Medicaid s Role: Issues for the Future Diane Rowland, Sc.D. Executive Vice President, Henry J. Kaiser Family Foundation and Executive Director, Kaiser Commission on Medicaid and the Uninsured for the National Medicaid Congress Arlington, VA June 1, 2012
FIGURE 1 Who Does Medicaid Serve: Medicaid has many roles in our health care system. Health Insurance Coverage 31 million children & 16 million adults in low income families; 9 million persons with disabilities Assistance to Medicare Beneficiaries 9.1 million aged and disabled 20% of Medicare beneficiaries Long Term Care Assistance 1.6 million institutional residents; 2.8 million community based residents MEDICAID Support for Health Care System and Safety net 17% of national health spending; 40% of long term care services State Capacity for Health Coverage Federal share for FFY 2012 ranges from 50 74.2%
FIGURE 2 Who Does Medicaid Serve: Medicaid plays a critical role for selected populations. Percent with Medicaid Coverage: Families Aged & Disabled SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of 2009 ASEC Supplement to the CPS; Birth data from Maternal and Child Health Update: States Increase Eligibility for Children's Health in 2007, National Governors Association, 2008; Medicare data from USDHHS.
FIGURE 3 Who Does Medicaid Serve: Medicaid provides benefits to reflect the needs of the population it serves. Low Income Families Individuals with Disabilities Elderly Individuals Pregnant Women: Pre natal 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) Autistic Child: 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 4 Who Does Medicaid Serve: The elderly and disabled dominate Medicaid spending. FY 2009 Total = 62.6 million FY 2009 Total = $346.5 billion NOTE: Percentages may not add up to 100 due to rounding. SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS 64, 2012. MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS 64.
FIGURE 5 Who Does Medicaid Serve: Medical and long term care needs drive spending. Medicaid Payments Per Enrollee by Acute and Long Term Care, 2009 Long Term Care Acute Care $15,453 $13,186 $2,313 $2,926 SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS 64, 2012. MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS 64.
FIGURE 6 Medicaid and Low Income Families Health Care Needs Situation Anthony Kay Michelle & Anthwonnia Oklahoma City, OK Portland, OR Silver Spring, MD Orthopedic care and speech therapy Improved physical abilities after surgery and physical therapy, and improved participation in class after speech therapy High blood pressure, diabetes, mental illness After Hurricane Katrina, received coverage through Medicaid and was able to seek diagnosis and treatment Prenatal care for Michelle; newborn care for Anthwonnia Born premature, Anthwonnia now is at a healthy weight and receives regular newborn care
FIGURE 7 Medicaid and Low Income Families: Many low income families are uninsured. FPL= Federal Poverty Level. The FPL was $22,050 for a family of four in 2010. NOTE: 2010 Data. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
FIGURE 8 Medicaid and Low Income Families: For children, Medicaid & CHIP offer broad eligibility. CA OR WA NV ID UT AZ (CHIP closed) MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL VT NY PA WV VA NC SC GA ME NH MA CT RI NJ DE MD DC TX LA AK HI FL < 200% FPL (4 states) 200 249% FPL (21 states) 250% or higher FPL (26 states, including DC) Children's Medicaid/CHIP Eligibility by Income, January 2012 NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
FIGURE 9 Medicaid and Low Income Families: But Medicaid coverage for parents lags far behind. WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL VT NY PA WV VA NC SC GA ME NH MA CT RI NJ DE MD DC TX LA AK FL HI < 50% FPL (17 states) 50% 99% FPL (16 states) 100% FPL or Greater (18 states, including DC) Working Parents Medicaid Eligibility by Income, January 2012 NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. SOURCE: Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
FIGURE 10 Medicaid and Low Income Families: And most non disabled adults without children lack coverage. WA OR* (closed) CA NV ID UT* (closed) AZ (closed) MT WY CO NM (closed) ND SD NE KS OK MN IA WI (closed) MO AR IL MS MI (closed) IN (closed) TN (closed) AL KY OH WV GA SC PA VT* VA NC NY ME NH CT* RI NJ DE MD DC* MA TX LA AK HI* (closed) No Coverage (26 states) Premium Assistance Only (4 states) More Limited than Medicaid (13 states) Medicaid Comparable (8 states, including DC) Closed denotes enrollment closed to new applicants FL Scope of Coverage of Low Income Adults, January 2012 NOTE: Map identifies the broadest scope of coverage in the state. SOURCE: Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
FIGURE 11 Medicaid and Low Income Families : Medicaid coverage helps people get care. 2010, Percent Reporting: Adults Children Adults Children No Usual Source of Care Went Without Needed Care Due to Cost NOTE: In past 12 months SOURCE: KCMU analysis of 2010 NHIS data.
FIGURE 12 Medicaid and Low Income Families: Increasingly through managed care arrangements. WA VT ME MT ND NH MN OR WI NY MA ID SD MI RI WY CT PA IA NJ NE OH DE NV IL IN MD UT WV CO VA KS MO KY DC CA NC TN OK AR SC AZ NM MS AL GA TX LA AK FL HI U.S. Overall = 65.9% 0% 50% (9 states) 51% 65% (15 states) 66% 80% (17 states and DC) 80%+ (9 states) Comprehensive Medicaid Managed Care Penetration by State, October 2010 SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011.
FIGURE 13 Medicaid and Low Income Families: The Affordable Care Act will broaden coverage. Universal Coverage Medicaid Coverage (up to 133% FPL) Individual Mandate Exchanges (subsidies 133 400% FPL) Health Insurance Market Reforms Employer Sponsored Coverage NOTE: In 2012, 133% FPL for family of 4 is $30,657 and 400% FPL is $92,200
FIGURE 14 Medicaid and Low Income Families: By expanding coverage options for the uninsured. Federal Poverty Level 400%+ Employer Sponsored Insurance 139 399% (Subsidies) Uninsured Medicaid* <139% (Medicaid) Private Non Group 266 M Nonelderly, 2010 * Medicaid also includes other public programs: CHIP, other state programs, Medicare and military related coverage. The federal poverty level for a family of four in 2010 was $22,050. Numbers may not add to 100 due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
FIGURE 15 Medicaid and Low Income Families: Many adults will gain Medicaid coverage. Median Medicaid/CHIP Eligibility Threshold January 2012 Minimum Medicaid Eligibility under Health Reform 133% FPL ($25,390 for a family of 3 in 2012) SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
FIGURE 16 Medicaid and Low Income Families: Those gaining coverage have high health needs and gaps in access and utilization. * Statistically different from Medicaid (p<0.05). SOURCE: Kaiser Family Foundation analysis of 2007 Medical Expenditure Panel Survey data.
FIGURE 17 Medicaid and People with Disabilities Matthew Darius Heather Age 50 Garden City, KS Age 9 Lincoln, NE Health Paraplegic Brain injury associated with premature birth (PVL) Situation Unable to get coverage for 20 years, now buys in to Medicaid program, gaining him coverage for preventive care and specialist care, as well as assistance with activities of daily living. Medicaid covers specialist care from multiple providers, medical equipment, ER visits, and nursing care. Early interventions have mitigated problems associated with PVL. Age 39 St. Joseph, MI Congenital disorder resulting in dislocated hips and knees Home health services help with activities of daily living, Medicaid covers preventive care, crutches, medications and mental health services.
FIGURE 18 Medicaid and People with Disabilities: Disabled Medicaid beneficiaries experience a range of conditions. Medicaid beneficiaries with disabilities, who include both children and adults, are a heterogeneous population, with a wide range of physical and mental disabilities and disabling conditions, including but not limited to: Blindness; Spinal cord and traumatic brain injury; Parkinson s disease; Cerebral palsy; Cystic fibrosis; Epilepsy; Severe mental or emotional conditions, including mental illness (e.g., depression, bipolar disorder) and intellectual disabilities (e.g., ADHD); Multiple sclerosis; Down Syndrome; Alzheimer s disease; Autism; Spina bifida; Muscular dystrophy; and HIV/AIDS
FIGURE 19 Medicaid and People with Disabilities: Most Medicaid spending is driven by a few with high health needs. Bottom 95% of Spenders Bottom 95% of Spenders Top 5% Children 3.7% Adults 1.9% 5% Top 5% Children 0.3% Adults 0.2% Disabled 2.5% Elderly 2.0% Disabled 30.4% Elderly 18.6% 55% FY 2009 Total = 62.6 million FY 2009 Total = $346.5 billion SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS 64, 2012. MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS 64.
FIGURE 20 Medicaid and People with Disabilities: Medicaid only enrollees account for most disability spending and enrollment. Spending per enrollee= $13,835 Spending per enrollee= $19,682 Medicaid enrollees with disabilities (9.1 million) Medicaid expenditures for enrollees with disabilities ($142 billion) SOURCE: MACPAC Analysis of FY 2008 Medicaid Statistical Information System (MSIS) Annual Person Summary (APS) data and CMS 64 Financial Management Report (FMR) net expenditure data.
FIGURE 21 Medicaid and People with Disabilities: Medicaid only disabled spending is mostly acute care. 2008 Total Spending= $98.2 billion SOURCE: MACPAC Analysis of Medicaid Statistical Information System (MSIS) Annual Person Summary (APS) data and CMS 64 Financial Management Report (FMR) net expenditure data.
FIGURE 22 Medicaid and Dual Eligible Beneficiaries Wanda Virginia Don Age 78 Tulsa Age 72 Oklahoma City Age 41 Owossa Residence Lives in senior living facility Lives alone at home Lives in his own apartment Health Situation Muscular and skeletal problems, degenerative joint disease in lower back, hip replacement, and poor circulation in legs Very relieved to be out of the nursing home and living in subsidized senior housing Uterine cancer, hypertension, acid reflux, hernia, poor circulation in legs Doing ok now, but was rehospitalized in the week after her cancer surgery Developmental disabilities, impulse control disorder, neuroleptic malignant syndrome Has full time caregivers; needs a broad range of services; worried the state will reduce his benefits
FIGURE 23 Medicaid and Dual Eligible Beneficiaries: Dual eligible beneficiaries have complex health needs. Share of Medicare beneficiaries with: Cognitively or Mentally Impaired 3+ Chronic Conditions In Fair or Poor Health Functionally Impaired SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
FIGURE 24 Medicaid and Dual Eligible Beneficiaries: Dual eligible beneficiaries use more services. Share of Medicare beneficiaries with: 1+ Hospital Stay 1+ Emergency Room Visit 1+ Skilled Nursing Facility Stay Long Term Care Facility Resident NOTE: Excludes Medicare Advantage enrollees. SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
FIGURE 25 Medicaid and Dual Eligible Beneficiaries: Dual eligible beneficiaries account for a disproportionate share of spending. Total Population: 46 Million Medicare Total Spending: $424 Billion Total Population: 60 Million SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form 64. Medicaid Total Spending: $330 Billion
FIGURE 26 Medicaid and Dual Eligible Beneficiaries : And account for a substantial share of Medicaid spending. Medicaid Enrollment, 2009 Medicaid Spending, 2009 Adults 26% Children 49% Other Aged & Disabled 10% Duals 15% Other Aged & Disabled Spending 28% Children & Adult Spending 34% Premiums 3% Medicare Acute 7% Long Term Care 25% Other Acute 2% Dual Spending 38% Total = 63 Million Total = $359 Billion Prescribed Drugs 0.4% SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS 64, 2012. MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS 64.
FIGURE 27 Medicaid and Dual Eligible Beneficiaries : 26 states are proposing to test new models for dual eligible beneficiaries. WA OR NV CA ID AZ UT MT WY CO* NM ND MN WI SD IA* NE IL KS MO* OK* AR MS VT NY MI PA OH IN WV VA KY NC* TN SC AL GA ME NH MA CT* RI NJ DE MD DC TX LA AK FL HI Proposed 2013 Start Date (14 states) Proposed 2014 Start Date (12 states) Not participating in demonstration (24 states and DC) * CO, CT, IA, MO, NC, and OK are proposing managed FFS models. All others have proposed capitated models. NOTE: MO has proposed a 2012 start date. SOURCE: Correspondence with CMS Medicare Medicaid Coordination Office, May 2012
FIGURE 28 Medicaid and Dual Eligible Beneficiaries : Few dual eligible beneficiaries are high spenders under both programs. SOURCE: KCMU/ Urban Institute analysis of MSIS MCBS 2007.
FIGURE 29 Medicaid and Dual Eligible Beneficiaries: Spending by service varies among high cost dual eligible beneficiaries by program. Total = $93.1 billion Total = $80.1 billion NOTE: Top 10% Medicaid spenders = Medicaid spending greater than $45,180 and Top 10% Medicare spenders = Medicare spending greater than $44,348. SOURCE: KCMU/Urban Institute analysis of MSIS MCBS 2007.
FIGURE 30 Medicaid Today and Tomorrow Health Insurance Coverage for Certain Categories Minimum floor for Health Insurance Coverage to 133% FPL Shared Financing States and Federal Govt. MEDICAID Additional Federal Financing for Coverage Assistance for Duals / Long Term Care Additional Options Long Term Care / Coordination for Duals Support for Health Care System
FIGURE 31 Looking Forward Will Medicaid become the main source of coverage for the low income population? Will the Affordable Care Act be sustained? How will the delivery system be restructured to better manage care? Will the dual eligible Medicare and Medicaid population receive better care at lower cost? How will care be organized and financed between states and federal government? How will state budget and federal deficit debates affect Medicaid? How will the nation address rising health costs and the growing need for long term care?