The Future of Medicaid

K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 1

The Future of Medicaid

Diane Rowland, Sc.D.Executive Vice President,

Henry J. Kaiser Family Foundationand

Executive Director, Kaiser Commission on Medicaid and the Uninsured

for

National Congress on Health ReformWashington, DC

September 23, 2008



Figure 2

Medicaid Today

Health Insurance Coverage

29 million children & 15 million adults in low-income families; 14 million elderly

and persons with disabilities

State Capacity for Health Coverage

43% of federal funds to states

MEDICAID

Support for Health Care System and Safety-net

16% of national spending on health services and supplies

Assistance to Medicare Beneficiaries

8.8 million aged and disabled — 21% of Medicare

beneficiaries

Long-Term Care Assistance

1 million nursing home residents; 41% of long-term

care services



Figure 3

IL

Percent of Nonelderly Residents Covered by Medicaid, by State, 2005-2006

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

SOURCE: Urban Institute and KCMU analysis of the March 2006 and 2007 Current Population Survey. Two-year pooled estimates for states and the US (2005-2006).

TX

FL

AL

10-12% (15 states)

13-15% (17 states)

< 10% (7 states)

US Average = 13%

NE

>15% (12 states including DC)



Figure 4

Medicaid’s Role for Selected Populations

Note: “Poor” is defined as living below the federal poverty level, which was $17,600 for a family of 3 in 2008. SOURCE: KCMU, KFF, and Urban Institute estimates; Birth data: NGA, MCH Update.

65%

44%

20%

51%

23%

41%

40%

27%

20%

21%

Nursing Home Residents

People Living with HIV/AIDS

People with Severe Disabilities

Medicare Beneficiaries

Births (Pregnant Women)

Low-Income Adults

Low-Income Children

All Children

Near Poor

Poor

Percent with Medicaid Coverage:

Families

Aged & Disabled



Figure 5

16% 17%

43%

9%13%

Total HealthServices and

Supplies

Hospital Care ProfessionalServices

Nursing HomeCare

PrescriptionDrugs

NOTE: Does not include spending on SCHIPSOURCE: A Catlin et al, “National Health Spending in 2006: A Year of Change for Prescription Drugs,” Health Affairs 27(1)14-29, January/February 2008. Based on National Health Care Expenditure Data, CMS, Office of the Actuary.

Total National

Spending(billions)

$1,966 $648 $660 $125 $217

Medicaid as a share of national health care spending:

Medicaid in the Health System, 2006



Figure 6

Enrollees Expenditures on benefits

Medicaid Enrollees and Expendituresby Enrollment Group, 2005

Children 18%

Elderly28%

Disabled42%

Adults 12%Children50%

Elderly10%

Disabled14%

Adults26%

Total = 59 million Total = $275 billion

SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.



Figure 7

Medicaid Payments Per Enrolleeby Acute and Long-Term Care, 2005

Children Adults Disabled Elderly

Long-Term Care

Acute Care

$1,617$2,102

$13,524

$11,839

SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.



Figure 8

Health Insurance Coverage of Children and Nonelderly Adults, 2006

Uninsured12%

Medicaid28%

Other Private4%

Employer56%

Uninsured20%

Medicaid11%

Other Private6%

Employer63%

Children Adults under 65

Total: 78.2 million Total: 181.8 million

Note Medicaid also includes S-CHIP, other state programs, Medicare, and military-related coverage. SOURCE: KCMU and Urban Institute estimates based on March 2007 Current Population Survey.



Figure 9

IL

Uninsured Rates Among the Low-Income Nonelderly 2005-2006

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

SOURCE: Urban Institute and KCMU analysis of the March 2006 and March 2007 Current Population Survey. Two-year pooled estimates for states and the US (2005-2006).

TX

FL

AL

28-33% (17 states)

≥ 34% (17 states)

< 28% (17 states including DC)US Average = 33%

NE



Figure 10

18%

28%

17%

39%

43%

61%

26%

49%

17%

40%

17%

39%

46%

34%

44%

17%

22%

43%

Medicaid/Other Public Employer/Other Private Uninsured

Poor

Near-Poor

(<100% Poverty)

(100-199% Poverty)

Poor

Near-Poor

Poor

Near-Poor

Children

Parents

Adults without Children

NOTE: Medicaid also includes SCHIP and other state programs, Medicare and military-related coverage. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

Medicaid’s Role for Low-Income Adults and Children, 2006



Figure 11

30%

92%

55%

4%

15%

4%

Poor Workers Higher Income Workers

Covered by Own orSpouse's Employer

Declined offer from Ownor Spouse's Employer

Not offered through Ownor Spouse's Employer

Access to Employer-Based Coverage by Family Income, 2005

SOURCE: Garrett B. and Clemens-Cope. Changes in Employer-Sponsored Health Insurance Coverage: 2001-2005. Kaiser Commission on Medicaid and the Uninsured report. June 2006

(Family Income <100% FPL)

(Family Income 400%+ FPL)



Figure 12

$2,137$3,785

$4,819

$8,825

$3,281$1,619$694$334

2000 2007 2000 2007

Employer Contribution

Worker Contribution

Average Annual Premium Costs for Covered Workers, 2000 and 2007

Note: Family coverage is defined as health coverage for a family of four. Data represents average for all types of plans.SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007.

$2,471

$6,438

$4,479

$12,106

Single Coverage Family Coverage



Figure 13

Children’s Eligibility for Medicaid/SCHIP by Income, January 2008

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TNNC

NH

MA

VT

PA

VAWV

CTNJ

DE

MD

RI

HI

DC

AK

SCNM

OK

GA

*The Federal Poverty Line (FPL) for a family of 3 in 2008 is $17,600 per year.**IL and NY use state funds to cover children above 200% FPL.***Since January 2008, SC, WI, and LA have implemented expansions.

TX

IL

FL

AL

< 200% FPL (9 states)

251-350% FPL (11 states including DC)

200% FPL (23 states)

201-250% FPL (8 states)U.S. Median Eligibility = 200% FPL

SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2008.



Figure 14

Medicaid Eligibility for Working Parents by Income, January 2008

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TNNC

NH

MA

VT

PA

VAWV

CTNJ

DE

MD

RI

HI

DC

AK

SCNM

OK

GA

*The Federal Poverty Line (FPL) for a family of three in 2008 is $17,600 per year.** Maryland plans to expand eligibility for parents to 116% FPL in 2008.SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2008.

TX

IL

FL

AL

50- 99% FPL (21 states)< 50% FPL (13 states)

100-150% FPL (8 states)US Median Eligibility = 63% FPL151-275% FPL (9 states including DC)



Figure 15

1%4%

2%4%

12%

37%

13%

2% 2%2%4%

17%

4%7%

12%

23%

30%

17%

No UsualPlace of Care

PostponedSeeking CareDue to Cost

Needed Carebut Did Not

Get it Due toCost

Last MDContact >2Years Ago

Unmet DentalNeed

Last DentalVisit >2 Years

Ago

Employer/Other Private Medicaid/Other Public Uninsured

Children’s Access to Care, by Health Insurance Status, 2006

NOTE: MD contact includes MD or any health care professional, including time spent in a hospital. Data is for all children under age 18, except for dental visit and unmet dental need, which are for children age 2-17. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All estimates are age-adjusted.SOURCE: KCMU analysis of National Center for Health Statistics, CDC. 2007. Summary of Health Statistics for U.S. Children: NHIS, 2006.



Figure 16

Barriers to Health Care Among Nonelderly Adults, by Insurance Status, 2006

4%

3%

6%

10%

14%

9%

11%

10%

23%

23%

26%

54%

Could Not AffordPrescription Drug

Needed Care butDid Not Get It

Postponed SeekingCare because of

Cost

No Regular Sourceof Care

Uninsured

Medicaid/Other Public

Private

NOTE: Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. SOURCE: KCMU analysis of 2006 NHIS data.

Percent of adults (age 19 – 64) reporting in past 12 months:



Figure 17

Medicaid Enrollees are Poorer and Sicker Than The Low-Income Privately Insured Population

61%

48%49%

16% 15%

27%

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 National and Thirteen States,” Health Affairs 24(4):1073-1083. Based on a 2002 NSAF analysis for Kaiser Commission on Medicaid and the Uninsured.

Medicaid Low-Income andPrivately Insured



Figure 18

Per Capita Spending For Medicaid Enrollees vs.Low-Income Privately-Insured

$1,752

$749

$2,253

$1,098

Medicaid

Low-Income Privately-Insured

Adults Children

SOURCE: Hadley and Holahan, “Is Health Care Spending Higher under Medicaid or Private Insurance? “ Inquiry, Winter 2003/2004.

Samples adjusted for health differences



Figure 19

Medicaid Financing of Safety-Net Providers

Medicare20%

State/Local Subsidies

14%

Self Pay/Other

7%

Commerical24%

Medicaid35%

Total = $29 billion

SOURCE: America’s Public Hospitals and Health Systems, 2004, National Association of Public Hospitals and Health Systems, October 2006. KCMU Analysis of 2006 UDS Data from HRSA.

Federal Grants

22%

Self Pay7%

State/Local13%

Private7%

Medicare6%

Medicaid37%

Other9%

Total = $8.1 billion

Public Hospital Net Revenues by Payer, 2004

Health Center Revenues by Payer, 2006



Figure 20

Medicaid as a Building Block for Health Reform

• The basis for affordable coverage for low-income families

• Key source of financing

• Serves key roles outside larger health reform including:

– Financing long-term services and supports

– Serving and managing complex populations

– Supporting safety net providers

– Emergency services for immigrants



Figure 21

VA

Federal Medical Assistance Percentages (FMAP), FY 2008

AZAR

MS

LA

WA

MN

ND

WY

ID

UTCO

OR

NV

CA

MT

IA

WIMI

NE

SD

ME

MOKS

OHIN

NY

IL

KY

TNNC

NH

MA

VT

PA

WV

CTNJ

DE

MD

RI

HI

DC

AK

SCNM

OK

GA

SOURCE: Federal Register, November 30, 3006 (Vol. 71, No. 230) pp. 69208-69211, at http://aspe.hhs.gov/health/fmap08.htm

TX

IL

FL

AL

71+ percent (6 states)

50 percent (13 states)

62 to <71 percent (16 states including DC)

51 to <61 percent (16 states)

VA



Figure 22

The Nonelderly Uninsured,by Age and Income Groups, 2006

Other Children6%

Low-IncomeParents

17%

Low-IncomeAdults without

Children34%

Low-IncomeChildren

14%

Other Parents8%

Total = 46.5 million uninsured

Low-income includes those with family incomes less than 200% FPL.SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

Other Adultswithout Children

21%



Figure 23

States Moving Forward with Initiatives to Address the Uninsured

42

3438

States with Plans to ExpandCoverage

States Using Medicaid toSupport Financing

States Using Medicaid toSupport Enrollment

SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2007.



Figure 24

Use of Medicaid to Expand Coverage

• Reach eligible, but not enrolled children

• Raise eligibility levels for parents

• Expand waivers or allow coverage for childless adults

• Provide premium subsidies for low-income workers that are financed with Medicaid funds

• Help finance safety net services / community-based care

• Provide broad-based coverage for people with disabilities



Figure 25

Challenges facing Medicaid within Broader Health Care System

• Financing– Federal deficit estimated at $482 billion for FY 2009

– State fiscal capacity (over half states face budget shortfall in FY 2009)

• Health care costs

– Health care spending growing about 2.5 percentage points faster than GDP

• Physician supply

– DHHS 2006 report projected shortfall of approximately 55,000 physicians in 2020

• Technology– Needed federal support in adoption of health IT

• Quality of care

– Geographic variation in treatment patterns

Documents

The Future of Medicaid