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State Health Reform: Lessons for the Nation. Jennifer Tolbert Principal Policy Analyst Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation for Healthcare Leaders Forum Detroit Regional Chamber and Federal Reserve Bank of Chicago Detroit, MI March 31, 2009. - PowerPoint PPT Presentation
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K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 1
State Health Reform:Lessons for the Nation
Jennifer TolbertPrincipal Policy Analyst
Kaiser Commission on Medicaid and the UninsuredKaiser Family Foundation
for
Healthcare Leaders Forum Detroit Regional Chamber and Federal Reserve Bank of Chicago
Detroit, MIMarch 31, 2009
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 2
SOURCE: KCMU and Urban Institute analysis of March 2008 CPS.
298.2 million
Employer-Sponsored
53%
Uninsured 15%
Medicaid/SCHIP
13%
Private Non-Group 5% Medicare
14%
Military/VA 1%
45.0 million uninsured
Adults36.1
Children8.9
Health Insurance Coverage of the Total Population, 2007
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 3
IL
Uninsured Rates Among the Nonelderly, by State, 2006-2007
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
TX
FL
AL
13-17% (19 states )
≥ 18% (18 states)
< 13% (13 states & DC)US Average = 18%
NE
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).
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 4
Availability of Employer-Based Coverage
Family Work Status of Uninsured, 2007
Total = 45 million uninsured
1 or More Full-Time Workers
69%
No Workers
19%
Part-TimeWorkers
12%
* Estimates are statistically different from each other within category (p<.05)SOURCE: KCMU/Urban Institute analysis of March 2008 CPS; Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007
99%
67%59% *
36% *
Small Firms
(3-199 workers)
Large Firms
(200+ Workers)
Lower Wage Firms
Higher Wage Firms
Percentage of Firms Offering Health Benefits, 2007
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 5
Affordability of Health Coverage
400% FPL and Above10%
200-399% FPL24%
100-199% FPL29%
<100% FPL37%
Family Income of Uninsured, 2007
Total = 45 million uninsured
The federal poverty level was $22,050 for a family of four in 2009. SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.
$721$3,354
$3,983
$9,325
Single Coverage Family Coverage
Employer ContributionWorker Contribution
$4,704
$12,680
Average Annual Premium Costs, 2008
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 6
Cumulative Changes in Health Insurance Premiums, Inflation, and Workers’ Earnings, 1999-2008
119%
34%
29%11%
22%
38%
57%
72%
88%
98%
109%
0%
25%20%17%14%
11%8%
4%
29%
3%7% 8% 11%
13% 17%21% 24%
0%
40%
80%
120%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Health Insurance Premiums Workers' Earnings Overall Inflation
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2008. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 2000-2008; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 2000-2008 (April to April).
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 7
Role of Public Programs
Children6%
Children14%
Parents8%
Total = 45.0 million uninsured
*National median Medicaid income eligibility level for working parents in 2008.SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.
Adults without Children
21%<200% FPL200% FPL +
200%
63%
0%
Children WorkingParents*
Childless Adults
Federal Poverty Line (For a family of four is
$22,050 per year in 2009)
Nonelderly Uninsured, 2007Median Medicaid/CHIP Income
Eligibility Thresholds, 2008
Adults without Children
35%
Parents 17%
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 8
Medicaid Enrollees are Poorer and Sicker Than the Low-Income Privately-Insured
49% 48%
61%
27%
15% 16%
0%
25%
50%
75%
100%
Percent of Enrolled Adults:
Poor Health Conditions that Limit Work
Fair or Poor Health
SOURCE: Coughlin et al, “Assessing Access to Care Under Medicaid: Evidence for the Nation and Thirteen States,” Health Affairs, July/August 2005.
Medicaid Low-Income andPrivately Insured
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 9
Cutting Back Care Due to Cost
12
21
27
30
34
22
37
41
61
71
Uninsured under 65
Insured under 65
Put off or postponed getting health care you needed
Skipped a recommended medical test or treatment
Not filled a prescription
Cut pills or skipped doses of medicine
Had problems getting mental health care
Percent of nonelderly adults who say because of cost they or a family member has:
SOURCE: Kaiser Health Tracking Poll: Election 2008, October 2008 (conducted October 8 – 13, 2008)
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 10
States Tackle Health Reform
• Initially, states focused on improving coverage through public program expansions and private market reforms
• As economy deteriorated, efforts broadened to address system reform
– care coordination
– system efficiency
– quality improvement
• Most states remain committed to implementing coverage expansions
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 11
Public Program Expansions
• Expanding coverage for children
– 11 states pursuing universal coverage for children
• Raising Medicaid eligibility levels for parents (examples: Maryland, New Jersey)
• Using/expanding Medicaid waivers to cover childless adults (examples: Wisconsin, Minnesota)
• Using Medicaid funding to purchase private insurance (examples: Indiana, Vermont)
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 12
Employer Incentives and Requirements
• Partnering with small employers – three-share models to assist employers in offering coverage
– tax incentives for small employers
– state examples: Maine, Montana, Oklahoma, Tennessee
• Employer Section 125 requirements– Allows employees to pay premiums on a pre-tax basis
• Pay or Play requirements – Require employers to provide coverage to employees or contribute
toward the costs of coverage
– Massachusetts, Vermont, San Francisco
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 13
Pay or Play in San Francisco Upheld
• San Francisco requires employers to make defined contribution toward health care for employees
• 9th Circuit Court of Appeals upholds requirement, saying no ERISA violation
• Implications for other states– cannot require employers to provide health coverage– must create universal coverage programs funded partly with
employer assessments– cannot specify what employer coverage must look like to
qualify for credit against the assessment
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 14
New Options for the Uninsured
• Premium subsidies for state-administered plans
– Plans offered through contracts with private insurers
– state examples: Connecticut, Massachusetts, Vermont
• Benefit plan redesign
– Wellness plans: emphasize preventive care, with financial incentives for participation in wellness programs
• state examples: Maryland, Rhode Island
– Low-cost plans: preventive benefit packages (usually include service limits and some do not cover hospitalizations)
• state example: Florida
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 15
Improving Access to Care
• Medical homes
– link patients with provider teams responsible for coordinating full range of care
– enhanced payment for care coordination
• Improving reimbursement for primary care
• Strategies to address primary care workforce shortages
– Scope of practice for non-physician providers
– Loan forgiveness programs
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 16
Improving System Efficiency and Quality
• Cost and quality transparency
– require provider reporting of cost and quality data
– comparison tools for consumers
• Inpatient quality initiatives
– non-payment for “never” events
– reporting of hospital-acquired infections
• Promoting HIT adoption
– statewide HIT infrastructure and standards for EHRs
– e-prescribing
• Provider payment reform???
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 17
Comprehensive Reform—The Massachusetts Model
• Individual Mandate– Mandate enforced through tax filings
• Employer Assessment– Employers with >10 employees that don’t offer coverage must
pay $295 per employee per year
• Subsidized Coverage– Sliding scale subsidies for individuals <300% FPL– Full subsidies for those <150% FPL
• The Connector– Links consumers & small employers to insurance– Establishes affordability standards and certifies insurance
products
• Medicaid Expansion to Children <300% FPL
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 18
Massachusetts Health Reform Successful in Improving Health Coverage
SOURCE: Massachusetts Division of Health Care Finance and Policy, Health Care in Massachusetts: Key Indicators, November 2008.
Private Insurance
33%
MassHealth18%
Individual Insurance
9%
Total = 442,000 Newly Insured
Commonwealth Care40%
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 19
Minnesota: Focus on System Improvement
• Comprehensive reform passed May 2008
• Expands MinnesotaCare to 250% PFL for childless adults
• Requires employers to establish Sec. 125 plans
• Provides tax credit for uninsured with access to Sec. 125 plans
• Requires care coordination for people with chronic conditions
– Will establish standards for medical homes and pay care coordination fee
• Creates tools for comparing providers on cost and quality measures; available to providers and public
• Establishes “baskets of care” to promote transparency and payment reform
• Requires e-prescribing by 2011
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 20
Looking Forward
• Economic picture remains bleak
– 8.1% unemployment in Feb. 2009 (up from 4.9% in Dec. 2007)
– 46 states facing budget shortfalls of $350 billion for the rest of 2009 through 2011
– Growing uninsured and increasing Medicaid and CHIP enrollment
• Federal legislation will help states
– CHIP reauthorization: bonuses to enroll currently eligible children in Medicaid plus federal funding for expansions
– American Recovery and Reinvestment Act: increased federal Medicaid matching funds for states
• Despite challenges, state continue to innovate and lead the way on health reform
– many health reform strategies being discussed at national level are currently being tested in the states
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 21
For more information
www.kff.org
www.kaisernetwork.org
www.kaiserEDU.org
Coming soon…Health reform webpage on kff.org