1. Medicaid in Rural Missouri April 7, 2006 Amy Lake Community Policy Analysis Center University of Missouri-Columbia 230 Middlebush Hall Columbia MO 65202 lakea@missouri.edulakea@missouri.edu or 573-882-5412 http://www.cpac.missouri.edu/

2. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 2 Missouri Medicaid Chart Book The Missouri Medicaid Program: A Graphical Profile Medicaid Work Group, University of Missouri--Columbia August 2005 http://oseda.missouri.edu/medicaid/

3. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 3 Total Medicaid Enrollment, FY2001 More than a million people were enrolled in Missouri Medicaid in 2001 NATIONAL MAPS

4. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 4 Percent of the Population Enrolled in Medicaid, 2001 Almost one- fifth of Missourians were enrolled in Medicaid in 2001 NATIONAL MAPS

5. Federal and State Medicaid Expenditures 2004 $5.7 billion = Total Medicaid Expenditures in Missouri (SFY 2004) $3.7 billion in Federal Funds $2.0 billion in Missouri funds (GR and other) Source: Kaiser Foundation

6. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 6 Missouri Medicaid Expenditures by Enrollment Group, FY2005 Source: MoDSS Summary Table 5, FY2005. Children accounted for 55% of enrollees, but only 20% of expenditures MISSOURI CHARTS Total Enrollees 992,622 Total Expenditures $5,557,804,149 Note: Other includes Medicaid Assistance to Pregnant Women and the Breast or Cervical Cancer Program.

7. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 7 Source: MoDSS Summary Table 5, FY2005. Missouri Medicaid Expenditures by Type of Service, FY2005 Pharmacy is the largest category of costs to Missouri Medicaid Note: All other includes rehabilitation & specialty care, EPSDT, buy-in premiums, and dental services. (in billions of $) MISSOURI CHARTS

8. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 8 Missouri Population Estimates, 2004 Missouri counties vary widely in population, ranging from 2,270 to more than a million

9. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 9 Percentage of Missouri Population in Poverty, 2002 Poverty is concentrated in the southeast, south central, northeast regions of the state and in St. Louis City MISSOURI MAPS

10. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 10 Missouri Medicaid Enrollees by County, Feb 2005 The highest concentrations of Medicaid recipients in Missouri are in the most populated areas MISSOURI MAPS

11. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 11 Medicaid Enrollees as Percentage of Total Population by County, Feb 2005 Counties with the highest percentages of population enrolled in Medicaid are in the southeast region and the City of St. Louis MISSOURI MAPS

12. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy

13. 28%-40% of the populations in 12 NON- METRO counties are enrolled in Medicaid The 2 METRO areas with the highest Medicaid enrollment are Washington Co and St. Louis City with 28% of overall population enrolled

14. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy For 17 NON-METRO counties, 50%-78% of children enrolled in Medicaid For METRO areas, only St. Louis City has over 50% of children enrolled in Medicaid

15. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy 55 NON-METRO counties had over 10% of population aged 20-64 enrolled in Medicaid. 11 rural counties had over 19% of adults enrolled. 8 METRO areas had over 10% of adults enrolled, with a high of 19%.

16. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy 15 NON-METRO counties had over 20% of elderly enrolled in Medicaid, and 56 had over 12.8% Only 1 METRO area (Washington Co.) had over 20% of elderly population enrolled in Medicaid. 8 METRO counties over 12.8 %

17. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy 24 NON-METRO counties had over 5% of overall population enrolled in Blind/ Disabled Medicaid Only 1 METRO area (Washington Co.) had this level of enrollment

18. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 18 Total Medicaid Expenditures by County, FY2004 Total expenditures were $4.8 billion in 2004 MISSOURI MAPS

19. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 19 Total Medicaid Expenditures per Enrollee by County, FY2004 Expenditures per Medicaid eligible enrollee ranged from $3,173 to $11,704 in counties, reflecting both relative need and the location of specialized services MISSOURI MAPS

20. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 20 Medicaid Expenditures per Capita by County, FY2004 Per capita expenditures ranged from $326 to $2,425, reflecting the relative need of the population MISSOURI MAPS

21. MO Medicaid Changes Estimated 120,000 people affected by changes since July 1, 2005 (and Sept. 1, 2005) Medicaid eligibility changes/ reductions: –People with disabilities (working, transitional, Permanently and Totally Disabled) and Old Age –Low income parents (eligibility reduced from 75% Federal Poverty Level to 22% FPL) –Medical services and equipment reduced –Increased cost sharing for recipients = increased monthly premiums and increased “spend downs”

22. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 22 Number of Persons Affected by Changes in Medicaid Provisions, FY2006 The urban areas of Missouri will have the largest number of people affected by the recent changes in Medicaid provisions MISSOURI MAPS

23. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 23 Percent of County Population Affected by Changes in Medicaid Provisions, FY2006 Missouri’s poorest regions will have the highest percent of population impacted by the recent changes in Medicaid provisions MISSOURI MAPS

24. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 24 Estimated Medicaid Expenditure Reduction due to Changes in Medicaid Provisions, FY2006 Medicaid expenditures will be reduced by an estimated $335 million as a result of recent Medicaid provision changes, with the greatest reductions occurring in urban areas MISSOURI MAPS

25. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 25 Estimated Medicaid Expenditure Reduction per Capita, FY2006 Estimated reductions in per capita Medicaid expenditures by county range from $19 to $228 MISSOURI MAPS

26. Change in Medicaid Enrollment for Blind / Disabled from 2/05 and 1/ 06 was 4,391 decrease Total change Medicaid Enrollment approximately 117,000 decrease Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA),

27. Source: Dept of Health and Senior Services, Missouri Information for Community Assessment (MICA), USDC Bureau of the Census, Federal Office of Rural Health Policy

28. Source: Entrepreneurship in Missouri By Office of Social and Economic Data Analysis (OSEDA) and MO Economic Research and Information Center (MERIC) MO Department of Economic Development) http://oseda.missouri.edu/meric/statewide.shtml http://oseda.missouri.edu/meric/statewide.shtml There is a growing emphasis on entrepreneurship as a rural economic development strategy “Entrepreneurs” for this analysis were defined as self- employed individuals

29. Less than 20 employees 20-49 employees 50-99 Employees More than 100 employees Number of Firms 129,46411,4794,2673,237 Percentage of Firms 87.2 %7.7 %2.9 %2.2 % Employment number 591,140343,010290,1801,037,270 Percentage employment 26.1 %15.2 %12.8 %45.9 % Total Wages (in Billions) $15.1 bill$10.1 bill$8.7 bill$37.7 bill Percentage wages 21.1 %14.2 %12.2 %52.6 % Annual Wages $25,528$29,577$30,044$36,342 From Employment and Wages by Firm Size by MERIC (Missouri Economic Research & Information Center http://www.missourieconomy.org/industry/firms/firms000299.stm Missouri Employment and Wages by Firm Size, 2002

30. Source: 2003 County Business Patterns and Federal Office of Rural Health Policy The concentration of firms that employ less than 10 people is highest in Missouri’s rural counties 81% of all firms in rural counties and 77% firms in urban counties employ less than 10 people

31. For 12 rural Missouri counties, firms that employed less than 20 people made up 95-100% of all employers 85% of all firms in rural counties and 90% firms in urban counties employ less than 10 people Source: 2003 County Business Patterns and Federal Office of Rural Health Policy

32. StatePremium Montana$6,388 Iowa$7,111 Missouri$7,639 South Dakota$7,853 Alabama$7,917 North Dakota$7,994 Oregon$8,150 Georgia$8,465 Minnesota$8,527 Top 10 States with the lowest average family premiums for businesses with less than 10 employees (2003 data) From Missouri Third in Nation in Small Business Health Insurance Costs 3/10/06 by MERIC (Missouri Economic Research & Information Center http://www.missourieconomy.org/newsletter/ins_costs.htm

33. Average Family Insurance Premiums in the Private Sector in Missouri, 2003 Total Number of Employees in Firm Cost Per Enrolled Employee Rank compared to other states Less than 10$7,7393 10-24$9,41330 25-99$8,77219 100-999$8,53016 1000+$9,34132 Average, all sizes$8,98420 From Missouri Third in Nation in Small Business Health Insurance Costs 3/10/06 by MERIC (Missouri Economic Research & Information Center http://www.missourieconomy.org/newsletter/ins_costs.htm

34. ©2005 Medicaid Work Group, University of Missouri--Columbia Missouri Medicaid Chartbook 34 National Health & State Medicaid Expenditure Trends 1998 - 2005 National health expenditures were $6,423 per person (over $1.9 trillion) and Missouri Medicaid expenditures were $5,599 per enrollee MISSOURI CHARTS Source: Centers for Medicare & Medicaid Services, Office of the Actuary and MoDSS Summary Table 5, FY98-05, US Census.

35. Private Sector Establishments That Offer Health Insurance by Firm Size, 2003 Total Number of Employees in Firm Percentage in MissouriPercentage in US Less than 1033.6%35.6% 10-2465.2%66.2% 25-9984.8%81.0% 100-99982.3%93.5% 1000+97.4%98.6% From Missouri Third in Nation in Small Business Health Insurance Costs 3/10/06 by MERIC (Missouri Economic Research & Information Center http://www.missourieconomy.org/newsletter/ins_costs.htm

36. The concentration of health and social services firms that employ less than 10 people is highest in Missouri’s rural counties 72% of health and social services firms in rural counties and 70% in urban counties have less than 10 employees Source: 2003 County Business Patterns and Federal Office of Rural Health Policy

37. Firms with less than 20 employees made up 90- 100% of all health and social services employers in 15 rural Missouri counties 84% of health and social services firms in both rural and urban counties have less than 20 employees Source: 2003 County Business Patterns and Federal Office of Rural Health Policy

38. Things to consider… Rural areas tend to have fewer options for employer-based health insurance Health insurance companies tend to levy high premiums, deductibles, exclusions on farmers and small businesses Rural health care providers tend to be small businesses themselves. They may be paying high costs for health insurance and/or sharing the high cost with employees

39. Things to consider… Significant program changes are happening both in Medicaid in MO and in Medicare Part D (prescription drug program) nationally –Rural populations tend to be older and sicker than urban counter parts –Health care providers are spending time and resources helping individuals find ways to pay –Pharmacies in rural areas are more often independently owned than in urban areas – Medicaid and Medicare Part D have been challenging for all pharmacies

40. Things to consider… Rural providers are currently being called on to provide more free / un-reimbursed /discounted care Rural providers may depend heavily on Medicare and Medicaid Rural providers may have smaller total profit margins so they may have less ability to absorb significant financial losses

41. Source: DHSS Primary and Rural Health Health Professional Shortage Areas HPSAs

42. Other Resources Medicaid Reform Commission h ttp://www.senate.mo.gov/medicaidreform/ ttp://www.senate.mo.gov/medicaidreform/ Missouri Hospital Association –http://web.mhanet.com/asp/Governmental_Relations/Medicaid.asphttp://web.mhanet.com/asp/Governmental_Relations/Medicaid.asp Dept of Social Services Reading Room Statistics http://www.dss.mo.gov/rr_stats.htm http://www.dss.mo.gov/rr_stats.htm Dept of Social Services http://www.dss.mo.gov/pr_health.htmhttp://www.dss.mo.gov/pr_health.htm MU Center for Health Policy http://healthpolicy.missouri.edu/publications.htm http://healthpolicy.missouri.edu/publications.htm MO Information For Community Assessment (MICA) DHSS http://www.dhss.mo.gov/MICA/nojava.html http://www.dhss.mo.gov/MICA/nojava.html Missouri Foundation For Health http://www.mffh.org/policy_medbasics.html http://www.mffh.org/policy_medbasics.html Centers for Medicare and Medicaid Services –http://www.cms.hhs.gov/http://www.cms.hhs.gov/