Medicaid 101 Policy Academy: Medicaid Overview

Medicaid Overview Samantha Artiga Director, Disparities Policy Project and Associate Director, Kaiser Program on Medicaid and the Uninsured Kaiser Family Foundation for Council of State Governments Medicaid 101 Policy Academy Washington, DC October 9, 2019

Figure 2

Medicaid plays a central role in our health care system.

Health Insurance Coverage For 1 in 5 Americans

Assistance to 10 million Medicare Beneficiaries

> 50% Long-Term Care Financing

MEDICAID Support for Health Care System and Safety-Net

State Capacity to Address Health Challenges

Figure 3

The basic foundations of Medicaid are related to the entitlement and the federal-state partnership.

Entitlement

Federal Sets core requirements on eligibility and benefits

Eligible Individuals are entitled to a defined set of benefits States are entitled to federal matching funds

State Partnership

Flexibility to administer the program within federal guidelines

Figure 4

Each Medicaid program is unique: Eligibility - All states have taken up options to expand coverage for children; many have opted to expand coverage for other groups.

Federal government sets core requirements, but states have flexibility regarding:

Benefits – All states offer optional benefits, including prescription drugs and long-term care in the community.

Delivery system & provider payment– States choose what type of delivery system to use and how they will pay providers; many are testing new payment models to better integrate and coordinate care to improve health outcomes.

Long-term care – States have expanded eligibility for people who need long-term care and are increasingly shifting spending away from institutions and towards community-based care.

State health priorities – States can use Medicaid to address issues such as the opioid epidemic, HIV, Zika, autism, dementia, environmental health emergencies, etc.

Figure 5

Medicaid plays a key role for selected populations.

Percent with Medicaid Coverage: Nonelderly Below 100% FPL

61%

Nonelderly Between 100% and 199% FPL

Families

43%

All Children

38%

Children Below 100% FPL Parents

83% 17%

Births (Pregnant Women)

Seniors & People with Disabilities

Medicare Beneficiaries Nonelderly Adults with a Disability Nonelderly Adults with HIV in Regular Care Nursing Home Residents

49% 19% 45% 42% 62%

NOTE: FPL-- Federal Poverty Level . The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $20,420 in 2017.

SOURCES: Kaiser Family Foundation analysis of the 2017 American Community Survey; Birth data-Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid

Budget Survey for State Fiscal Years 2016 and 2017, KFF, October 2016; Medicare data -Centers for Medicare & Medicaid Services (CMS), Office of Enterprise Data and Analytics, Chronic Conditions Data Warehouse, CY 2016; Disability - KFF Analysis of 2017 ACS; Nonelderly with HIV - 2014 CDC MMP; Nursing Home Residents - 2015 OSCAR/CASPER data.

Figure 6

Medicaid’s benefits reflect the needs of the population it serves.

LowIncome Families

Individuals with Disabilities

• • •

• • • • •

Elderly Individuals

• •

Pregnant Women: Prenatal care and delivery costs Children: Routine and specialized care for childhood development (immunizations, dental, vision, speech therapy) Families: Affordable coverage to prepare for the unexpected (emergency dental, hospitalizations, antibiotics) Child with Autism: In-home therapy, speech/occupational therapy Cerebral Palsy: Assistance to gain independence (personal care, case management and assistive technology) HIV/AIDS: Physician services, prescription drugs Mental Illness: Prescription drugs, physicians services Medicare beneficiary: help paying for Medicare premiums and cost sharing Community Waiver Participant: community based care and personal care Nursing Home Resident: care paid by Medicaid since Medicare does not cover institutional care

Figure 7

Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive MCOs. VT

WA MT

ND

NH

MN

OR

WI

SD

ID

WY

NV

UT

CA AZ

CO

NM

PA IL

KS OK

MO

AK

WV

NC

TN

AR

AL

VA

CT NJ DE MD DC

MA RI

SC GA

LA FL

HI

U.S. Overall = 69%

OH

IN

KY

MS TX

NY

MI

IA

NE

ME

Share of Medicaid beneficiaries in MCOs >75% (24 States) 50-75% (12 States including D.C.) 1 < 50% (3 States) No MCOs (12 States)

SOURCE: Medicaid Managed Care Enrollment Reports, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, 2019.

Figure 8

Nationally, Medicaid is comparable to private insurance for access to care; the uninsured have more limited access.

Medicaid/Other Public

ESI/Other Private

Uninsured

96% 98% 88% 89%

85% 88% 73%

73% 70% 56%

50% 37% 30% 24% 14% 16%

9%

7% Usual Source of Care

Well-Child Checkup^

Children (0-17)

Specialist Visit^

Usual Source of Care

General Doctor Visit^

Specialist Visit^

Nonelderly Adults (18-64)

NOTES: ^ Indicates in the past 12 months. Respondents who said usual source of care was the emergency room are not counted as having a usual source of care. All estimates are statistically significant from the uninsured group (p<0.05).

SOUCE: Kaiser Family Foundation analysis of the 2017 National Health Interview Survey (NHIS).

Figure 9

Medicaid is a budget item and a revenue item in state budgets.

Other Elementary & Secondary Education Medicaid

36% 54%

61% 9%

19% 25% 26% Total State Spending $1.9 Trillion

55%

14% State Funds (General & Other Funds) 1.3 Trillion

Federal Funds $612.2 Billion

SOURCE: Kaiser Family Foundation estimates based on the National Association of State Budget Officers (NASBO) 2018 State Expenditure Report: Fiscal Years 2016-2018 (data for Actual FY 2017).

Figure 10

Medicaid spending is mostly for the elderly and people with disabilities.

14% 9%

40%

34% 21% 19% 43% 19% Enrollees Total = 80.7 Million

Expenditures Total = $462.8 Billion

NOTE: Totals may not sum to 100% due to rounding.

SOURCE: KFF estimates based on analysis of data from the FFY2014 Medicaid Statistical Information System (MSIS) and CMS64 reports. Because FFY2014 data was missing some or all quarters for some states, we adjusted the data using secondary data to represent a full fiscal year of enrollment.

Figure 11

Medicaid enrollment and spending growth peaked during economic downturns and with implementation of the ACA. Annual Percentage Changes, FY 1998 â&#x20AC;&#x201C; FY 2019 Total Medicaid Spending

Medicaid Enrollment

13.2%

12.7%

4.7%

10.4% 9.3% 8.7% 8.5% 7.7% 7.5% 6.8% 6.4% 5.6% 3.2% 0.4%

-1.9%

9.7%

10.5%

7.8%7.2% 7.6% 6.8% 6.6% 5.8% 5.3% 5.3% 4.8% 4.3% 4.2% 4.1% 3.8% 3.5% 3.2% 3.2% 3.1% 2.8% 3.9% 2.3% 1.5% 1.3% 0.9% 0.2% -0.5% -0.6%

-4.0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018Proj 2019 NOTE: Spending growth percentages refer to state fiscal year (FY).

SOURCE: FY 2018-2019 spending data and FY 2019 enrollment data are derived from the KFF survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2018; historic data from various sources including: Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. FY 2014-2018 are based on KFF analysis of CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports and from KFF Analysis of CMS Form 64 Data.

Figure 12

The Medicaid expansion was designed to fill the gaps in Medicaid coverage.

NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,743 for an individual and $28,676 for a family of three in 2018.

Figure 13

To date, 37 states and DC have adopted the Medicaid expansion.

VT

WA MT

ND MN

OR

ID ◊

WI

SD WY NE

NV

UT ◊

CO

CA AZ

NM

MI PA

IA

◊

IL

KS OK

MO

TX

OH

IN

WV KY

AR

AL

VA

NH MA CT RI NJ DE MD DC

NC

TN MS

AK

NY

ME

SC GA

LA FL

HI Adopted (37 States including DC) Not Adopting At This Time (14 States) NOTES: Current status for each state is based on KFF tracking and analysis of state activity. ◊Expansion is adopted but not yet implemented in ID, NE, and UT. (See link below for additional state-specific notes).

SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated September 20, 2019. https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Figure 14

Gaps in coverage for adults remain in states that have not implemented the ACA Medicaid expansion.

41% FPL $8,745 for parents in a family of three as of October 2014 January 2019

$12,140 for an individual

$48,560 for an individual

Figure 15

Across states, eligibility levels are higher for children and pregnant women than parents and other adults.Income Eligibility Thresholds by Expansion Status, January 2019 Median Medicaid/CHIP Implemented the Medicaid Expansion

Has not Implemented Expansion

288% ($61,430) 215% ($45,860)

213% ($45,432)

200% ($42,660) 138% ($29,435)

138% ($17,236) 41% ($8,745)

Children

Pregnant Women

Parents

($0) 0% Childless Adults

NOTE: These medians are based on Medicaid expansion decisions made by January 2019. Eligibility levels are based on 2019 federal poverty levels (FPLs) for a family of three for children, pregnant women, and parents, and for an individual for childless adults. In 2019, the FPL was $21,330 for a family of three and $12,490 for an individual. Thresholds include the standard five percentage point of the FPL disregard.

SOURCE: Based on results from a national survey conducted by the Kaiser Family Foundation and the Georgetown University Center for Children and Families, 2019.

Figure 16

Evidence from over 200 studies suggests that the Medica expansion has positive effects for beneficiaries and states Reduction in the Number of Uninsured Increased Access to Care and Service Utilization ↑ Affordability and Financial Security

+ Federal + State Funds

Increased State Savings ↓ Uncompensated care costs ↓ State-funded health programs (e.g. behavioral health and corrections)

Increased Economic Activity ↑ General fund revenue and GDP ↑ or neutral effects on employment SOURCE: L. Antonisse, R. Garfield, R. Rudowitz, and S. Artiga, The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2 018

Figure 17

MCO managed care penetration rates have grown across Medicaid eligibility groups.

Number of States by MCO Penetration Rates for Select Enrollee Groups as of July 1, 2018

1 1 Children 1 39 states*; 01

1 1 2 3

ACA Expansion ACA AdultsExpansion 2 Adults 1 27 states*; 0 27 states*; 0 35

5 7 3

31 23

Children 39 states*

3

ACA Expansion Adults All Other Adults 27 states* 39 states*

Excluded <25% 25-49% 50-74% 75+%

20

Elderly and Disabled 39 states*

NOTES: Limited to 39 states with MCOs in place on July 1, 2018. Of the 32 states that had implemented the ACA Medicaid expansion as of July 1, 2018, 27 had MCOs in operation. Illinois did not report penetration rates for any of the above eligibility categories; therefore, state counts above do not sum to totals below the bars.

SOURCE: KFF Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, October 2018.

Figure 18

Medicaid/CHIP enrollment has declined in recent years.

Change in Monthly Medicaid and CHIP Enrollment December 2017 to June 2019

se on a e illi r c M De .8 -2

43 States 8 States

NOTES: Data do not sum due to rounding.

SOURCE: CMS, Medicaid & CHIP: Monthly Application and Eligibility Reports, as of April 25, 2019.

Figure 19

States can use Section 1115 waivers to reshape their programs in ways not otherwise allowed under federal rules.

•

The HHS Secretary can waive certain Medicaid provisions to implement “experimental, pilot or demonstration projects” that are “likely to assist in promoting the objectives of the Medicaid program”

•

Must be budget neutral to the federal government and subject to state and federal public notice and comment periods

•

Each Administration has some discretion over which waivers to approve and encourage; however, that discretion is not unlimited.

•

The Trump Administration has issued waiver guidance in November 2017 (waiver approval criteria) and January 2018 (work/community engagement)

Figure 20

There are 49 approved waivers in 40 states as of September 18, 2019 Set Aside by Court (3 across 3 states) Pending (21 across 18 states) Approved (49 across 40 states)

8

3 4 10

3 8 6

31 1 4

1

16

3

1

13

15

7

NOTES: Some states have multiple approved and/or multiple pending waivers, and many waivers are comprehensive and may fall into a few different areas. Therefore, the total number of pending or approved waivers across states cannot be calculated by summing counts of waivers in each category. Pending waiver applications are not included here until they are officially accepted by CMS and posted on Medicaid.gov. For more detailed information on each Section 1115 waiver, download the detailed approved and pending waiver tables posted on the tracker page. â&#x20AC;&#x153;MLTSSâ&#x20AC;? = Managed long-term services and supports.

Figure 21

State Medicaid programs are increasingly focused on social determinants of health.

Economic Stability

Neighborhood and Physical Environment

Education

Food

Employment

Housing

Literacy

Hunger

Income

Transportation

Language

Expenses

Safety

Debt

Parks

Early childhood education

Access to healthy options

Medical bills

Playgrounds

Support

Walkability

Vocational training

Zip code / geography

Higher education

Community and Social Context

Health Care System

Social integration

Health coverage

Support systems

Provider availability

Community engagement

Provider linguistic and cultural competency

Discrimination Stress

Quality of care

Health Outcomes Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations

Figure 22

Large shares across parties say they have a favorable opinion of Medicaid In general, do you have a favorable or an unfavorable opinion of Medicaid?

Very unfavorable

Somewhat unfavorable

8%

Total

13%

Somewhat favorable

34%

40%

By Political Party ID

5% 8%

Democrats

Independents

Republicans

8%

12%

13%

17%

26%

56%

36%

41%

NOTE: Donâ&#x20AC;&#x2122;t know/Refused responses not shown.

SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted February 15-20, 2018)

38%

24%

Very favorable