Alan Weil Executive Director National Academy for State Health Policy

1. Medicaid and the ACA:
Issues for Reporters
Reporting on Health
March 5, 2013
Alan Weil
Executive Director
National Academy for State Health Policy

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. 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 expand
Source: Kaiser Family Foundation, “Medicaid and Children’s Health Insurance
Program Provisions in the New Health Reform Law”, April 2010

4. Four Perspectives
on the Medicaid Expansion
• Coverage
• Cost
• Health
• Health system performance

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%+ FPL
FPL= 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. 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 expansion
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.

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

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 and
access to care among adults after state medicaid
expansions. N Engl J Med 2012;367:1025–34.

10. Medicaid and Health System
Performance
• Coverage continuity
• Care continuity
• Aligned quality metrics
• Aligned purchasing and reporting
strategies

11. SOURCE: The Advisory Board Company. Where each state stands on the ACA’s Medicaid
expansion. Accessed February 27, 2013 at http://www.advisory.com/Daily-
Briefing/2012/11/09/MedicaidMap#lightbox/0/.

12. SOURCE: State Reforum: Tracking Medicaid Expansion Decisions. Accessed February
27, 2013 at http://www.statereforum.org/medicaid-expansion-decisions

13. Medicaid Beyond the Expansion
• Eligibility and enrollment systems
• Dual eligible demonstrations
• Health homes
• Reductions in Safety Net Hospital funding
(DSH)

14. Eligibility System Upgrades
State Responses Regarding Streamlined Eligibility and Enrollment Requirements
SOURCE: Department of Health and Human Services. Office of the Inspector General. Most
States Anticipated Implementing Streamlined Eligibility and Enrollment by 2014. February
2013. Accessed Feb 28, 2013 at https://oig.hhs.gov/oei/reports/oei-07-10-00530.pdf

15. Duals Demonstration States
SOURCE: Kaiser Family Foundation. State Adoption of Integrated Financing
and Care Delivery for Dually Eligible Beneficiaries Provided by the Affordable
Care Act, August 2012. Accessed Feb 28, 2013 at
http://statehealthfacts.kff.org/comparemaptable.jsp?ind=1067&cat=17

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. 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 Disproportionate
Share Hospital Payments. Washington (DC): CRS; 2012 Dec 18. Available from:
https://www.fas.org/sgp/crs/misc/R42865.pdf

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 Level
SOURCE: Sommers BD, Rosenbaum S. Issues In Health Reform: How Changes
In Eligibility May Move Millions Back and Forth Between Medicaid And Insurance
Exchanges. Health Affairs, February 2011, vol 30, no 2, pgs 228-236.

19. The Remaining Uninsured
Distribution of Nonelderly Uninsured Adults Under the ACA
SOURCE: BuettgensM, Hall MA. The Urban Institute. Who Will Be Uninsured After Health
Insurance Reform? Accessed Feb 28, 2013 at
http://www.urban.org/UploadedPDF/1001520-Uninsured-After-Health-Insurance-

20. Statereforum.org 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. Alan Weil
Executive Director
aweil@nashp.org
www.nashp.org
www.nashp.org/onceinaweil
www.statereforum.com
@nashphealth