1. Medicaid and the 4 A’s: Use of 1115 Waivers and State Plan Amendments American Cancer Society Washington, Dc June 5, 2008 Erin Reidy Erin.Reidy@cancer.org

2. Why a Medicaid Evaluative Tool? ACS 4A’s campaign Recent 1115 and SPA activity Uncertainty about Medicaid reform among ACS state advocates

3. 3 We cannot reach our goals without addressing Access to Care 2015 Goals – Reduce Mortality by 50 Percent 2003 Rate 190.1 1991 Baseline 215.1 2015 Goal 107.6 2015 Rate 160.5

4. Why the Cancer Lens The cancer community can play a greater role in influencing what public policy approaches are followed than they do today It is difficult to understand all the complexities of health care reform proposals, but people do understand cancer If it works for cancer patients, then it can work for almost any condition

5. Why do we care about Medicaid? Increases access to care Cancer screening Cancer treatment

6. Percent Received recommended colorectal cancer screening in past 10 years, 2005 Pap Test in Past Three Years, 2005 Mammogram in Past Two Years, 2005 Adults, 50-64 Women, 18-64 Women, 40-64 SOURCES: Ward, Elizabeth, et al. "Association of Insurance with Cancer Care Utilization and Outcomes." CA: A Cancer Journal for Clinicians 58.1 (2008): 9-31. Why do we care about Medicaid?

7. Increases access to care Cancer screening Cancer treatment Health disparities Low-income Racial/ethnic minorities Smoking Higher rate of smoking in the Medicaid population

8. Odds of More Advanced Stage at Diagnosis Breast Cancer, NCDB, 1998-2004 *Odds ratio is significant at the 95% confidence level. Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of diagnosis, and facility type. Source: Halpern et al, 2007 (manuscript in preparation) InsuranceStage II vs. I Stage III or IV vs. I Private1.0 (Ref.) Uninsured 1.5* 2.4* Medicaid 1.5* 2.5* Medicare Age 65+ 0.9*1.0 Race Non-Hispanic White1.0 (Ref.) Non-Hispanic Black 1.5* 1.9* Hispanic 1.3* 1.4*

9. What’s behind poor Medicaid outcomes? Retroactive enrollment Social Determinants of Health High rates of co-morbidities Continuities in care

10. The 4 A’s Available Affordable Adequate Administratively Simple

11. Illustration of the 4 A’s and Medicaid Available Must meet specific eligibility criteria Affordable Premiums and co-pays may be high Adequate Benefits, providers may not meet needs of cancer patients Administratively Simple Awareness and transparency may be lacking Appeals may be burdensome

12. Medicaid- Availability Eligibility “optional” groups Spend-down/pay-in programs Application Face to face interviews Self-declaration of income Enrollment Presumptive eligibility Enrollment caps Waiting periods

13. Medicaid- Affordability Premiums Premiums charged to beneficiaries greater than 150% FPL Multiple payment options Cost-sharing Under the DRA, co-payments to 20% of cost of services, or 10% of cost for lower-income beneficiaries. Total cost sharing can exceed 2-3% of a family’s income Can be denied at point of service

14. Medicaid- Adequacy Covered benefits “Benchmark” benefits Tiered benefits “Optional” services Benefit limits Annual/lifetime benefit limit Limited number of prescriptions Limits on number of treatments, visits, etc.

15. Medicaid- Administrative Simplicity Awareness Widely advertised Use of community organizations for enrollment Transparency Written in clear, simple language Materials in multiple languages Access to a live person for benefit explanations Plan Assignment Simple, publicized methods for switching Reassign enrollees to same plan after break in coverage

16. Conclusion Evaluative Tool can help advocates better questions about Medicaid reform proposals Provides the basis for developing practical and more specific evaluative criteria in the four main areas: adequacy, availability, affordability, and administrative simplicity The Society is not currently offering its own plan, but rather will evaluate proposals put forth by others and decide whether to support them

17. Thank you!