The Role of Medicaid and the State Children

1
The Role of Medicaid and the State Childrens
Health Insurance Program in State Health Reform

• Jennifer Tolbert,
• Principal Policy Analyst
• Kaiser Commission on Medicaid and the Uninsured
• for
• National Congress on the Un and Underinsured
• September 23, 2008
• Washington, DC

2
Number of Nonelderly Uninsured Americans, 2004 -
2007
Uninsured in Millions
46.5
45.0
44.4
43.0
SOURCE KCMU/Urban Institute analysis of March
CPS for each year.
3
Uninsured Rates Among the Nonelderly, by State,
2006-2007
NH
VT
ME
WA
ND
MT
MN
MA
OR
NY
ID
WI
SD
RI
MI
CT
WY
PA
NJ
IA
NE
OH
IN
NE
IL
NV
DE
WV
UT
VA
MD
CO
KY
CA
MO
KS
NC
DC
TN
SC
OK
AR
AZ
NM
GA
MS
AL
TX
LA
AK
FL
HI
18 (18 states)
13-17 (19 states)
US Average 18
lt 13 (13 states DC)
SOURCE Urban Institute and KCMU analysis of the
March 2007 and 2008 Current Population Survey.
Two-year pooled estimates for states and the US
(2006-2007).
4
The Nonelderly Uninsured,by Age and Income
Groups, 2007
Other Adultswithout Children21
Total 45.0 million uninsured
Low-income includes those with family incomes
less than 200 FPL. SOURCE KCMU/Urban Institute
analysis of March 2008 CPS.
5
Medicaid Today
Health Insurance Coverage 29 million children
15 million adults in low-income families 14
million elderly and persons with disabilities
Assistance to Medicare Beneficiaries 7.5
million aged and disabled 18 of Medicare
beneficiaries
Long-Term Care Assistance 1 million nursing home
residents 43 of long-term care services
MEDICAID
State Capacity for Health Coverage 43 of federal
funds to states
Support for Health Care System and Safety-net 15
of national health spending
6
Health Insurance Coverage of Low-Income Adults
and Children, 2007
Children
Parents
Adults without Children
SOURCE KCMU/Urban Institute analysis of March
2008 CPS.
7
Medicaid Enrollees and Expendituresby Enrollment
Group, 2005
Elderly 10
Elderly 28
Disabled 14
Adults 26
Disabled 42
Children 50
Adults 12
Children 18
Total 59 million
Total 275 billion
SOURCE Kaiser Commission on Medicaid and the
Uninsured and Urban Institute estimates based on
2005 MSIS data.
8
Percentage of Children Without Health Insurance,
By Poverty Level, 1997-2005
23
Children below 200 of poverty
21
14
6
Children above 200 of poverty
5
5
Survey method change in 2005 affects comparison
with earlier years slightly. Children less than
18 years old. Source L. Ku, Medicaid Improving
Health, Saving Lives, Center on Budget and
Policy Priorities analysis of National Health
Interview Survey data, August 2005.
9
The Uninsured by Income and Eligibility for
Public Coverage, 2004
Not Eligible, 300 FPL 15
Not Eligible, 300 FPL 21
Eligible 14
Not Eligible, lt300 FPL 11
Eligible 74
Not Eligible, lt300 FPL 65
Adults 36.6 Million
Uninsured
Children 8 Million
Uninsured
The Federal Poverty Line (FPL) for a family of
three in 2004 is 15,067 per year
SOURCE Urban Institute analysis of 2005 CPS for
KCMU.
10
Medicaid and SCHIP as Building Blocks

• Medicaid provides
• Mechanism for expanding coverage to children and
  some adults
• Source of federal assistance through matching
  funds for increased coverage and provider
  payments
• Delivery system on which to build
• Additional financing vehicle through redirected
  DSH funds
• SCHIP provides
• Successful model for covering children
• Enhanced federal financing, though amount is fixed

11
Challenges to Building on Medicaid and SCHIP

• Medicaid
• Federal rules limit coverage options (childless
  adults excluded except with waiver)
• Budget neutrality requirements
• Partnership with federal government sometimes
  uncertain
• SCHIP
• Federal funding capped
• August 17th directive limited expansion efforts
• Reauthorization debate raises questions about
  future of program
• States must still raise matching funds

12
Medicaid and SCHIP Expansions for Children

• 25 states plus DC expanded eligibility for
  children
• Several states expanded eligibility up to 300
  FPL
• Focus on outreach and simplifying enrollment
  processes
• Ten states enacted universal coverage for
  children
• Hawaii, Illinois, Iowa, Maine, Massachusetts, New
  Jersey, Pennsylvania, Vermont, Washington,
  Wisconsin
• Universal coverage builds on Medicaid/SCHIP
  coverage
• Full buy-in for families with higher incomes
• Connecticut automatic enrollment of all
  uninsured newborns

13
Leveraging Medicaid/SCHIP to Expand Coverage for
Adults

• Raising eligibility levels for parents (Maryland,
  New Jersey)
• Using/expanding waivers to cover childless adults
  (Wisconsin, Minnesota)
• Using Medicaid funding to purchase private
  insurance (Indiana, Vermont)
• Targeting small businesses (Oklahoma, New Mexico)
• New group insurance options for small employers
• Premium subsidies for low-income workers
• Financed with Medicaid funds

14
Using Medicaid to Address Other Health System
Reforms

• Access to care
• medical homes model
• Chronic care management
• development of chronic care programs
• advancing HIT
• Quality improvement
• paying for performance
• non-payment for medical errors
• Focus on prevention, consumer responsibility

15
Massachusetts Medicaid as Foundationfor
Broader Reform

• MassHealth
• Expanded eligibility for children up to 300 FPL
• Enrollment increase 90,000
• Commonwealth Care
• New public coverage option for adults up to 300
  FPL
• Care provided by Medicaid managed care plans
• Financed with state and federal Medicaid funds
• Enrollment 175,000
• Other components
• Individual and employer mandates
• Commonwealth Connector

16
Public Programs and Health Reform

• Recent public program expansions show
  opportunities for gains in coverage
• States continuing to implement enacted expansions
• Poor fiscal outlook for states may limit future
  efforts
• Problems with health care system remain
• uninsured, rising health care costs, quality and
  access issues
• public programs offer states mechanism for
  addressing some of these problems
• Despite challenges to health reform, states are
  not waiting on federal action