1. Sarah Steenhausen Senior Policy Advisor
CFILC
Statewide Conference
February 27, 2017
Perspectives in California Examining State and Federal Policy Issues and Advocacy in LTSS
Sarah Steenhausen
Senior Policy Advisor

2. System Challenges Fragmentation Infrastructure/capacity
Workforce shortages
Financing
Legislative and state leadership
…If the problems were easy to solve, they wouldn’t be problems

3. System Change Developing Integrated Systems of Care
Coordinated Care Initiative
Medi-Cal 2020
Themes
Importance of social determinants
Care coordination is key to success
Role of social determinants of Health in meeting health care needs

4. Emerging Considerations: Federal Policy Climate
Potential Policy Change:
Affordable Care Act repeal/repair: Impact on Long-Term Services and Supports (LTSS)
Medicaid block grants
Medicaid per capita cap

5. ACA: LTSS Provisions Home and community-based services
Care coordination
Workforce Investment
LTC financing (CLASS)- already repealed
Home and Community Based Services:
Signifies shift away from federal nursing home bias
Provides financial incentives to increase access to HCBS
Extends nursing home transition program
Implements spousal impoverishment provisions for HCBS
Medicaid HCBS provisions are voluntary for states
Care Coordination Opportunities in the ACA:
Provider Level:
Medicare “Shared Savings” Program - Accountable Care Orgs.
Medicaid Health Homes
Incentivize providers to collaborate and improve care
Federal Level:
Federally Coordinated Health Care Office
Center for Medicare/Medicaid Innovation
Workforce Investment
Federal Level
National Health Care Workforce Commission
State Level
Health Care Workforce Development Grants
Personal and Home Care Aide State Training Program
Nursing Assistant/Home Health Aide Training Program

6. ACA: Potential for Repeal/Repair
President Trump’s Executive Order
Likely process: Budget reconciliation
Timing?
Not clear what will be reconciled in budget and impact on the above mentioned LTSS provisions
The coverage provisions are the main target. very little or nothing has been said about the LTSS/delivery system provisions at this point

7. Medicaid Block Grant Fixed amount of Medicaid funding to states
Caps federal spending
Increased state flexibility
A “block grant” is a fixed amount of money that the federal government gives to a state for a specific purpose. If Medicaid was turned into a block grant, the federal government would set each state's Medicaid spending amount in advance

8. Per Capita Cap Fixed amount of Medicaid funding per enrollee
Payments to states based on Medicaid enrollment
Increased state flexibility
A a per-beneficiary federal cap (either total or by population group) would be determined for a base year.  Each year, the per enrollee cap would be adjusted annually based on a federally-determined growth limit.  A state’s total federal Medicaid funding limit for each subsequent year would be determined by multiplying the base year per capita amount, the growth limit percentage, and enrollment.  To achieve federal savings, the per capita growth amounts would be set below the projected rates of growth under current law.
Payments to states would reflect changes in enrollment but not changes in the costs per enrollee beyond the growth limit. For example, should Medicaid enrollment increase due to tough economic times, as was seen in the Great Recession, the payments to states would be higher; however if enrollment declines, the federal payments to states would be lower.  Details about state matching requirements are not clear in current proposals. State matching dollars could be required to draw down federal dollars up to the per capita cap, but after reaching the cap, states could be responsible for additional costs.  Health care costs of the population, including changes due to an increase in the prevalence of chronic disease or new technology would not be factored into the payments for states.
What are key challenges in designing a per capita cap?
The key design questions and challenges in developing a per capita cap proposal are tied to decisions about methodology used to calculate the base spending per enrollee, the allowable growth rate for spending per enrollee, and what federal core requirements could be changed.
Setting the Base Spending Per Enrollee.  Determining the base spending per enrollee in a per capita model would involve a number of decisions.  Policy makers may include or exclude certain Medicaid payments (such as disproportionate share hospital payments (DSH) or Medicare premium amounts) and may include or exclude “partial benefit” enrollees (those who may be eligible for limited benefits such as family planning or home and community-based services only).
Per capita caps could be based on per enrollee spending for each state or nationally; similarly, there could be one per enrollee spending base or separate base amounts for each eligibility group.  If the cap were to use a historical spending per enrollee by state as the base, states effectively would be locked into their policy choices, and inequalities between the different Medicaid programs would become permanent.  On the other hand, implementing a uniform per capita cap across states would likely result in large changes in the distribution of funds across states.  Some proposals may include provisions to attempt to address these issues.
Based on current flexibility in the Medicaid program, there is considerable variation in per enrollee costs across eligibility groups and across states.  Total spending per full benefit enrollee ranged from a low of $4,010 in Nevada to $11,091 in Massachusetts in FY   (Figure 1)  Spending for the elderly and individuals with disabilities may be more than four times the spending for an adult and more than seven times spending for an average child covered by the program.5  (Figure 2)  In addition, even within a given state and eligibility group, per enrollee costs may vary significantly, particularly for individuals with disabilities.
What’s next in Congress?
Budget reconciliation
Replacement plan?
State implementation and budget/policy implications

9. Emerging Considerations: State Policy Climate and LTSS
Governor anticipates budget deficit
Changes to the Coordinated Care Initiative
Other funding reductions

10. Focus on: Coordinated Care Initiative (CCI)
Background and purpose
Budget actions on CCI
IHSS implications
Impact on care coordination
Considerations for the future of integrated service delivery in California

11. LTSS: Unresolved Issues
State and system planning
LTC Financing
HCBS Infrastructure
Others

12. Cross-Cutting Issues Competing priorities
Relationship between feds, state administration, and legislature
How to focus an LTSS agenda
Sarah to Cover this Slide

13. Advocacy’s Important Role
Collaboration across disability and aging (California Collaborative and Regional Coalitions)
Identifying common priorities
Developing strategy for local, state and federal level advocacy

14. Questions/Comments?
Thank you!

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Our Vision: A society where older adults can access health and supportive services of their choosing to meet their needs.
Our Mission:
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