Medicaid and the ACA: Issues for Reporters


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Alan Weil
Executive Director
National Academy for State Health Policy

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  • Figure 1 shows the estimate of aggregate DSH allotments for FY2012 through FY2024 prior to ACA, under ACA, and under current law (i.e., under ACA and the Middle Class Tax Relief and Job Creation Act of 2012). Under current law, the aggregate DSH reductions will be nominal from FY2014 to FY2016. Then, the aggregate reductions will phase up to an estimated 43% reduction in FY2019, and in FY2020 and FY2021, the aggregate DSH reductions will phase down to roughly a 30% reduction. In FY2022, DSH allotments will rebound to the pre-ACA reduced levels.
  • N = 19 million
  • Medicaid and the ACA: Issues for Reporters

    1. 1. Medicaid and the ACA:Issues for ReportersReporting on HealthMarch 5, 2013Alan WeilExecutive DirectorNational Academy for State Health Policy
    2. 2. What We Will Discuss• How the ACA affects Medicaid• The Medicaid expansion• Medicaid beyond the expansion• Medicaid’s relationship to the health insurance exchange• The remaining uninsured
    3. 3. Health Reform & Medicaid • Maintains children’s CHIP and Medicaid eligibility levels through 2019; adults through 2013 • Expands for adults to 133% of the federal poverty level without regard to family structure or assets as of January 1, 2014 • Option for benchmark benefit package based on essential health benefits package for new adults • Full federal funding for individuals newly eligible for Medicaid for 2014-2016, phasing down to 90% in 2020 and beyond • Supreme Court rules federal government cannot penalize states that decline to expandSource: Kaiser Family Foundation, “Medicaid and Children’s Health InsuranceProgram Provisions in the New Health Reform Law”, April 2010
    4. 4. Four Perspectiveson the Medicaid Expansion• Coverage• Cost• Health• Health system performance
    5. 5. Who Are the Currently Uninsured? Health Insurance Coverage of the Nonelderly by Poverty Level, 2011 Employer/Other Private Medicaid/Other Public Uninsured 6% 19% 4% 42% 37% 9% 23% 90% 34% 73% 41% 24% <100% FPL 100-199% FPL 200-399% FPL 400%+ FPLFPL= Federal Poverty Level. The FPL was $22,250 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.
    6. 6. Who Gets Covered by Expansion?• Medicaid in 2022: – 52.4 million enrolled if no ACA – 58.1 million enrolled with ACA and no states electing expansion – 73.7 million enrolled with ACA and all states electing expansionSOURCE: Holahan, John; Buettgens, Matthew; Caroll, Caitlin; Dorn, Stan.Urban Institute for the Kaiser Commission on Medicaid and the Uninsured.The Cost and Coverage Implications of the ACA Medicaid Expansion:National and State-by-State Analysis.
    7. 7. How Big a Reduction in Uninsured? With all states expanding, the number of uninsured in the US is estimated to be 27.9 million in 2022, while it would have been 53.3 million without the ACA. This amounts to a 47.6% reduction in the uninsured.SOURCE: Holahan, John; Buettgens, Matthew; Caroll, Caitlin; Dorn, Stan.Urban Institute for the Kaiser Commission on Medicaid and the Uninsured.The Cost and Coverage Implications of the ACA Medicaid Expansion:National and State-by-State Analysis.
    8. 8. 8
    9. 9. Unadjusted Mortality and Rates of Medicaid Coverage among Nonelderly Adults before and after State Medicaid Expansions (1997–2007).SOURCE: Sommers BD, Baicker K, Epstein AM. Mortality andaccess to care among adults after state medicaidexpansions. N Engl J Med 2012;367:1025–34.
    10. 10. Medicaid and Health SystemPerformance• Coverage continuity• Care continuity• Aligned quality metrics• Aligned purchasing and reporting strategies
    11. 11. SOURCE: The Advisory Board Company. Where each state stands on the ACA’s Medicaidexpansion. Accessed February 27, 2013 at
    12. 12. SOURCE: State Reforum: Tracking Medicaid Expansion Decisions. Accessed February27, 2013 at
    13. 13. Medicaid Beyond the Expansion• Eligibility and enrollment systems• Dual eligible demonstrations• Health homes• Reductions in Safety Net Hospital funding (DSH)
    14. 14. Eligibility System Upgrades State Responses Regarding Streamlined Eligibility and Enrollment RequirementsSOURCE: Department of Health and Human Services. Office of the Inspector General. MostStates Anticipated Implementing Streamlined Eligibility and Enrollment by 2014. February2013. Accessed Feb 28, 2013 at
    15. 15. Duals Demonstration StatesSOURCE: Kaiser Family Foundation. State Adoption of Integrated Financingand Care Delivery for Dually Eligible Beneficiaries Provided by the AffordableCare Act, August 2012. Accessed Feb 28, 2013 at
    16. 16. Section 2703 Health Home Activity AK WA VT ME MT ND MN NH OR NY WI MA ID SD MI RI WY PA CT IA NJ NE OH DE NV IL IN MD UT WV VA CO KS MO KY DC CA NC TN OK SC AZ AR NM MS AL GA LA HI TX FL Approved (12 SPAs in 8 States) Submitted (4 States) As of December 2012 Planning Grant (16 States and D.C.)16
    17. 17. Cuts in Medicaid Safety Net Funds Total DSH Allotments Before the Reductions, with the ACA Reductions, and Under Current Law ($ in billions)SOURCE: Mitchell A. Congressional Research Service. Medicaid DisproportionateShare Hospital Payments. Washington (DC): CRS; 2012 Dec 18. Available from:
    18. 18. Churn between Medicaid and the Health Insurance Exchanges Income Changes Over Time Among Adults Aged 19-60 With Incomes Initially Between 133 Percent and 200 Percent Of The Federal Poverty LevelSOURCE: Sommers BD, Rosenbaum S. Issues In Health Reform: How ChangesIn Eligibility May Move Millions Back and Forth Between Medicaid And InsuranceExchanges. Health Affairs, February 2011, vol 30, no 2, pgs 228-236.
    19. 19. The Remaining Uninsured Distribution of Nonelderly Uninsured Adults Under the ACASOURCE: BuettgensM, Hall MA. The Urban Institute. Who Will Be Uninsured After HealthInsurance Reform? Accessed Feb 28, 2013 at
    20. 20. is a space for…• Peer-to-peer learning and discussion• Exchanging reform ideas• Posting, organizing, and sharing useful state documents• Announcing off-line events and activities• Spotlighting the keys to successful implementation• Mapping states’ progress in implementing health reform
    21. 21. Alan WeilExecutive @nashphealth