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

Figure 1

Medicaid’s Origins

Mandatory services and populations for participating

states with options for broader coverage

Means-tested, with focus on welfare population: -single parents with dependent children -aged, blind, and disabled

Federal State

Entitlement

• Enacted in 1965 as title XIX of the Social Security Act • Means-tested; originally focused on the public assistance population

Eligible Individuals are entitled to a defined set

of benefits

States are entitled to federal matching

funds

Sets core requirements on

eligibility and benefits

Flexibility to administer the program within

federal guidelines partnership

Figure 2

Medicaid plays a central role in our health care system.

Health Insurance Coverage

State Capacity for Health Coverage

MEDICAID

Support for Health Care System and Safety-Net

Assistance to Medicare Beneficiaries

Long-Term Care Assistance

Figure 3

Children 48%

Children 21%

Adults 27%

Adults 15%

Elderly 9%

Elderly 21%

Disabled 15%

Disabled 42%

EnrolleesTotal = 68.0 Million

ExpendituresTotal = $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.

Medicaid spending is mostly for the elderly and people with disabilities.

Figure 4

97%*

84%

14%

87%*

71%

27%

98%

85%

15%

90%

71%

26%

75%*

56%*

7%*

47%*

37%*

8%*

Usual Sourceof Care

Well-ChildCheckup

SpecialistVisit

Usual Sourceof Care

General DoctorVisit

SpecialistVisit

Medicaid ESI Uninsured

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.

Medicaid and private insurance provide similar access to care – the uninsured fare far less well.

Children Nonelderly Adults

Figure 5

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. 73779 – 73782 (Nov. 5, 2015) accessed September 8, 2016, http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/.

Medicaid costs are shared by the states and the federal government based on each state’s federal matching rate.

WA

OR

WY

UT

TX

SD

OK

ND

NM

NV NE

MT

LA

KS

ID

HI

CO

CA

AR AZ

AK

WI

WV VA

TN SC

OH

NC MO

MS

MN

MI

KY

IA

IN IL

GA

FL

AL

VT

PA

NY

NJ

NH

MA

ME

DC

CT

DE

RI

MD

50.1-59.9 percent (12 states)

50 percent (14 states)

60.0-66.9 percent (13 states)

67.0-74.2 percent (12 states, including DC)

FFY 2017 FMAP

Figure 6

25.6% 18.4%

50.4%

19.8% 35.4%

9.8%

54.5% 46.2% 39.8%

Total State Spending$1.74 Trillion

State General Funds$705.7 Billion

Federal Funds$529.9 Billion

Medicaid Elementary & Secondary Education Other

SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on the NASBO’s November 2015 State Expenditure Report (data for Actual FY 2014.)

Medicaid is a budget item and a revenue item in state budgets.

Figure 7

4.7%

6.8%

8.7%

10.4%

12.7%

8.5% 7.7%

6.4%

1.3%

3.8%

5.8% 7.6%

6.6%

9.7%

-4.0%

6.9%

9.6%

13.9%

6.9%

-1.9%

0.4%

3.2%

7.5%

9.3%

5.6% 4.3%

3.2%

0.2% -0.5%

3.1%

7.8% 7.2%

4.8%

2.3%

1.5%

8.3%

13.8%

4.0%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016Proj.

Medicaid Total Spending Medicaid EnrollmentAnnual Percentage Changes, 1998 - 2016

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 2014. Historic Medicaid spending growth rates are derived from KCMU Analysis of CMS Form 64 Data. FY 2014-2016 data are derived from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015.

Economic conditions and policy changes drive growth in Medicaid enrollment and total spending.

Figure 8

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.

The ACA Medicaid expansion fills historic gaps in coverage.

Figure 9

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

ACA Vision PAST

Real-time determination

Data Hub

$

#

Dear __, You are eligible for…

Apply in person Multiple options to apply

Provide paper documentation

Electronic verification

Wait for eligibility determination

Medicaid CHIP

Marketplace

No Wrong Door to Coverage

Figure 10

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, 2016. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

32 states (including DC) had adopted the ACA Medicaid Expansion as of September 2016.

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT*

MO

MS

MN

MI*

MA

MD

ME

LA

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO

CA

AR* AZ

AK

AL

Adopted (32 States including DC)

Not Adopting At This Time (19 States)

Figure 11

297%

213%

138% 138%

214% 199%

44%

0%

Children Pregnant Women Parents Childless Adults

Adopted the Medicaid Expansion (32 states) Not Adopting the Expansion at this Time (19 states)

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.

Median Medicaid/CHIP Income Eligibility Thresholds, January 2016

($59,667)

($42,791)

($27,724)

($8,839)

($16,242)

($0)

($42,992) ($39,979)

Figure 12

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.

About half of the remaining uninsured are eligible for financial assistance but not enrolled in coverage.

Medicaid Eligible Adult 18%

Medicaid/CHIP Eligible Child

10%

Tax Credit Eligible 22%

In the Coverage Gap

9%

Ineligible for Coverage Due to

Immigration Status 15%

Ineligible for Financial Assistance

due to ESI Offer 15%

Ineligible for Financial Assistance

due to Income 12%

Total = 32.3 Million Nonelderly Uninsured

Eligible for Financial

Assistance 49%

Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015

Figure 13

Work Status of Adults in the Coverage Gap

No worker 38%

Part-time worker

21%

Full-time worker

41%

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.

48% 55%

6%

14%

46% 17%

8%

6%

Most people left without coverage options are in working families.

Family work status :

Total = 2.9 Million in the Coverage Gap

Firm size and industry among those working:

<50 employees

50-99 employees

100+ employees

Agriculture/ Service

Education/ Health

Professional/ Public Admin

Manufacturing/Infrastructure

Other

Total = 1.5 Million Workers in the Coverage Gap

Figure 14

Studies point to positive results from the Medicaid expansion.

+ State Economic Activity

+ Provider Revenue + Access to Care

- Uninsured

- Uncompensated Care Costs - State-funded health

programs (e.g. Corrections)

State Savings

Federal + State Funds

+

- Jobs and Revenues

SOURCES: The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review, KCMU, June 2016;

Figure 15

SOURCE: Medicaid Managed Care Enrollment and Program Characteristics, CMS, Spring 2016. Data as of July 1, 2014.

Over half of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs.

WY

WI

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV NE

MT

MO

MS

MN

MI

MA

MD

ME

LA

KY KS

IA

IN IL

ID

HI

GA

FL

DC

DE

CT

CO

CA

AR AZ

AK

AL

U.S. Overall = 61% 26-50% (5 states) 51-75% (13 states, including DC)

76-100% (16 states)

0% (11 states)

1-25% (6 states)

As of July 1, 2014

Figure 16

13

21

27

46

13

19

28

46

Managed CareExpansions to New

Groups

Managed Care QualityInitiatives

Emerging Delivery SystemInitiatives

HCBS Expansions

FY 2015 FY 2016

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.

Medicaid programs continue to add and expand payment and delivery system reforms in FYs 2015 and 2016.

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

Figure 18

Medicaid Priorities

ACA Implementation

Cost Control Payment and

Delivery System Reform

Systems and Administration

Population Health and

Social Determinants

of Health

Medicaid directors reported many key priorities.

Figure 19

Source: Faces of Medicaid. http://kff.org/medicaid/video/faces-of-medicaid/

There are many “Faces of Medicaid”.

Figure 20

For more information on the Medicaid program and health reform, visit…

www.kff.org