State coverage of adults: an overview

1
State coverage of adults an overview

• NASHP Conference
• August 8, 2005
• 830 am
• Stan Dorn
• Economic and Social Research Institute
• 2100 M St. NW, Ste. 605
• Washington, DC 20037
• www.esresearch.org
• 202.833.8877, ext. 14
• sdorn_at_esresearch.org

2
Topics

• Federal law
• State implementation
• Key facts
• Policy issues

3
Federal law

• Parents
• State plan amendment OK, up to any income level
• Non-custodial adults who are neither pregnant,
  severely disabled, nor elderly
• No federal match, unless 1115 waiver
• Budget neutrality no extra federal money
• Bottom line need another source of money
  (unspent DSH, unspent SCHIP dollars, unused UPL,
  etc.), or rob Peter to pay Paul

4
The Medicaid statutes denial of federal match
for childless adults some history

• The Elizabethan Poor Law of 1601
• In the 1930s, federally matched cash assistance
  programs
• In 1965, Medicaid was created for recipients of
  federally-matched cash aid
• Later incremental expansions kept the basic
  two-fold structure of eligibility related to
• Children
• Seniors and people with disabilities

5
Back to the present state coverage of poor adults

• Median state covers working parents up to 71 FPL
  (952 a month for a family of 3 in 2005)
• Most states do not cover non-custodial adults

6
Medicaid coverage of working parents July 2004
Source Center on Budget and Policy Priorities
for KCMU, Oct. 2004. Notes (1) In states with
capped and uncapped programs, uncapped programs
are shown. (2) FPL numbers are for families of
three.
7
Medicaid or other coverage of childless adults
January 2004
Source ESRI for KCMU, August 2004.
8
Key facts
9
Distribution of uninsured, by income and
relationship to children
Source KCMU, December 2003 Urban/KCMU, produced
for ESRI, Aug. 2004. Analysis of March 2003 CPS.
10
Policy issues Why would a state do this?
11
Some possible reasons for state action

• Altruistic
• Typically the neediest group of uninsured
• Unfair and arbitrary to deny coverage just
  because no minor, dependent child lives at home
• Supports work, independence
• Political
• Some influential sub-populations
• Offer workers mainstream-type coverage, with some
  financial responsibility bipartisan appeal
• If program succeed as a local pilot, other
  localities may want it, too (pattern in
  Washington State)
• Mercenary offsets from federal match displacing
  state-only dollars

12
Policy issues factors lowering net state costs
13
Are offsets possible? How many poor, uninsured
adults might receive state-funded services today?
Source Davidoff, et al., February 2005
(Urban/KCMU).
14
Examples of state-only programs where federal
match could generate offsetting savings

• Mental health treatment
• Substance abuse treatment
• Public hospitals
• Payments for uncompensated care
• Publicly funded facilities for veterans
• Services for troubled teens/young adults
• Indigent care programs
• Publicly funded medical schools

15
Policy issues non-custodial adults can include
many near-elders and people with disabilities
16
Near-elderly adults as a share of (a)
non-custodial adults in two broad state programs
and (b) low-income, uninsured adults nationally
2001-2003
Source ESRI, Aug. 2004. Note For the U.S. and
Washington, the bars show the percentage of 55-64
year-olds among all adults, ages 19-64.
Minnesota displays its published data
differently, showing older adult enrollment
starting at age 50.
17
People with disabilities served by childless
adult programs

• People awaiting SSA determinations of disability
• People not meeting the SSA standard, developed
  for cash assistance programs

18
Implications of covering these near-elders and
people with disabilities

• Tremendous impact on access to care, health
  status
• Some offsetting Medicare savings
• Potential to engage influential constituencies
• Potential for high per capita costs, depending on
  program design

19
Costs vary with program type examples from
Minnesota and Washington State, 2001-2002
Source Source ESRI for KCMU, Aug. 2004. Notes
(1) P.m.p.m. means per member per month. (2)
Because they come from multiple sources, cost
data are from (a) 2002 for programs for
uninsured workers (b) 2001-2002 for programs for
the destitute and chronically ill and (c) FY
2001 for Medicaid.
20
Policy issues the federal governments denial of
matching funds to states that wish to help
childless adults
21
Characterizing current federal policy a
subjective view

• Federal statute Medicaid will not cover certain
  adults (those who are neither pregnant,
  parenting, seniors, or disabled), no matter how
  poor or hard-working
• Almost an accident of history
• Were these adults found unworthy? Yes while
  establishing cash aid programs in the 1930s
• Should that determination continue to govern
  health policy in 21st Century America?

22
What could a new federal policy look like?

• Option to cover poor adults via state plan
  amendment
• Enhanced match to encourage implementation
• If a state covers all poor adults, perhaps
  increased programmatic flexibility above FPL

23
A limited bibliography
Donna Cohen Ross and Laura Cox. Beneath the
Surface Barriers Threaten to Slow Progress on
Expanding Health Coverage of Children and
Families. Center On Budget and Policy Priorities,
for Kaiser Commission on Medicaid and the
Uninsured (KCMU). October 2004.
http//www.kff.org/medicaid/loader.cfm?url/common
spot/security/getfile.cfmPageID47039. Amy
Davidoff, Alshadye Yemane, and Emerald Adams.
Health Coverage for Low-Income Adults
Eligibility and Enrollment in Medicaid and State
Programs, 2002. The Urban Institute, for KCMU.
February 2005. http//www.kff.org/uninsured/loader
.cfm?url/commonspot/security/getfile.cfmPageID5
1750. Stan Dorn, Sharon Silow-Carroll, Tanya
Alteras, Heather Sacks, Jack A. Meyer. Medicaid
and Other Public Programs for Low-Income
Childless Adults An Overview of Coverage in
Eight States. Economic and Social Research
Institute (ESRI), for KCMU. August 2004.
http//www.kff.org/medicaid/loader.cfm?url/common
spot/security/getfile.cfmPageID4617522. Stan
Dorn. Medicaid Coverage for Poor Adults A
Potential Building Block for Bipartisan Health
Reform. ESRI, for The California HealthCare
Foundation. November 2004. http//www.esresearch.o
rg/Documents/MedicaidAdults.pdf.