The Future of Medicaid and Health Care Access in Ohio
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Since its expansion in 2014, Ohio’s Medicaid program has played a critical role in cutting the number of uninsured Ohioans almost in half. With talk of repealing the Affordable Care Act at the federal level, what are the implications on Ohio’s budget process? Speakers include: - Loren Anthes, Public Policy Fellow, Medicaid Policy Center, The Center for Community Solutions - Wendy Patton, Senior Project Director, Policy Matters Ohio - Brandi Slaughter, Chief Executive Officer, Voices for Ohio’s Children
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The Future of Medicaid and Health Care Access in Ohio
- 1. The Future of Medicaid and Health Care Access in Ohio A look at what’s next for the Affordable Care Act and Medicaid
- 2. a statewide coalition of over 485 organizations and thousands of individual advocates. Advocates for Ohio’s Future is…
- 3. Ohio should be a great place for ALL Ohioans to live and work. Participate in the economy Be healthy and saf e Afford the basics
- 4. Advocate with us! • You’ll receive a follow-up email from this webinar • Look for “Act Now” email alerts, webinar invitations, and new resources • Unsubscribe at any time
- 5. Webinar Presenters Loren Anthes Public Policy Fellow, Medicaid Policy Ce nter Brandi Slaughter Chief Executive Officer Voices for Ohio’s Children Wendy Patton Senior Project Director Policy Matters Ohio
- 6. Medicaid Background Loren C. Anthes, MBA Public Policy Fellow, Center for Medicaid Policy 1.12.17
- 7. Additional Research When you see this… More info is on our website!
- 8. You’ve Seen One State’s Program… “No one designed the existing program; rather it is a perplexing Rube Goldberg of incremental adjustments and periodic enhancements or cutbacks, at both the national level and the state level, which rarely work in concert.”
- 9. What Will be Covered • The 5 W’s • The Money • A Quick Review of the State’s “Group VIII Assessment”
- 10. THE 5 W’S… (AND ONE H)
- 11. Who Children Pregnant Women Parents Childless Adults Disabled Workers Disabled Medicaid Marketplace 138% FPL 200% FPL 250% FPL 400% FPL
- 12. What • Early and Periodic screening, diagnosis and treatment (EPSDT) for children • Inpatient hospital • Physician • Lab and X-ray • Outpatient, including services provided by hospitals, rural health clinics, and Federally Qualified Health Centers • Medical and surgical vision • Medical and surgical dental • Transportation of Medicaid services • Nurse midwife, certified family nurse and pediatric nurse practitioner • Home Health • Nursing facility • Medicare premium assistance • Prescription drugs • Durable medical equipment and supplies • Vision, including eyeglasses • Dental • Physical Therapy • Occupational therapy • Speech therapy • Podiatry • Chiropractic services for children • Independent psychological services for children • Private duty nursing • Ambulance/ambulette • Community alcohol/drug addiction treatment • Home and Community based alternatives to facility based care • Intermediate care facilities for people with developmental Disabilities • Hospice • Community mental health services FEDERALLY MANDATED STATE OPTIONAL
- 13. Where
- 14. When Ohio Medicaid spends $48,000/minute
- 15. Why
- 16. How: State Plan REASONABLE PROMPTNESS • States must promptly provide Medicaid to recipients without delay caused by agency’s procedures EQUAL ACCESS TO CARE • States must set payment rates that are adequate to assure Medicaid recipients reasonable access to services of adequate quality COVERAGE OF MANDATORY SERVICES • CMS requires state Medicaid programs to provide certain medically necessary services to covered populations http://www.medicaid.ohio.gov/MEDICAID101/MedicaidStatePlan.aspx
- 17. How: Waivers Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid. The purpose of these demonstrations is to demonstrate and evaluate policy approaches such as: • Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible; • Providing services not typically covered by Medicaid; or • Using innovative service delivery systems that improve care, increase efficiency, and reduce costs. • States who want to request a program under this authority must submit a written application to CMS for approval that details the goals and operational aspects of the program, and those applications are subject to public review and comment. Other waiver authorities include Section 1915(b) Freedom of Choice (Managed Care) Waivers and Section 1915(c) Home and Community-Based Services Waivers.
- 18. MONEY
- 19. The Money: Federal Match Source: HPIO
- 20. The Money: Federal Match Source: Ohio Legislative Service Commission, All-Funds Medicaid Expenditure History $5,598 $5,322 $4,711 $5,250 $6,723 $6,950 $7,349 $7,383 $7,756 $8,139 $10,095 $11,279 $12,431 $11,678 $11,907 $13,511 $16,084 $17,538 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 State Federal 116% 39% 08 09 10 11 12 13 14 15 16 STATE SHARE 40.8% 34.5% 29.5% 29.7% 36.5% 36.9% 35.2% 31.5% 30.7% FEDERAL SHARE 59.2% 65.5% 70.5% 70.3% 63.5% 63.1% 64.8% 68.5% 69.3%
- 21. The Money: Since 1975 Source: Ohio Legislative Service Commission, Total State and Federal GRF Expenditure History - 5 10 15 20 25 30 35 FY1975 FY1977 FY1979 FY1981 FY1983 FY1985 FY1987 FY1989 FY1991 FY1993 FY1995 FY1997 FY1999 FY2001 FY2003 FY2005 FY2007 FY2009 FY2011 FY2013 FY2015 FY2017 Billions EXPENDITURES 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% FY1975 FY1977 FY1979 FY1981 FY1983 FY1985 FY1987 FY1989 FY1991 FY1993 FY1995 FY1997 FY1999 FY2001 FY2003 FY2005 FY2007 FY2009 FY2011 FY2013 FY2015 FY2017 SHARE OF BUDGET
- 22. The Money: Spending 12.1% 47.3% 57.2% 28.4% 22.6% 21.3% 8.0% 3.0% ENROLLMENT EXPENDITURE ABD CFC Medicaid Expansion Other • Most of the resources consumed by Aged, Blind and Disabled (ABD) • Question: How do you become efficient?
- 24. Ohio Expansion Cost Source: Ohio Legislative Service Commission, Budget Footnotes
- 25. Ohio Expansion Results ACCESS • Uninsured rates for low-income Ohioans at an all-time low • 64.3% of enrollees reported better access • Mostly benefited white, unmarried men with a highschool diploma or less OUTCOMES • Half reported an improvement in health • Ability to manage disease increased http://medicaid.ohio.gov/
- 26. Ohio Expansion Results RURAL IMPACT • 43.5% of population in small hubs were covered by Medicaid (compared to 38.5% in big cities) • 35 of the 47 small towns also had a hospital as one of the major employers CREATES ECONOMIC MOBILITY • National Bureau of Economic Research – Does not create job-lock – Children who were covered are healthier, living longer, and working SUPPORTED WORKING • 22.9% reported financial situation improved • 58.6% stated coverage made it easier to purchase food • 48.1% said is was easier to pay mortgage • 44.8% said it eliminated their medical debt INCENTED WORKING • 40% working • 50% stated it was easier to secure and maintain work • 75% of unemployed stated it would be easier to find a job • Of the unemployed, half had a mental health issue (compared to 28% of those without)
- 27. Ohio Expansion Cost Source: Ohio Legislative Service Commission, Budget Footnotes
- 28. THANK YOU Additional Resources: www.communitysolutions.com/Medicaid Follow me! @lorenanthes @CCSPolicy
- 29. Repeal of the ACA will hurt Ohio – especially Medicaid Wendy Patton, Senor Project Director Policy Matters Ohio wpatton@policymattersohio.org
- 30. The Affordable Care Act has Helped Ohio •900,000 more have health coverage •5,000,000 with pre-existing conditions are protected •Lifetime caps, limits on care, are eliminated •Free preventative care in all health coverage
- 31. Where Americans Get Health Coverage Source: New York Times, January 3, 2017 3% 1.2% other
- 32. Repeal Would Hurt Financially • State loses billions of federal $$$$ • Indigent care swamps hospitals • Insurers lose customers • Families and individuals lose coverage • Seniors lose help paying for prescriptions • 117,000 children lose insurance in 2019
- 33. Repeal Would Hurt Low-Income Workers 7,070 8,490 8,770 9,190 9,320 13,530 14,000 16,090 18,010 60,030 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 Hotels/motels Building services (janitor, extermination, cleaning) Department and discount stores Grocery stores Child day care services Home health care services Employment services (temp agencies) Nursing care facilities Construction Restaurants and other food services Number of adult workers by sector enrolled in Medicaid expansion. These are the ten sectors with the largest numbers of workers enrolled in Medicaid expansion. Source: Analysis of the 2015 American Community Survey. Adults are those aged 19 through 64. Workers are those who have worked within the past year. The ten industries above are those with the largest number of Medicaid enrolled workers in the Medicaid expansion income-eligibility range in Ohio. All figures are rounded to the nearest ten workers.
- 35. Danger of Proposed Structures • Block grant • Per-capita Cap • Premiums • Lock-outs • Reduction in eligibility What happened under block grant structure in TANF illustrates danger
- 36. Erosion of Value Would Further Reduce Health Services Over Time
- 37. VoiceOhioKids Voices for Ohio’s Children
- 38. Medicaid is a Critical Health Social Support • Children and Families • People with Disabilities • Seniors
- 39. The U.S. and Ohio Have Achieved Historic Low Uninsured Rates Among Children 9.3% 4.8% 6.8% 4.4% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% 2008 2009 2010 2011 2012 2013 2014 2015 Child Uninsured Rate in the U.S. and Ohio Over Time United States Ohio
- 40. Largely Thanks to Increased Participation in Medicaid and CHIP 81.7% 84.3% 85.8% 87.2% 88.1% 88.3% 91.0% 83.3% 86.6% 88.5% 87.8% 89.5% 90.2% 92.1% 76.0% 78.0% 80.0% 82.0% 84.0% 86.0% 88.0% 90.0% 92.0% 94.0% 2008 2009 2010 2011 2012 2013 2014 Participation in Medicaid/CHIP
- 41. Close to half of Medicaid enrollees in Ohio are children * Source: CMS Medicaid and CHIP Enrollment Report, October 2016 Children 42% Adults 58%
- 42. • For every 1 child enrolled in CHIP there are 6.5 enrolled in Medicaid in Ohio • CHIP = Healthy Start • CHIP in Ohio is an expansion of Medicaid but children must be uninsured CHIP Rests on the Shoulders of Medicaid Source: MACPAC “Child Enrollment in CHIP and Medicaid in 2015”
- 43. Snapshot of CHIP History Bipartisan support created CHIP CHIP was reauthorized with funding extended through 2013 ACA strengthened CHIP by extending funding through September 2015 and boosting CHIP match rate by 23 percentage points in 2016 Congress must act to extend CHIP funding beyond September 2017 1997 2009 2010 2017 Going forward, renewing CHIP funding is essential for maintaining our gains in coverage and ensuring quality, affordable care for kids.
- 44. CHIP: Federal-State Partnership Federal Government States Administration Oversight Direct administration Financing Pays 65% to 85% of costs; with a 23% point bump in 2016 Pays non-federal share of cost Program Rules Fewer minimum standards than Medicaid • Set provider payment rates • Determine eligibility rules, benefits, and cost sharing within guidelines Coverage Guarantee None required Can freeze or cap enrollment or require waiting periods CHIP: Federal-State Partnership
- 45. What do we know about past restructuring proposals and the impact of ACA repeal?
- 46. Potential Risks to Children in Restructuring Proposals Cuts to Medicaid in exchange for state flexibility could eliminate core protections for children in federal standards: • Guarantee of coverage • Comprehensive benefits through EPSDT • Cost-sharing limitations
- 47. Repeal of ACA Direct Impact on Children and Families • Maintenance of Effort provision (MOE) requiring states to hold children’s eligibility levels steady • Coverage of former foster youth up to age 26 • Loss of parent expanded coverage and impact on: • Parent health • Family economic security • Welcome mat effect on child enrollment • Loss of Marketplace coverage for 1 million kids in the U.S.; approximately 30,000 in Ohio.
- 48. Other Policy Changes Proposed in the Past • Substantial changes through waiver activity • Elimination of 23% point e-FMAP increase for CHIP • Mandated vs. optional 5 year waiting period for lawfully present immigrant children
- 49. Healthy Start is Still Essential Designed specifically to meet the needs of kids More comprehensive benefits for kids compared to Marketplace plans More affordable for families: Healthy Start does not require premiums or cost-sharing for children Not all families will qualify for financial assistance to purchase Marketplace plans Healthy Start federal funding provides state budget stability and predictability
- 50. Contact Us www.raiseyourvoiceforkids.org Brandi Slaughter, CEO brandi@raiseyourvoiceforkids.org Dana Dunlap, Policy Director danaj@raiseyourvoiceforkids.org
- 51. • You’ll receive a follow-up email with links to video, slides and resources • Join the conversation on social media: • @Advocates4OH • Facebook.com/advocatesforohio • @PolicyMattersOH • Facebook.com/policymattersohio Next Steps • @CommunitySols • Facebook.com/CommunitySols • @VoiceOhioKids • Facebook.com/voicesforohioschildren
- 52. Call Ohio Senators Rob Portman (202-224-3353) and Sherrod Brown (202-224-2315) and tell them not to repeal the Affordable Care Act without a replacement. Make Your Voice Heard!
- 53. Thank you for joining us today!
Editor's Notes
- Loren has already spoken a great deal about Medicaid, how its financed, who it covers. From a kids perspective Medicaid helps children and families thrive now and in the future. Children who have Medicaid are more likely to be healthy, do better in school, and become financially independent adults. Additionally Medicaid helps families afford care for children with special needs. It also contributes to family economic security.
- Thanks to Medicaid, the Children’s Health Insurance Program (CHIP) and the ACA, ninety-five percent of children in the United States have health coverage – an historic high. Nationwide, 1.7 million children gained coverage between 2013-2015, as the rate of uninsured kids dropped to 4.8%, down from 7.1%. Put another way, the number of uninsured children declined by almost a third, dropping from 5.3 million in 2013 to 3.5 million in 2015. In Ohio, more than 95% children have health coverage as the uninsured rate feel to historic lows in the wake of Obamacare. Several states have fewer than 2% of children uninsured compared to 4.4% in Ohio, yet 4.4% is down from 5.3% and been under the national average now and in recent years. Most newly insured kids acquired health coverage thought Medicaid expansion and CHIP according to a report from Georgetown University’s Center for Children and Families, while employee sponsored coverage remained stable, covering 46.5% of children nationwide. Despite Ohio’s success, more can be done. In Ohio, 26,000 children gained coverage between 2013-2015, leaving an estimated 115,000 younger than 19 without health insurance.
- Thanks to Medicaid, the Children’s Health Insurance Program (CHIP) and the ACA, ninety-five percent of children in the United States have health coverage – an historic high. Nationwide, 1.7 million children gained coverage between 2013-2015, as the rate of uninsured kids dropped to 4.8%, down from 7.1%. Put another way, the number of uninsured children declined by almost a third, dropping from 5.3 million in 2013 to 3.5 million in 2015. In Ohio, more than 95% children have health coverage as the uninsured rate feel to historic lows in the wake of Obamacare. Several states have fewer than 2% of children uninsured compared to 4.4% in Ohio, yet 4.4% is down from 5.3% and just under the national average. Most newly insured kids acquired health coverage thought Medicaid expansion and SCHIP according to a report from Georgetown University’s Center for Children and Families, while employee sponsored coverage remained stable, covering 46.5% of children nationwide. Despite Ohio’s success, more can be done. In Ohio, 26,000 children gained coverage between 2013-2015, leaving and estimated 115,000 younger than 19 without health insurance.
- Slightly more than half of Medicaid enrollees are children. In Ohio? And we know that children with Medicaid become healthier adults, have greater academic achievement, and attain greater economic success. Parents with Medicaid are healthier and better able to support their children’s healthy development. Families with Medicaid have greater economic security and are less likely to have medical debt or bankruptcy. Coverage provides peace of mind that reduces family stress.
- Healthy Start provides uninsured low and moderate-income children with affordable health care coverage. Ohio uses federal funds from the Children’s Health Insurance Program (CHIP) to finance Healthy Start. Under Ohio guidelines, children in families with up to 200% of poverty, $48,600 a year for a family of four, qualify for coverage. Ohio chose to expand Medicaid with CHIP funds rather than create a separate coverage program. That means that children enrolled in Healthy Start receive the same benefits as children enrolled in Medicaid but the state receives the higher CHIP federal matching rate. In 2016, less than 200,000 children are enrolled in Healthy Start. Healthy Start federal funding provides stability and predictability for the state budget, while ensuring access to quality health care for Ohio’s uninsured children.
- CHIP BACKGROUND: It was enacted in 1997 to encourage states to expand coverage to uninsured children Reauthorized in 2009 - 2013 (CHIPRA) with additional state options Funding extension through 2015 (ACA) with additional federal match (23 percentage point bump) and requirement to maintain eligibility (MOE) Funding extended through 2017 (MACRA) but reduced state ability to carry over more than 2/3’s of unspent allotment Block grant with capped annual allotments No entitlement to coverage
- Healthy Start is funded through the Children’s Health Insurance Program, a federal-state partnership. The federal government matches Ohio’s investment in Healthy Start by a 3:1 match rate. CHIP has worked in conjunction with Medicaid to bring down the national rate and Ohio’s rate of uninsured children to the lowest level on record. However, CHIP funding is set to expire on September 30, 2017. Congress must renew CHIP funding in order to continue the success of Healthy Start.
- CHIP has been extremely successful program, bi-partisianly supported and works with Medicaid to provide coverage to children and families. Therefore we are watching closely the debates on the ACA repeal and the restructuring models. The Urban Institute recently released a report modeled on the 2015 reconciliation bill what was approved by Congress and vetoed by President Obama. That report found that the number of uninsured children would more than double nationwide if Congress follows through on its plan to repeal the Affordable Care Act without immediately replacing it. As I previously mentioned, in Ohio, more than 26,000 children gained coverage between 2013-2015 and the state’s rate of uninsured children also fell to 4.4% down from 5.3%.
- Evaluating the restructuring proposals, Voices is most concerned that we maintain core protections for children in the federal standards such as: guarantee of coverage, comprehensive benefits through EPSDT (The gold standard) and cost sharing limitations. Congress should be keeping the unique needs of children in mind as they consider the future of the Affordable Care Act (ACA) and ensure that any changes do no harm to children.
- CHIP is important, as is Medicaid and those covered by the ACA. As the debate continues it’s important that children not lose ground: any health reforms must build on achievements already made to further improve coverage for children. We look forward to working with you to ensure no child is worse off as changes to our health care system are contemplated, and that we can work together to make even more progress for children.