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Emerging Trends in Medicaid


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Emerging Trends in Medicaid, presented by Robin Rudowitz of the Kaiser Family Foundation

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Emerging Trends in Medicaid

  1. 1. Emerging Trends in Medicaid Health Care Unscrambled 2018 Atlanta, GA January 11, 2018 Robin Rudowitz, Associate Director Kaiser Program on Medicaid and the Uninsured Kaiser Family Foundation
  2. 2. Figure 1 The basic foundations of Medicaid are related to the entitlement and the federal-state partnership. Federal State Entitlement 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 guidelinesPartnership
  3. 3. Figure 2 Medicaid plays a central role in our health care system. Health Insurance Coverage For 1 in 5 Americans State Capacity to Address Health Challenges MEDICAID Support for Health Care System and Safety-Net Assistance to 10 million Medicare Beneficiaries > 50% Long-Term Care Financing
  4. 4. Figure 3 Nationally, Medicaid is comparable to private insurance for access and satisfaction – the uninsured fare far less well. 85% 74% 30% 85%86% 69% 24% 87% 53% 36% 9% 44% Well-Child Checkup Doctor Visit Among Adults Specialist Visit Among Adults Adults Satisfied With Their Health Care 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. SOURCE: KCMU analysis of 2015 NHIS data. Percent reporting in the last year:
  5. 5. Figure 4 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% 3.2% 6.8% 10.5% 3.5% 3.9% 5.2% -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% 5.3% 13.2% 3.9% 2.7%1.5% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Proj. Total Medicaid Spending Medicaid Enrollment Annual Percentage Changes, FY 1998 – FY 2018 NOTE: For FY 1998-2013, enrollment percentage changes are from June to June of each year. FY 2014-2017 reflects growth in average monthly enrollment. Spending growth percentages refer to state fiscal year. FY 2018 data are projections based on enacted budgets. SOURCE: Enrollment growth rates for FY 1998-2013 are as reported in Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. FY 2014-2017 are based on KFF analysis of CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports, accessed September 2017. Historic Medicaid spending growth rates are derived from KCMU Analysis of CMS Form 64 Data. FY 2017-2018 data are derived from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2017. Medicaid enrollment and spending peaked during economic downturns and after implementation of the ACA.
  6. 6. Figure 5 In Georgia, Medicaid covers 17% of the population, but 3 in 4 nursing home residents. 1 in 12 adults <65 2 in 5 low-income individuals 2 in 5 children 3 in 4 nursing home residents 2 in 5 people with disabilities Employer 49% Non-Group 7% Medicaid/ CHIP 17% Medicare 12% Other Public 4% Uninsured 12% SOURCE: Kaiser Family Foundation estimates based on the Census Bureau's March Current Population Survey (CPS: Annual Social and Economic Supplements), 2014-2017.
  7. 7. Figure 6 NOTES: Includes non-institutionalized children ages 0-17 with special health care needs with Medicaid/CHIP only and Medicaid/CHIP and private insurance. SOURCE: Kaiser Family Foundation analysis of the 2016 National Survey of Children’s Health, Topical File. Medicaid covers nearly half of all children with special health care needs. CTWY 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 KYKS IA INIL ID HI GA FL DC DE CO CA ARAZ AK AL 35-49% (22 states) 23-34% (7 states) 50-67% (22 states) U.S. = 48% Share of children with special health care needs covered by Medicaid/CHIP:
  8. 8. Figure 7 252% 225% 37% 0% 73% 255% 205% 138% 138% 73% Children Pregnant Women Parents Childless Adults Seniors & People w/ Disabilities GA US (Median) Eligibility levels are based on the FPL for a family of three for children, pregnant women, and parents, and for an individual for childless adults and seniors & people w/ disabilities. Seniors & people w/ disabilities eligibility may include an asset limit. Eligibility levels are highest for children and pregnant women. ($52,071) ($41,861) ($28,180) ($16,643) ($8,820) ($7,555) ($8,820) ($51,458) ($45,945) Eligibility Level as a Percent of FPL, as of January 1, 2017
  9. 9. Figure 8 Hospital* 13% Physician & Outpatient* 8% Rx Drugs* 2% Other* 7% Long-term Care* 25% Managed Care 37% Payments to Medicare 4% Disproportionate Share Hospital Payments 4% In FY 2016, Medicaid spending in Georgia was $9.8 billion. Adults and children accounted for 3 in 4 enrollees but 55% of spending. *Fee-for-service Elderly & Disabled 25% Elderly & Disabled 45% Adults & Children 75% Adults & Children 55% Enrollees Expenditures SOURCE: KFF analysis of CMS (Form 64) data for Medicaid spending. KFF estimates of based on analysis of data from the 2014 Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports for distribution of enrollees and spending.
  10. 10. Figure 9 Spending per enrollee for the aged and individuals with disabilities is lower than average in Georgia. $1,520 (NV) $1,657 (AR) $9,448 (AL) $8,623 (SC) $5,137 (NM) $9,135 (MT) $38,442 (ND) $44,752 (DE) GA GA GA GA Children Adults Individuals with Disabilities Aged Per capita spending by enrollment group SOURCE:KFF estimates based on analysis of data from the 2014 Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports. enrollee/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
  11. 11. Figure 10 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 = $16,643 for an individual and $28,180 for a family of three in 2017. The Medicaid expansion was designed to fill the gaps in Medicaid coverage….
  12. 12. Figure 11 ….but gaps in coverage for adults remain for adults in states that do not adopt the ACA Medicaid expansion. asofOctober2014asofJanuary2017 44%FPL $8,985forparents inafamilyofthree $12,060 foranindividual $48,240 foranindividual NOTE: An estimated 2.3 million fall into the coverage gap. In Georgia, and estimated 240,000 are in the coverage gap. Another 75,000 uninsured are eligible but not enrolled in Medicaid and 148,000 uninsured are may be eligible for Marketplace coverage between 100-138% FPL In Georgia, 240,000 fall into the coverage gap
  13. 13. Figure 12 NOTES: Current status for each state is based on KFF tracking and analysis of state executive activity. *AR, AZ, IA, IN, MI, MT, and NH have approved Section 1115 waivers. ME adopted the Medicaid expansion through a ballot initiative in November 2017; the ballot measure requires submission of a state plan amendment within 90 days and implementation of expansion within 180 days of the measure’s effective date. 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 November 8, 2017. To date, 33 states have adopted the Medicaid expansion. 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 KYKS IA* IN*IL ID HI GA FL DC DE CT CO CA AR*AZ* AK AL Adopted (33 States including DC) Not Adopting At This Time (18 States)
  14. 14. Figure 13 • Administration Actions on Waivers • Congressional Actions – CHIP – Action on Entitlements • State Actions – Expansion – Opioids Medicaid: What’s Next?
  15. 15. Figure 14 • New era of federal/state Medicaid partnership implemented through waivers • Use taxpayer $ to serve “truly vulnerable”…seniors, children, people with disabilities • Return Medicaid to its welfare roots – Deserving poor vs able-bodied adults – Work requirements and “community engagement” – Time limits on coverage and other restrictions • Align Medicaid policies and commercial health insurance products to facilitate beneficiary transitions CMS: The New Direction Seema Verma 11/7/17
  16. 16. Figure 15 As of January 8, 2017 there were 42 approved waivers in 34 states and 23 pending waivers in 22 states. 16 15 12 16 7 - 7 5 4 14 4 3 1 9 10 8 Delivery System Reform Behavioral Health MLTSS Other Targeted Waivers Medicaid Expansion Work Requirements Eligibility and Enrollment Restrictions Benefit Restrictions, Copays, Healthy Behaviors Approved (42 in 34 states) Pending (23 in 22 states) Notes: Some states have multiple approved and/or multiple pending waivers, and many waivers are comprehensive and may fall into a few different areas. “MLTSS” = Managed long-term services and supports.
  17. 17. Figure 16 42% 18% 40% Own Work Status, 24.6 Million Medicaid Adults Not Employed Part-Time Full-time NOTE: Totals may not add due to rounding. Includes nonelderly Medicaid adults who do not receive Supplemental Security Income (SSI). SOURCE: Kaiser Family Foundation analysis of March 2017 Current Population Survey. More states are seeking waivers to condition Medicaid on work requirements, but most not working face barriers to work. Ill or disabled, 36% Retired, 9% Taking care of home or family, 30% Going to school, 15% Could not find work, 6% Other, 3% Not Employed = 9.8 Million Medicaid Adults Main Reasons for Not Working
  18. 18. Figure 17 • Coverage through Medicaid supports enrollees’ ability to work. – Many of the jobs held by enrollees do not offer health insurance. • Addressing barriers to work requires adequate funding and supports. – TANF spending on work activities and supports is critiqued by some as too low, but it exceeds estimates of state Medicaid program spending to implement a work requirement. • Implementing work requirements can create administrative complexity. – States can incur additional costs and demands on staff, and eligible people could lose coverage. SOURCE: KFF, Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience (August 2017). The TANF experience with work requirements can provide some lessons for Medicaid.
  19. 19. Figure 18 SOURCE: The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings, Kaiser Family Foundation, June 2017. populations-updated-review-of-research-findings/ States are also seeking waivers to impose premiums and cost sharing, but research shows negative effects of policies for low-income populations. New/increased premiums • Decreased enrollment and renewal in coverage • Largest effects on lowest income • Many become uninsured and face increased barriers to care and financial burdens New/increased cost-sharing • Even small levels ($1-$5) decrease use of services, including needed services • Increased use of more expensive services (e.g., ER) • Negative effects on health outcomes • Increased financial burdens for families Rx • States savings are limited • Offset by disenrollment, increased costs in other areas, and administrative expenses
  20. 20. Figure 19 • What is the waiver doing? What are the stated goals and objectives? – Have similar waivers been approved in other states? What have we learned? • What provisions of the law are being waived? What populations are affected by the proposal? • What are the state estimates for PMPM costs and coverage with and without the waiver? • Does the state have an implementation plan? – What are the administrative costs and challenges? • What is the process to receive public input? If the waiver was open for public comment, did the waiver incorporate these comments? • What are the requirements for reporting and evaluation? – How often do states need to submit data? Key questions to ask about new waiver proposals and approvals:
  21. 21. Figure 20 • Reauthorization of CHIP??? • Deficit reduction and entitlement reform in 2018 – Reframing the scope and reach of Medicaid – Reducing federal Medicaid costs – Restructuring Medicaid financing What Congressional Actions?
  22. 22. Figure 21 SOURCE: Kaiser Family Foundation CHIP Survey of Medicaid Officials conducted by Health Management Associates, Summer 2017 with November 2017 update. *Indicates state did not provide updated projections in November. In December, Congress temporarily extended CHIP funds which may push back estimates of when states expect to exhaust funds. 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 February - March 2018 (21 states, including DC) April 2018 or later (11 states) By end of January 2018 (16 states) Not Reported (3 states)
  23. 23. Figure 22 Federal Spending Year Current law Federal Cap Medicaid block grants or per capita caps, designed to cap federal spending could be part of entitlement reform discussions. Current law: Reflects increases in health care cost, changes in enrollment, and state policy choices Block grant: Does not account for changes in enrollment or changes in health care costs Per capita cap: Does not account for changes in health care costs
  24. 24. Figure 23 • Shift costs and risks to states, beneficiaries, and providers if states restrict eligibility, benefits, and provider payment • Lock in past spending patterns – If expansion funding is cut, the impact could be even greater for the 32 states that expanded Medicaid • Limit states’ ability to respond to rising health care costs, increases in enrollment due to a recession, or a public health emergency such as the opioid epidemic, HIV, Zika, etc. Reducing and capping federal Medicaid funds could:
  25. 25. Figure 24 20.9% 10.1% 47.7% 24.5% 27.8% 16.7% 54.6% 62.1% 35.6% Total State Spending (State & Federal Funds) $47.5 Billion State Funds (General & Other Funds) $32.5 Billion Federal Funds $13.9 Billion Medicaid Elementary & Secondary Education Other SOURCE: Kaiser Family Foundation estimates based on the NASBO’s November 2017 State Expenditure Report (data for Actual FY 2016.) Medicaid accounts for nearly half of all federal funds in Georgia’s state budget.
  26. 26. Figure 25 Medicaid Expansion Decision / Limited Medicaid Programs Challenging Demographics Poor Health Status High Cost Health Markets Low Spending and Low Tax Capacity SOURCE: which-states-are-most-at-risk/ Certain characteristics put some states at higher risk than others under federal Medicaid cuts and caps.
  27. 27. Figure 26 Highest Uninsured Rate Texas Georgia Florida Mississippi Oklahoma Largest Number of People in the Coverage Gap Texas Florida Georgia North Carolina South Carolina High Poverty New Mexico Kentucky Mississippi Louisiana Georgia Low State Spending Per Capita Idaho Arizona Georgia Nevada Tennessee High Rate of New HIV Cases District of Columbia Louisiana Georgia Florida Maryland NOTE: Eleven states rank in the top five for five or more risk factors (AL, AZ, FL, GA, KY, LA, MS, NM, SC, TX, WV). states-are-most-at-risk/ Georgia ranks in the top 5 for multiple risk factors in responding to federal Medicaid reductions.
  28. 28. Figure 27 Evidence from over 150 studies suggest that the Medicaid expansion has positive effects for beneficiaries and states. Increased Economic Activity Increased Access to Care and Service Utilization Reduction in the Number of Uninsured ↓ Uncompensated care costs ↓ State-funded health programs (e.g. behavioral health and corrections) Increased State Savings Federal + State Funds + ↑ General fund revenue and GDP ↑ or neutral effects on employment ↑ Affordability and Financial Security SOURCE: L. Antonisse, R. Garfield, R. Rudowitz, and S. Artiga, The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review (Washington, DC: Kaiser Family Foundation, September 2017), medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-september-2017/
  29. 29. Figure 28 • New opportunities for states – New flexibility through waivers – Re-examination of Medicaid expansion • Uncertainty about state fiscal issues – Extension of CHIP – Implications of the tax legislation – New debate on entitlement reform and Medicaid cuts • Key policy priorities – Cost containment – Improving outcomes – Addressing opioid epidemic and substance use disorders – Rural health Key Priorities and Issues for States in 2018
  30. 30. Figure 29 NOTE: Don’t know/Refused responses not shown. Question wording abbreviated. See topline for full question wording. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted June 14-19, 2017) Would you say the current Medicaid program is working well for most low-income people covered by the program, or not? Majorities across political parties say Medicaid is working well for most low-income people covered by the program. By Political Party ID …in the nation, overall? …in your state? Total Democrats Independents Republicans 61% 68% 62% 52% 26% 20% 28% 35% Working well Not working well 67% 72% 68% 59% 23% 18% 25% 29%
  31. 31. Figure 30 Source: Faces of Medicaid. There are many “Faces of Medicaid”.