1. Medicaid: Past and Future Presentation to the Center for Children and Families Georgetown University July 22, 2015

2. 2 Growth in Medicaid Role and Market Influence Now single largest source of health insurance in the nation Pre-ACA in 2013 Projected in 2015 ESI 47% Medicaid 16% Medicare 15% Uninsured 14% Other Private 6% ESI 47% Medicaid 22% Medicare 15% Uninsured 7% Other Private 3% Exchanges 4% U.S. Health Insurance Enrollment by Source Source: National Health Expenditure Projections 2011-2021 http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf CHIP 1% CHIP 2%

3. 3  “Categorical” Eligibility: Not Enough to be Poor Eligibility for Medicaid Linked to Eligibility for Welfare Medicaid Started as An Adjunct to Welfare Programs Application for Welfare was the Application for Medicaid  Long applications  In-person interviews at welfare office  Applicants required to prove eligibility with paper-based documentation  Other requirements often imposed  Enrollment not encouraged

4. 4 Medicaid has also played a historic role of meeting care needs of special populations Key Turning Points for Eligibility and Enrollment Welfare Reform: Eligibility For Parents De-Linked from Welfare 1996 Expansions for Children/De-Linked from Welfare 1988–1990 CHIP Created/ Medicaid Application Process Simplified for Children 1997+ With ACA, Medicaid shifts to broad-based coverage

5. 5 The New Coverage Paradigm

6. 6 New Coverage Paradigm Sources: http://www.ncsl.org/portals/1/documents/health/TFCMannLS12.pdf; http://kff.org/medicaid/fact-sheet/medicaid-eligibility-for-adults-as-of-january-1-2014/ Medicaid is one of three Insurance Affordability Programs providing a continuum of subsidized insurance for those without affordable ESI Coverage gap in median non- expansion states Other Adults Jobless Parents Pregnant Women Working Parents Children Varies by State Medicaid/CHIP Children 133% FPL 48% FPL 33% FPL 100% FPL 400% FPL 241% FPL Exchange Subsidies Adults

7. 7 Making the Coverage Continuum Work Simplified Eligibility Rules - Aligned With Marketplace One Application for the 3 Insurance Affordability Programs No In-Person interviews: Online Application (or In-Person, Mail, Phone) Data-driven Verifications and Renewals One IT System or Shared Service Across Programs Applicant enrolled in whichever program is appropriate

8. 8 Medicaid as Health Insurance: Real Time Eligibility Improved online application processes allow states to verify application information against electronic sources, all during one application sitting. Rhode Island estimates it can process up to two thirds of its Medicaid applications for enrollees subject to new ACA rules without manual intervention or additional information being required from the applicant Continuity of coverage at renewal is also improving as states implement data- driven verification processes and reduce paperwork requirements. Washington estimates it can renew coverage for up to two thirds of enrollees subject to new ACA rules without requiring additional action or information from enrollees

9. 9 What’s Next?

10. 10 Ensuring Coverage Completing the Transition Ending the Coverage Gap  Seamless Enrollment  Data-Driven Verification  “Real time” Eligibility Determinations  “Non-Magi” Simplifications  Multi-Benefit Applications  Continuous Coverage Eligible for Medicaid …But Not Enrolled  Medicaid Expansion

11. 11 30 States Have Expanded Medicaid California Nevada Arizona Utah Idaho Montana Wyoming Maine Vermont New York North Carolina South Carolina Alabama Nebraska Georgia Mississippi Louisiana Texas Oklahoma Pennsylvania Wisconsin Minnesota North Dakota Ohio South Dakota Kansas Iowa Illinois Tennessee Missouri Delaware New Jersey Connecticut Massachusetts Virginia Maryland Rhode Island Hawaii New Hampshire Not Expanded Medicaid (21) Alaska Expanded Medicaid (29 + DC) West Virginia Colorado New Mexico Oregon Washington Michigan Arkansas Kentucky Washington, DC Medicaid expansion decisions as of June 2015. Montana has passed legislation to implement an waiver-based expansion and the waiver review process is pending Iowa Waiver-Based Medicaid Expansions (5) Indiana 5 States Expanding through Section 1115 Waivers

12. 12 Features of Alternative Medicaid Expansions Premiums Premium Assistance – Marketplace and ESI Cost Sharing Health Savings-Like Accounts Healthy Behavior Incentives Connecting to Work, but no work requirements

13. 13 Returning to Welfare Paradigm? Work requirements Time limits Policies inconsistent with Medicaid’s role as an insurer:

14. 14 Delivery System and Payment Reform: What’s a Child Advocate to Do?

15. 15 New Managed Care Proposed Regulations Principle of Alignment Encouraging Value Based Purchasing  Opportunities for State Direction/Incentives Beneficiary Protections  Choosing a Plan  Appropriate Use of Service Authorizations Accountability  State Oversight and Data Requirements  MLR Examples Comments Due July 27, 2015

16. 16 Block Grants Per Capita Caps Medicaid “Reform”: Follow the Money ?

17. 17 Medicaid Spending Growth in Context Source: http://blogs.wsj.com/washwire/2015/04/16/public-vs-private-health-insurance-on-controlling-spending/ Medicaid spending growth has been driven largely by enrollment. Per capita growth slower than private insurance and Medicare.

18. 18 Celebrate the Gains!

19. 19 Historic Gains in Childrens’ Coverage Source: http://www.childstats.gov/americaschildren/tables/hc1.asp/ The uninsurance rate for children has been cut in half since 1997 Uninsured Rates Among U. S. Children (0-17) 1997 2013 uninsuredinsured

20. 20 ACA Resulted in Dramatic Drop in Uninsurance Gallup found sharp declines in the number of U.S. adults indicating a lack of health insurance coverage between 2014 and 2015 http://www.gallup.com/poll/182348/uninsured-rate-dips-first-quarter.aspx

21. 21 Decline of 33% Decline of 49% Source: Urban Institute Health Reform Monitoring Survey: http://hrms.urban.org/quicktakes/Trends-in-Uninsurance-and-State-Marketplace-and-Medicaid-Expansion-Decisions.html ACA Resulted in Dramatic Drop in Uninsurance, Cont.

22. 22 Happy 10 th Anniversary to CCF and Its Partners!!