1. Medicaid As a Platform for Health Reform
Barbara Lyons, Ph.D.
Vice President and Deputy Director
Kaiser Commission on Medicaid and the Uninsured
Henry J. Kaiser Family Foundation
for
Health Access and Coverage Panel
Washington DC Health Policy Seminar
University of St. Thomas, Opus College of Business
April 21, 2009

2. Medicaid’s Role Today MEDICAID Health Insurance Coverage
29.5 million children & 15 million adults in low-income families; 14 million elderly and persons with disabilities
Assistance to Medicare Beneficiaries
8.8 million aged and disabled — 19% of Medicare beneficiaries
Long-Term Care Assistance
1 million nursing home residents; 2.8 million community-based residents
MEDICAID
HI Coverage data from FY 2004….MSIS
Duals—2003, based on MSIS and Medicare State Enrollment data from CMS
LTC assistance—NH residents from SHFO;
Support for System and % of LTC services from Natl Health Expendure data released January 2009.
State Capacity—for 2006, source: NASBO, fall 2007 state expenditure report
Support for Health Care System and Safety-net
16% of national health spending; 40% of long-term care services; about 1/3rd of CHC and public hospital revenues
State Capacity for Health Coverage
Federal share ranges 50% to 76%; 44% of all federal funds to states

3. Percent of Nonelderly Residents Covered
by Medicaid, by State, NH VT ME WA MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH NE IN NV IL DE WV UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM GA MS AL TX LA
<10%: NH, NV, VA, NJ, CO, ND, MD, NE (8 states)
10-12%: WY, UT, FL, HI, MN, DE, SD, IL, IN, OR, ID, AK (12 states)
13-15%: CT, MT, TX, WI, PA, IA, MO, GA, NC, OH, OK, SC, MI, AL, WA, KS (16 states)
>15%: AR, CA, TN, WV, AZ, NM, RI, MS, NY, ME, VT, DC, LA, KY, MA (15 states plus DC) AK FL HI
>15% (15 states including DC)
13-15% (16 states)
US Average = 13%
10-12% (12 states)
< 10% (8 states)
SOURCE: Urban Institute and KCMU analysis of the March 2006 and 2007 Current Population Survey. Two-year pooled estimates for states and the US ( ).

4. Medicaid Enrollees and Expenditures by Enrollment Group, 2005
Elderly
10%
Elderly
28%
Disabled
14%
Adults
26%
Disabled
42%
Children
50%
Adults 12%
Children 18%
Total = 59 million
Total = $275 billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.

5. Medicaid As a Logical Building Block to Broaden Coverage

6. Health Insurance Coverage of the Total Population, 2007
Total = million
SOURCE: KCMU and Urban Institute analysis of March 2008 CPS.

7. Health Insurance Coverage of the Nonelderly by Poverty Level, 2007
The federal poverty level (FPL) was $21,203 for a family of four in Data may not total 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.

8. Over Half the Nonelderly Uninsured are Low-Income Adults
Nonelderly uninsured by age and income groups, 2007:
Other Adults without Children 21%
Total = 45.0 Million Uninsured
Low-income defined as those with family incomes less than 200% of the federal poverty level. Nonelderly includes <age 65.
SOURCE: KCMU/Urban Institute analysis of 2008 ASEC Supplement to the CPS

9. Children’s Eligibility for Medicaid/CHIP by Income, January 2009NH VT WA ME MT ND MA MN OR NY ID SD WI MI RI WY CT PA IA IL NJ NE OH IN NV IL WV DE UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA
IMPLEMENTED:
<200% FPL: AK (175), OR (185), ID (185), MT (133), ND (140), NE (185), OK (185) – 7 states
200% - 250% FPL: AL (200), AZ (200), AR (200), DE (200), FL (200), IL (200), IA (200), KS (200), KY (200), ME (200), MI (200), MS (200), NV (200), NC (200), OH (200), SC (200), SD (200), TX (200), UT (200), VA (200), WY (200), CO (205), WV (220), GA (235), NM (235), CA (250), IN (250), LA (250), NY (250), RI (250), TN (250), WA (250), WI (250)
>250% FPL: MN (280), CT (300), DC (300), HI (300), MD (300), MA (300), MO (300), NH (300), PA (300), VT (300), NJ (350) AK FL HI
< 200% FPL (7 states)
% FPL (33 states)
*The Federal Poverty Line (FPL) for a family of three in 2008 is $17,600 per year.
***IL uses state funds to cover children above 200% FPL.; MA uses state funds to cover children above 300% FPL; NY uses state funds to cover children from 250% to 400% FPL; WI uses state funds to cover children from 250% to 300% FPL.
SOURCE: KCMU/CBPP annual survey of state eligibility and enrollment policies, 2009.
>250% FPL (11 states including DC)

10. Views of Public Coverage Among
Low-Income Parents with an Uninsured Child
Medicaid/SCHIP a good program*
Parent would enroll child if
eligible for public coverage
*Based on those who have heard of Medicaid/SCHIP
SOURCE: Kaiser Survey of Children’s Health Coverage, 2007.

11. Median Medicaid/SCHIP Income Eligibility Thresholds, 2008
Federal Poverty Line
(For a family of four is
$21,200 per year in 2008)
SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.

12. Medicaid Eligibility for Working Parents by Income, January 2009NH VT WA ME MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH IN NV IL IL WV DE UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA
<50% FPL: AL (25), AR (20%), ID (28), IN (26%), KS (34), LA (26), MS (46), MO (26), OK (48), PA (36), TX (27), VA (30), WV (34)
13 states
50-99% FPL: AK (85), CO (66), FL (55), GA (52), IA (86), KY (62), MI (66), MT (58), NE (58), NV (91), NH (51), NM (69), NC (51), ND (62), OH (90), SC (90), SD (54), UT (68), WA (77), WY (54): 20 states
100% or higher: AZ (200), CA (106), CT (191), DE (121), DC (207), HI (100), IL (185), ME (206), MD (116), MA (133), MN (275), NJ (200), NY (150), OR (100), RI (181), TN (134), VT (191), WI (200): 18 states AK FL HI
20-49% FPL (13 states)
50- 99% FPL (20 states)
US Median Eligibility = 68% FPL: $11,968 per year
> 100% FPL (18 states including DC)
*The Federal Poverty Line (FPL) for a family of three in 2008 is $17,600 per year.
SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.

13. Options for Expanding Coverage
Percent of registered voters who favor each way to expand coverage:
Tax breaks to businesses
Expanding Medicaid/ SCHIP
Expanding Medicare
Tax credits to people
Employers pay or play
Individual mandate
Single government plan
Note: Not exact wording of options
Source: Kaiser Health Tracking Poll: Election (conducted Sep , 2008).

14. How Can Medicaid be Strengthened in Health Reform?

15. Barriers to Health Care Among Low-Income Nonelderly Adults, by Insurance Status, 2007
* In the past 12 months
Respondents who said usual source of care was the emergency room were included among those not having a usual source of care.
SOURCE: KCMU analysis of 2007 NHIS data.

16. Samples adjusted for health differences
Per Capita Spending For Medicaid Enrollees vs. Low-Income Privately-Insured
Samples adjusted for health differences
Adults
Children
SOURCE: Hadley and Holahan, “Is Health Care Spending Higher under Medicaid or Private Insurance? “ Inquiry, Winter 2003/2004.

17. Health Conditions that Limit Work
Medicaid Enrollees are Poorer and Sicker Than the Low-Income Privately-Insured
Percent of Enrolled Adults:
Medicaid
Low-Income and
Privately Insured
Poor
Health Conditions that Limit Work
Fair or Poor Health
SOURCE: Coughlin et al, “Assessing Access to Care Under Medicaid: Evidence for the Nation and Thirteen States,” Health Affairs, July/August 2005.

18. Top 5% of Enrollees Accounted for More than Half of Medicaid Spending in 2004
Bottom 95%
of Spenders
Top 5%
Bottom 95%
of Spenders
Children 3.5%
Adults 1.6%
Top 5%
Disabled 29.2%
57%
Children 0.3%
Adults 0.2% 5%
Disabled 2.3%
Elderly 22.5%
Elderly 2.2%
Total = 57.4 million
Total = $265.4 billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on MSIS 2004.

19. More than One in Three Uninsured Low-Income Adults Reports a Mental or Physical Condition
(<100% FPL)
(100%-199% FPL)
Adults includes all individuals age “Physical condition” includes heart disease, hypertension, stroke, diabetes, pulmonary conditions and cancer or a malignancy. “Mental condition” includes ever being diagnosed with autism, bipolar, dementia, psychosis, schizophrenia and experiencing memory loss or depression in the past year.
Source: KCMU analysis of 2007 NHIS data.

20. Strengthening Medicaid’s Protection for Low-income People
Improve benefits and maintain cost-sharing limits
Strengthen EPSDT for children
Reduce benefit variability and gaps for adults
Improve provider participation
Set federal standards for Medicaid payment rates
Link payments to performance and quality
Utilize additional strategies (ease paperwork, expedite payments, develop workforce)
Improve care strategies for complex populations
Support community care

21. How Can Medicaid Financing Support Health Reform Goals?

22. Total Medicaid Spending Growth, FY 1996-2009
Economic Downturn, Enrollment & Cost Growth,
Health Care Cost Growth
Start Economic Recovery, Slower Enrollment Growth
Strong Economy, Welfare Reform, Enrollment Declines, Managed Care
Economic Downturn & Program Improvements
Adopted
Rx Spending for Duals Moved From Medicaid to Part D & Low Enrollment Growth
NOTE: Estimates in State Fiscal Year. Figures for 2009 do not include CA . CA budget was adopted on 9/23/08 but spending projections for FY 2009 were not available.
SOURCE: KCMU Analysis of CMS Form 64 Data for Historic Medicaid Growth Rates FY 2007, 2008 and 2009 based on KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, September 2008.
Adopted

23. Federal Medical Assistance Percentages (FMAP), FY 2009NH VT WA ME MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH IN NV IL IL WV DE UT VA CO VA MD CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA
50% minimum, 83% maximum (not counting any temporary “stimulus” bump AK FL HI
71+ percent (6 states)
62 to <71 percent (19 states including DC)
51 to <61 percent (12 states)
50 percent (14 states)
SOURCE: Federal Register, November 28, 2007 (Vol. 72, No. 228), pp , at correction for North Carolina at Federal Register, Friday, December 7, 2007 (Vol. 72, No. 235), p , at

24. Total Spending = $ 287.3 billion
Spending on Dual Eligibles as a Share of Total Medicaid Spending, FFY 2005
Dual Spending46%
Total Spending = $ billion
Note: Medicare acute includes acute care services that Medicare may already cover in whole or part. Source: Urban Institute estimates based on data from MSIS 2005 and CMS Form 64, prepared for the Kaiser Commission on Medicaid and the Uninsured, 2008.

25. Medicaid and Health Reform
Today…..
Medicaid is a cornerstone of coverage for 60 million low- income and disabled Americans
Looking forward…..
Building on Medicaid to reach the low-income uninsured is a
practical and efficient strategy
Strengthening Medicaid's focus on access and quality can be a key part of overall health reform
Stabilizing and enhancing Medicaid financing supports national
coverage goals
Beyond health reform….
Medicaid serves key roles in financing long-term care, serving
complex populations, and supporting safety net providers