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WHAT’S THE MATTER WITH THE MEDICAID GAP IN KANSAS? Kathryn Schartz, MSN, RN, CPNP.

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Presentation on theme: "WHAT’S THE MATTER WITH THE MEDICAID GAP IN KANSAS? Kathryn Schartz, MSN, RN, CPNP."— Presentation transcript:

1 WHAT’S THE MATTER WITH THE MEDICAID GAP IN KANSAS? Kathryn Schartz, MSN, RN, CPNP

2 U.S. HEALTH CARE SYSTEM High costs/low quality Services restricted/rationed Inexplicable range of costs Innovation/diffusion of best practices very slow “Competition... currently exists at the wrong level.”

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4 HEALTH CARE COVERAGE PRIOR TO ACA Employer-subsidized plans – 59% Uninsured – 19% Individual – 6% Government – 23% (2009) nsurance.html

5 WHO ARE THE UNINSURED? 41.3 million non-elderly 86% were adults 27% below poverty 80% are US citizens 85% low- or moderate-income families 71% in families with one or more FT workers 14% with PT workers Rates affected by occupation, race, state of residence

6 UNINSURED EMPLOYEES Employee-sponsored coverage offered by 57% of companies 80% of eligible employees participated Half of those covered were employees/half were dependents Two-thirds of adult uninsured were workers Didn’t work enough hours Employer didn’t offer Employers cited cost as the main barrier to offering insurance to employees Availability of employer-sponsored insurance eroded over time, even in a strong economy Majerol, M. Newkirk, V. & Garfield, R. (December 2014).

7 FINANCIAL IMPLICATIONS OF UNINSURANCE -- INDIVIDUAL Most uninsured do not receive care free or at reduced charge Hospitals charge 2-4 times what 3 rd party payers pay Often must pay “up front” Total expenditures less than for those with insurance, but out-of-pocket much higher Increased risk of amassing unaffordable medical bills Few savings and assets to use for health care costs Risk difficulty paying off debt

8 BURDEN OF UNCOMPENSATED CARE $84.9 billion in 2013 $53.3 billion paid to providers to help offset costs Burden by provider: 60% by hospitals 26% by community-based providers 14% by office-based physicians Burden to consumer Increased premiums (>$1,000/yr) Increased out-of-pocket costs

9 NON-GROUP HEALTH INSURANCE COVERAGE Private insurance purchased on individual market Very few covered prior to ACA (5%) Obtaining coverage difficult Pre-existing conditions Older adults High rates if covered 41% reported policy too expensive, 6% were denied coverage at any price

10 Patient Protection and Affordable Care Act “ACA” or “Obamacare”

11 THE AFFORDABLE CARE ACT Individual mandate Employer mandate Medicaid expansion Premium & cost-sharing subsidies Health insurance exchanges

12 THE AFFORDABLE CARE ACT Changes to private insurance Temporary high-risk pool Dependent coverage up to age 26 80% of premiums spent on direct care No pre-existing conditions, life-time caps Must cover preventive care such as immunizations Health care choice compacts and national plans

13 THE AFFORDABLE CARE ACT New regulations on payers/employers Some incentives to change at provider level – new health care delivery models Incentives/requirements for some innovations (EMR)

14 MEDICAID EXPANSION ACA required expansion of Medicaid to legal residents up to 138% of FPL Goal of ACA -- extend coverage to 32 million people by 2019 CBO projected that 16 million would get coverage through Medicaid expansion Supreme court ruling reduced this trajectory to 12 million

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16 IMPACT OF INSURANCE EXPANSION ON UNCOMPENSATED CARE COSTS Volumes of uninsured less, especially in Medicaid-expansion states Inpatient admissions ED visits Volumes of Medicaid patients increased in Medicaid-expansion states UCC estimated to be $5.7 billion lower in 2014 DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in Department of Health and Human Services, September 24, Retrieved on January 6, 2015 from:

17 WHAT IS THE MEDICAID GAP? In states that do not expand Medicaid (currently 21), most childless adults below 100% of FPL will not have access to coverage 4 million people nationally are in the coverage gap with income: greater than Medicaid eligibility below lower limit for Marketplace premium tax credits

18 / states-that-do-not-expand-medicaid-an-update

19 The ACA in Kansas Kansas has one of the lowest standards for Medicaid eligibility For non-pregnant, non- elderly adults, income must be less than 38% of the FPL Must be between 100% and 400% of FPL to qualify for subsidies for insurance on the exchanges

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21 The Medicaid Gap in Kansas Most childless adults in Kansas (unless disabled or elderly) do not qualify for Medicaid 182,000 Kansans are in the ‘Medicaid Gap’ – too poor for tax credits too ‘well-off’ for Medicaid.

22 Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act? Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015 from:

23 KanCare Expansion KHA lobbying for a “Kansas-based” solution KanCare 2.0 – a statewide demonstration program to provide coverage for all individuals < 138% of FPL Utilize 100% federal match – provision to opt out if this drops below 90% Helps keep Kansas taxpayer dollars in Kansas Preservation of Kansas health care system Focus on health delivery reform initiatives Improving health status/quality of care Promoting patient-centered medical homes Reducing ED utilization Increase use of prenatal care Reduce infant mortality rates KHA. (2015) Guiding principles for KanCare 2.0, Kansas Hospital Association. Retrieved on January 29, 2015 from:

24 Estimated costs to hospitals in Kansas without KanCare expansion SVRHC -- $7,626, St. Francis -- $3,587, All hospitals -- $106,075,220.00

25 RESOURCES – EDUCATE YOURSELVES! American Nurses Association Henry J. Kaiser Family Foundation affordable-care-act/ affordable-care-act/ Henry J. Kaiser Family Foundation Kansas Hospital Association https://www.healthcare.gov/ HealthCare.Gov American Hospital Association Kansas Health Institute

26 References AMA News Room. (2013). AMA analysis lists states where one private health insurer rules. Retrieved from assn.org/ama/pub/news/news/2013/ study-anticompetitive-market-conditions.pagehttp://www.ama- assn.org/ama/pub/news/news/2013/ study-anticompetitive-market-conditions.page Cauchi, R & Landess, S. (2012). Out-of-state health insurance: allowing the purchase, Retrieved from state-health-insurance-purchases.aspxhttp://www.ncsl.org/research/health/out-of- state-health-insurance-purchases.aspx DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in Department of Health and Human Services, September 24, Retrieved on January 6, 2015 from: Henry J. Kaiser Family Foundation (April 25, 2013). Summary of the Affordable Care Act. Henry J. Kaiser Family Foundation. Retrieved on January 28, 2015 from: Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act? Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015 from: sheet/state-profiles-uninsured-under-aca-kansas/http://kff.org/health-reform/fact- sheet/state-profiles-uninsured-under-aca-kansas/ Huang, C.C & Smith, S. (2014). Number of uninsured Kansans in 2013 unchanged from 2012: Trend shows more people receiving public coverage. Kansas Health Institute. December 17, Retrieved on February 7, 2015 from: kansans-unchanged-2012-trend-shows-http://www.khi.org/policy/article/rate-uninsured- kansans-unchanged-2012-trend-shows- Institute of Medicine. (2013). Consequences of uninsurance, IOM Retrieved on January 31, 2014 from: Keckley, PH, Coughlin, S, Korenda, L, & Rice, E. (2011) The impact of health reform on the individual insurance market: a strategic assessment. Deloitte Issue Brief. Retrieved from UnitedStates/Local%20Assets/Documents/Health%20Reform%20Issues%20Briefs/us_chs_HealthReformAndTheIndividualInsuranceMarket_Issue Brief_ pdfhttp://www.deloitte.com/assets/Dcom- KHA (2015). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: net.org/CriticalIssues/KanCareExpansion/http://www.kha- net.org/CriticalIssues/KanCareExpansion/ KHA (2015). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: net.org/CriticalIssues/KanCareExpansion/http://www.kha- net.org/CriticalIssues/KanCareExpansion/ Majerol, M. Newkirk, V. & Garfield, R. (December 2014). The uninsured: A primer. Key facts about health insurance and the uninsured in America. Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on January 29, 2015 from: Porter, ME & Teisberg, EO. (2013). Redefining competition in healthcare, Harvard Business Review. Retrieved from Rockefeller Institute of Government. (2014). Kansas: Baseline report. State-leve field network study of the implementation of the Affordable Care Act, State University of New York, December 1, 2014, Retrieved on February 7, 2015 from: Stoll, K. and Bailey, K. (2009) Hidden health tax: Americans pay a premium, Families USA, May, Retrieved on January 31, 2015 from: UC Atlas (2011) Health care spending, US Atlas of Global Inequality. Retrieved on January 31, 2015 from:

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