1. Medicaid Expansion: Where are Red States Going? Georgians for a Healthy Future’s 2015 Health Care Unscrambled Breakfast Joan Alker Executive Director Georgetown University Center for Children and Families Atlanta, Georgia January 15, 2015

2. Source: Health Insurance Policy Simulation Model 2012 from “What is the Result of State Not Expanding Medicaid?” Urban Institute, August 2014. 2

3. Why Covering Parents is Key for Kids o Enhances the financial security of the family o Improves the health of the parent o Maternal depression concrete example of benefits o Reduces the # of uninsured kids too! o MA health reform resulted in 50% reduction in uninsured kids – most uninsured kids (68%) are eligible for Medicaid/CHIP but not enrolled 3

4. Source: State decisions on the Medicaid expansion as of December 15, 2014. Based on state legislative scan by Georgetown CCF. Status of Medicaid Expansions Moving Forward at this Time (24 States including DC) Moving Forward with a Section 1115 Waiver (4 States) Section 1115 proposal submitted to Federal Government (1 State) Governors with Section 1115 proposals that require legislative approval (3 States) 4

5. How are States Thinking about Medicaid Expansion? o Most states (24) implementing the Medicaid expansion through a State Plan Amendment (SPA) using flexibility provided in the law o States have more flexibility than they think o Limited number of states are seeking waivers for alternative approaches to implement the ACA (4 states approved,1 pending, 3 in formation ) o Will most states go the waiver route in the future? Source: The Kaiser Commission on Medicaid and the Uninsured 5

6. What is a Section 1115 waiver? o 1115 Waiver authority is for demonstrations that promote the objectives of the Medicaid program o Authorizes the HHS Secretary to waive certain federal Medicaid requirements and provide federal funds for costs that would not otherwise be matched o Section 1115 waivers are required to be budget neutral to the federal government o Waiver approval involves negotiations between state and HHS o The ACA requires transparency and meaningful opportunities for public input in the 1115 waiver process 6

7. What Role Do Waivers Play in Medicaid Policy? o Long history of being used to drive changes o Popular to show your bona fides esp. if a Republican Governor o Very opaque process which is now slightly better due to ACA transparency rules o There are certain parts of the statute that cannot be waived o FMAP 7

8. Key Themes that are Emerging o Premiums and cost-sharing in all kinds of new forms for adults o Using private insurance or premium assistance – very sweeping change possible for kids eventually o Requiring work or job training o Promoting “healthy behaviors” and “personal responsibility” 8

9. Key Themes have Emerged in Alternative Approaches to the Medicaid Expansion Source: The Kaiser Commission on Medicaid and the Uninsured 9 Premium Assistance PremiumsHealth Behavior Incentives Benefit Changes Work Search Health Saving Accounts Arkansas (approved) xx Iowa (approved) xxxx Michigan (approved) xx Pennsylvania (approved) xxxxx Indiana (proposed) xxxxxx Tennessee (proposed) xxxx

10. How has Obama Administration Reacted? o Trying to thread the needle; not overly political o Have drawn some mostly clear lines o No partial expansion at full match (WI) o No premiums below poverty tied to eligibility o Limits on cost-sharing (using existing flexibility) o Benefits except transportation o Wraparound benefits o All of this is contributing to complexity 10

11. For More Information o Joan Alker: o jca25@georgetown.edu o Twitter @JoanAlker1 o CCF website: ccf.georgetown.edu ccf.georgetown.edu o Twitter @GeorgetownCCF o Say Ahhh! Our child health policy blog: ccf.georgetown.edu/blog/ ccf.georgetown.edu/blog/ 11