TOP 12 ISSUES WEBINAR SERIES Health: Medicaid and Health Reform
Health Today’s webinar will cover: Medicaid Health Reform – Health Insurance Exchanges – Essential Health Benefits – Opposition Actions
Presenters Martha King NCSL Health Program Group Director Melissa Hansen NCSL Senior Policy Specialist Martha Salazar NCSL Policy Associate Dick Cauchi NCSL Health Program Director
Medicaid Medicaid overview Why Medicaid is a top issue for states in 2012 4 things for states to consider as they address Medicaid issues
Health Insurance Assistance to Long-Term Care Coverage Medicare Beneficiaries AssistanceOver 30 million children & 17 9.2 million aged and disabled 70% of nursing homemillion adults in low-income — 16% of Medicare residents; over 2.8 million families; over 16 million beneficiaries community-based residents elderly and persons with disabilities MEDICAID Support for Health Care State Capacity for Health System and Safety-net Coverage 15% of national health spending; Federal share ranges 50% to 75%; 48% of long-term care costs 45% of all federal funds to states SOURCE: Kaiser Commission on Medicaid and the Uninsured, 2011; MACPAC Report to the Congress, March 2011.
Medicaid’s Role for Selected Populations Poor 42% Percent with Medicaid Coverage: Near Poor 24% Families All Children 30% Low-Income Children 56% Low-Income Adults 21% Births (Pregnant Women) 41% Aged & Disabled Medicare Beneficiaries 17% People with Severe Disabilities 20% People Living with HIV/AIDS 44% Nursing Home Residents 70%SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of 2009 ASEC Supplement to the CPS; Birth data from Maternal and
Why Medicaid is a top issue for states in 2012 Fiscal situation in states
Why Medicaid is a top issue for states in 2012 Fiscal situation in states Enrollment increase associated with the Great Recession
Total and State Medicaid Spending Growth FY 2000 – FY 2012 Total State 28.7% ARRA Enhanced FMAP (2009-2011) 12.9% 12.7% 10.4% 10.8% 9.9% 10.1% 8.7% 8.5% 8.4% 7.7% 7.6% 7.3% 6.4% 6.6% 5.5% 5.8%5.7% 4.9% 4.0% 3.0% 3.8% 2.2% 1.3% Enhanced FMAP / Federal Fiscal Relief -4.9% (2003-2005) Adopted -10.9% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012NOTE: State Fiscal Years. SOURCE: Historic Medicaid Growth Rates, KCMU Analysis of CMS Form 64 Data; FY 2008, 2009 and 2010, KCMU survey of Medicaid officials in 50 states
Why Medicaid is a top issue for states in 2012 Fiscal situation in states Enrollment increase associated with the Great Recession Affordable Care Act expansion in 2014
Affordable Care Act expansion in 2014 2014 expansion will qualify all Americans under age 65 with family incomes at or below 133 percent of federal poverty guidelines. – This includes childless adults New eligibility calculation called “modified adjusted gross income,” (MAGI) will effectively raise the eligibility level to 138 percent of the poverty level for most applicants.
Non-Elderly Medicaid Enrollees Will Grow by 16 Million to 51 Million in 2019 Average Annual Medicaid Enrollment Non-Elderly Only in Millions With Reform Without ReformSource: Andrew Bindman, M.D., California Medicaid Research Institute (CBO data).
Other ACA-related Medicaid changes Requires maintenance of effort (MOE) for state Medicaid and Children’s Health Insurance Program (CHIP) eligibility levels. Includes new mandatory and optional benefits in Medicaid. Requires states to improve outreach and enrollment for Medicaid and to coordinate Medicaid eligibility with the new health benefit exchanges, which must be operational by 2014.For a list of Medicaid changes, please visit:http://www.ncsl.org/issues-research/health/medicaid-home-page.aspx
Why Medicaid is a top issue for states in 2012 Fiscal situation in states Enrollment increase associated with the Great Recession Affordable Care Act expansion in 2014 State actions to improve efficiency and effectiveness within Medicaid programs
Why Medicaid is a top issue for states in 2012: State Actions … More than 200 Medicaid-related bills have been filed this session in at least 34 states. – More than 150 of these bills are related to ACA implementation. Many of these bills attempt to contain costs within the program.
4 things for states to consider as they address Medicaid issues Know what the cost drivers are in your states Medicaid program.
Top 5% of Enrollees Accounted for More than Half of Medicaid Spending, FY 2008 Bottom 95% Bottom 95% Top 5% of Spenders of Spenders Children 3.7% Adults 1.8% Top 5% Disabled 31.8% 54% Children 0.4% Adults 0.2%5% Disabled 2.6% Elderly 1.8% Elderly 16.8% Total = 60.6 million Total = $292.2 billion
Medicaid Dual Eligibles: Enrollment and Spending, FFY 2007 Medicaid Enrollment Medicaid Spending Premiums Medicare 4% Acute 6% Adults Other Acute 25% Other Aged & Disabled 2% 10% Non-Dual Spending Long- Dual Duals Spending 60% Term Care 15% 39% Children 27% 50% Prescribed Drugs 0.4% Total = 58 Million Total = $311 Billion
4 things for states to consider as they address Medicaid issues Know what the cost drivers are in your states Medicaid program. Understand your states Medicaid managed care programs challenges and opportunities.
Figure 23 Medicaid Managed Care Penetration Rates by State, 2008 NH VT WA ME MT ND MA MN OR NY ID SD WI MI RI CT WY PA IA NJ NE OH NV IN DE IL WV UT IL VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI 0-50% (5 states) 51-70% (20 states including DC) U.S. Average = 70% 71-80% (9 states) 81-100% (17 states)Note: Unduplicated count. Includes managed care enrollees receiving comprehensive and limited benefits.SOURCE: Medicaid Managed Care Enrollment as of December 31, 2008. Centers for Medicare and MedicaidServices.
4 things for states to consider as they address Medicaid issues Know what the cost drivers are in your states Medicaid program. Understand your states managed care contracts. Fraud and abuse prevention and recovery
4 things for states to consider as they address Medicaid issues Know what the cost drivers are in your states Medicaid program. Understand your states managed care contracts. Fraud and abuse prevention and recovery Health information systems – Medicaid Electronic Health Records (EHR) Incentive Program
Health Insurance Exchanges Marketplace for health insurance. Provide coverage options for individuals and small businesses with more transparency than currently exists today. Vehicle for administering the new federal tax credits for certain people who don’t have coverage through their employer. Enrollment "facilitator" for public programs.
What is Required? Every state must have Exchange(s) for individuals and small businesses (up to 100 employees), effective Jan. 1, 2014. Will it be a state-based exchange, federally facilitated exchange or a partnership? Exchange health plans must offer a minimum level of coverage.
Upcoming Deadlines and Decisions State-based exchanges must demonstrate process is underway to establish an exchange that will be operational by January 2014 via a State Plan before January 1, 2013.
Options for StatesIf a state decides to establish an exchange, it has the following options: A state agency – Existing agency – Independent public agency A non-profit entity Who will serve on the governing board? Contract with other eligible entities to carry out various functions of the exchange. How will the state regulate insurers in the exchange?
Concerns and Challenges Timeframe Guidance – First regulations published in July – Medicaid coordination, subsidies, quality, and other regulations still to come Building/Upgrading Health Information Technology Systems
Medicaid/Exchange Eligibility Systems Simpler eligibility rules Efficient and easy to use seamless enrollment "No Wrong Door" Approach
Summary of Establishment Legislation As of February 7, 2012 NH*AK* WA VT ME* MT ND MA MN* OR WI* NY RI* ID SD MI* CT WY PA* IA* NJ NE OH NV IL IN DE UT WV VA CO CA KS MO KY MD NC TN DC OK* SC* AZ NM AR GA MS AL HI LA TX FL Legislation Pending Enacted Exchange Establishment or Intent Exchange Establishment Not Addressed (So Far)* Introduced in 2011. Indicates that the bill(s) carried over from 2011.
State ExchangesState Structure Governance Carrier SelectionCA Independent State Agency 5 Member Board Active PurchaserCO Non-Profit 12 Member Board All Plans AllowedCT Quasi-Public 14 Member Board Active PurchaserHI Non-Profit 15 Member Interim Board Commissioner will decideMD Independent State Agency 9 Member Board Board will decideMA Independent State Agency 11 Member Board Active PurchaserNV Independent State Agency 10 Member Board TBDOR Quasi-Governmental 9 Member Board Active PurchaserUT Existing Agency Up to 9 Members All Plans AllowedVT Existing Agency Deputy Commissioner All Plans AllowedWA Public/Private Partnership 11 Member Board TBDWV New Agency with Office of 10 Member Board All Plans Allowed Insurance
Federal Funding Awarded 49 states and DC received up to $1 million in exchange planning grants. Four territories received similar grants on March 21, 2011. – FL, LA and NH returned grants, AK did not apply. 6 states and a multi-state consortium led by the University of Massachusetts Medical School received over $241 million in Early Innovator grants to develop model Medicaid/Exchange IT systems. – KS, OK and WI returned grants. 29 states and the District of Columbia were awarded $1-$39 million in level one exchange Establishment grants. – More expected to come…
Essential Health Benefits Defining what services will be covered The ACA requires HHS to define "essential health benefits" for exchanges + small group + individual plans nationwide. – 10 uniform categories listed in the law. – Additional details & definitions must be resolved in 2012. ACA does not directly change or preempt state mandates. Starting in 2014, states must cover extra cost of mandated benefits that go beyond essential benefits package.
State Mandate Laws: a Major Factor? Every state has a substantial but varied number of state laws (about 1,600 nationwide) that "mandate" commercial market health insurance to cover specific benefits/providers. Actual coverage mandates vary widely – Autism = 29 states Home health = 20 states – Diabetes = 47 states Acupuncturist= 11 states
Timeline: Latest developments Oct 6, 2011 Institute of Medicine Report - Dec. 16, 2011: Major change; HHS proposes to allow each state to pick among its health plans. – 1 of largest state "small group" plans or – 1 of largest state employee plans – Largest state HMO in commercial market – 1 of largest Federal Employee plans (FEHBP) Jan. 25 - HHS list of 50-states small group plans Jan. 31, 2012 - Comments filed with HHS (including NCSL) By May 1, 2012 - HHS final rules expected.
Expected state action for 2012-13 Most states will choose a single state-based or FEBHP “essential benefit plan” in 2012. Will legislatures weigh in or make decisions? Legislatures may address existing state law mandates in 2012 and 2013. States could Expand? Repeal? Review?
Opposition to Health Reform: States and the U.S. Supreme Court State Attorneys General in the lead with court suits 25 federal court cases filed, divided rulings
28 States with AGs supporting legal challenge + Alabama Mississippi (2010)* Alaska Missouri (single state lawsuit, 21 amicus states)+ Arizona * Nebraska Colorado § Nevada (2010)* Florida North Dakota (20110)* Georgia* Ohio (2011)** Idaho Pennsylvania Indiana South Carolina Iowa (2011)** South Dakota Kansas (2011) Texas Louisiana Utah Maine Virginia (single-state lawsuit; Appeals Court) Michigan ** Washington § Wisconsin (2011)*** = States where legal action was initiated by governors offices.** New executive branch officials for 2011 announced support for lawsuit. Wyoming (2011)**§ = States where Attorney General initiated action but Governor publiclysupported law, opposes challenge.+ = Lt. Governor in the lead.
4 Legal Issues in 3 Days of Oral Argument Individual mandate - "Whether Congress had the power under Article I of the Constitution to enact the minimum coverage provision." Medicaid expansion - "Does Congress exceed its enumerated powers ... when it coerces States into accepting onerous conditions that it could not impose directly by threatening to withhold all federal funding" for non-compliance? Severability - "To what extent (if any) can the mandate be struck down but) severed from the remainder of the Act?" Delay decision due to Anti-Injunction Act- whether the penalty provision in the ACA is a tax, which could prevent a court challenge until it is in effect, 2014.
State Legislation Opposing, Opting Out or Avoiding Certain Reforms• In 2011: 45 states considered 210 proposals.• In 2012: 34 states are considering 125 proposals (so far)• Most bills seek to block state government involvement; creating a policy of no implementation or enforcement of mandates (federal or state) to require: – purchase of insurance by individuals, – or contribution to premiums by employers, – or imposing fines or penalties for those who fail to do so. 90% of state bills do not discuss federal constitutionality.
Missouri ballot question, election day , 8/3/10
Enforceable or Symbolic? Examining the legal language “No law or rule shall compel any person or employer to participate in any health care system.” -[AZ constitutional amendment, 2010] Declares it state policy that every resident "shall be free to choose or to decline to choose any mode of securing health care services without penalty or threat of penalty;" [TN statute, 2011] No state or local public official, employee, or agent "shall act to impose, collect, enforce, or effectuate any penalty in this state." [TN statute, 2011]
Some 2011-12 Specific Opposition Provisions: (Wording and enforceability varies among bills) Block state agency implementation unless approved by the legislature - Filed in 10 states; laws in 4. Health Freedom Interstate Compacts - Filed in 16 states; laws in 4. Nullification and state sovereignty: include seeking state criminal penalties for federal or state enforcement of ACA - Filed in 11 states; no penalties enacted. As of 2/9/2012
Upcoming Webinars:Feb.13 Putting Election Laws to the TestFeb. 17 Corrections, Juvenile Justice and Drugged DrivingFeb. 20 Transportation Funding, Natural Gas and Environmental RegulationsFeb. 24 Funding Education in a Climate of Cutting
Questions & Contact Information•The webinar archive and power points will beemailed to you next week.•Contact •Healthemail@example.com•For more information: •www.ncsl.org/healthreform •www.ncsl.org/issues-research/health/medicaid-home-page.aspx