S. Territories. SOURCES: 2008, 2009, and 2010 Annual Survey of State Government Finances. U.S. Census Bureau, 2012. KCMU and Urban Institute estimates based on data from HCFA/CMS (Form 64), 2010. 15

12.9% 12.9% 13.0% 13.1% 12.4% 12.8% 12.7% 12.4% 12.5% 11.7% 11.6% 11.3% 11.0% 11.7% 11.5% 11.5% 11.3% 10.0% Medicaid is a budget Item and a revenue item in state budgets. Medicaid Elementary & Secondary Education Other Figure 31 56.1% 48.2% 43.8% 12.5% 20.2% 35.1% 23.7% 16.7% 43.7% Total State Spending $1.66 Trillion General Funds $635.5 Billion Federal Funds $565.9 Billion SOURCE: Actual FY 2011 data reported in: State Expenditure Report. NASBO, December 2012. Shares of state general fund spending for Medicaid and education have remained fairly stable over time. Elementary and Secondary Education Medicaid Higher Education Figure 32 33.4% 34.4% 34.5% 35.2% 35.7% 35.7% 35.2% 35.1% 35.8% 35.8% 35.4% 34.4% 34.1% 35.0% 35.2% 35.5% 35.1% 34.7% Economic Downturn, Slow Recovery, ARRA-Enhanced Matching Funds 19.6% 14.4% 14.7% 14.6% 14.8% 14.4% 14.4% 15.2% 15.8% 17.2% 16.9% 17.1% 17.4% 16.6% 16.0% 16.3% 16.7% 14.8% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Estimated SOURCE: State Expenditure Report. NASBO, December 2012. 16

Medicaid helps to generate jobs in state economies. Figure 33 Federal Medicaid Matching Dollars Injection of New Money State Medicaid Dollars Direct Effects Health Care Services JOBS Vendors (ex. Medical Supply Firm) Indirect Effects Employee Income Consumer Goods and Services Taxes Induced Effects State budget pressures have resulted in Medicaid cost containment efforts, but eligibility is protected. Figure 34 2012 Adopted for 2013 48 47 45 42 18 10 8 7 6 2 Any Cost Containment Action Provider Payments Benefits Long-Term Care Eligibility NOTE: Past survey results indicate not all adopted actions are implemented. Provider payment restrictions include rate cuts for any provider or freezes for nursing facilities or hospitals. Survey was conducted in July and August 2012. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2012. 17

Figure 35 States are also moving ahead with initiatives to better coordinate care, especially for more complex populations. FY 2012 Adopted FY 2013 45 35 30 34 20 Any Managed Care Expansions or Initiatives Any Care Coordination Initiatives Any Dual Eligible Initiatives SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2012. #3: What is Medicaid s role in state budgets? Answers Figure 36 The Medicaid program is jointly funded by states and the federal government. Medicaid is a counter-cyclical program; during economic downturns, individuals lose jobs, incomes drop, state revenues decline, and more individuals qualify and enroll in Medicaid which increases spending. Medicaid is the largest source of federal revenue for states. Medicaid funds support health care providers, jobs and state economies overall. Due to budget pressures over the last decade, states have adopted an array of cost containment measures. 18

Figure 37 #4: What is Medicaid s role in the federal budget? Figure 38 Medicaid is the third largest domestic program in the federal budget. Social Security 23% Defense and Nondefense Discretionary 34% Medicare 1 17% Other 2 13% Medicaid 7% Net Interest 6% Projected FY 2013 Total Federal Outlays = $3.6 trillion NOTE: FY is fiscal year. 1 Amount for Medicare is mandatory spending and excludes offsetting premium receipts (premiums paid by beneficiaries and state contribution (clawback) payments to Medicare Part D). 2 Other category includes other mandatory outlays and offsetting receipts. SOURCE: Kaiser Family Foundation based on Congressional Budget Office, Budget and Economic Outlook Fiscal Years 2013-2023, February 2013. 19

Figure 39 CBO s most recent projections of federal Medicaid spending are lower than previous projections as current spending has slowed. 700 600 500 400 300 200 March 2012 Baseline August 2012 February 2013 Baseline 622 577 540 592 506 549 474 572 514 451 425 479 536 505 446 383 476 416 449 337 382 422 399 341 275 276 372 258 305 275 331 253 267 297 251 265 100 0 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 SOURCE: Medicaid Spending and Enrollment Detail for CBO s March 2013 Baseline and the February 2013 Baseline Figure 40 The House Budget Plan is estimated to result in a 38% reduction in federal Medicaid spending over the 2013-2022 period. -$932 Cut due to ACA repeal -$4,591 38% Reduction in Spending -$810 Cut due to Block Grant -$2,849 Spending Under Current Law, Including ACA Spending Under the House Budget Plan Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured, October 2012 20

Medicaid enrollment in 2022 would decline significantly under the House Budget Plan. Enrollment Cut: 37.5 Million ACA Repeal 17.0 17.0 Figure 41 Enrollment Cut: 31.3 Million 75.0 20.5 37.5 Block Grant 14.3 43.7 Current Law, Including ACA Scenario 1: Assuming Current Per Enrollee Spending Growth Scenario 2: Assuming Reduction in Per Enrollee Spending Growth % Enrollment Cut from 50% 42% Repeal and Block Grant %Enrollment Cut from 35% 25% Block Grant Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured, October 2012. #4: What is Medicaid s role in the federal budget? Answers Figure 42 Medicaid is the third-largest domestic program in the federal budget. Medicaid is exempt from automatic budget reductions; however Medicaid continues to be discussed as part of federal deficit reduction efforts. Leading budget proposals for FFY 2014 released by the Administration and House Republicans take fundamentally different approaches to Medicaid spending. The FMAP formula that determines the federal share of Medicaid spending has remained steady since the start of the program; Congress has only amended the formula to provide more federal funding, not less. 21

Figure 43 #5: What is Medicaid s role in health reform? Expanding Medicaid is a key element in health reform. Figure 44 Universal Coverage Medicaid Coverage For Low-Income Individuals Individual Mandate Exchanges With Subsidies for Moderate Income Individuals Health Insurance Market Reforms Employer-Sponsored Coverage 22

Figure 45 Under the ACA, there will be fewer uninsured as individuals gain coverage through Medicaid and new exchanges. Total Nonelderly Population = 288 million Uninsured Medicaid/CHIP Private Non-Group/Other 19% 13% 10% 10% 17% 9% 8% Uninsured Medicaid/CHIP Exchange Private Non-Group / Other Employersponsored Insurance 58% 56% Employersponsored Insurance Without Health Reform (56 Million Uninsured) With Health Reform (29 Million Uninsured) NOTE: This assumes that all states choose to expand Medicaid eligibility up to 138% FPL January 2014. SOURCE: Congressional Budget Office, February 2013. Total may not equal 100% due to rounding Figure 46 More than half of the uninsured have incomes at or below 138% of poverty, the Medicaid eligibility floor under the ACA. Income Family Type 10% 400% + 16% Children Employer- Sponsored Insurance, 56% Medicaid* 21% Uninsured 18% 39% 51% 139-399% FPL (Subsidies) 138% (Medicaid) 25% 59% Parents Adults without Dependent Children Private Non-Group, 6% 266.4 M Nonelderly 47.9 M Uninsured NOTES: * Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage. The federal poverty level for a family of four in 2011 was $22,350. Numbers may not add to 100 due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS. 23

Figure 47 There is significant variation in the share of the uninsured that is below the Medicaid expansion limit across states. WA OR NV CA CA ID UT AZ MT WY CO NM ND MN SD WI IA NE IL KS MO OK AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME MA RI CT NJ DE MD DC NH AK HI TX LA FL United States: 51% Uninsured <138% FPL 26% 47% (17 states, including DC) 48% 52% (18 states) 53% - 61% (16 states) SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements). Figure 48 The ACA streamlines enrollment processes, making it easier to obtain coverage. HEALTH INSURANCE Medicaid CHIP Exchange $ Data Hub # Dear, You are eligible for Multiple Ways to Enroll Single Application for Multiple Programs Use of Electronic Data to Verify Eligibility Real-Time Eligibility Determinations 24

The federal government will fund the vast majority of Medicaid expansion costs. Figure 49 $952 Billion $76 Billion Federal State 26% 3% 21.3 Million New Enrollees by 2022 State Savings Provider Revenue Increased Economic Activity Cost Impact NOTE: Assumes all states expand Medicaid. #5: What is Medicaid s role in health reform? Answers Figure 50 Health reform builds on Medicaid as a base of coverage for low-income Americans. As they plan their FY 2014 budgets, states are debating whether to adopt the Medicaid expansion. The Federal Government will finance over 90% of the cost of the Medicaid expansion in new states; overall, many states are likely to see net savings from the Medicaid expansion. The Medicaid expansion would significantly reduce the uninsured and increase access to care. The ACA provides new options to expand community-based long-term care and to coordinate care for high cost populations. 25

the henry j. kaiser family foundation Headquarters 2400 Sand Hill Road Menlo Park, CA 94025 Phone 650-854-9400 Fax 650-854-4800 Washington Offices and Barbara Jordan Conference Center 1330 G Street, NW Washington, DC 20005 Phone 202-347-5270 Fax 202-347-5274 www.kff.org This publication (#8162-03) is available on the Kaiser Family Foundation s website at www.kff.org. The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a non-profit private operating foundation, based in Menlo Park, California.