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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 0 Medicaid: The Basics Diane Rowland, Sc.D. Executive Director Kaiser Commission.

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Presentation on theme: "K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 0 Medicaid: The Basics Diane Rowland, Sc.D. Executive Director Kaiser Commission."— Presentation transcript:

1 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 0 Medicaid: The Basics Diane Rowland, Sc.D. Executive Director Kaiser Commission on Medicaid and the Uninsured and Executive Vice President Kaiser Family Foundation June 2005 KaiserEDU.org Tutorial

2 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 1 Medicaid’s Origin Enacted in 1965 as companion legislation to Medicare (Title XIX) Established an entitlement Provided federal matching grants to states to finance care Focused on the welfare population: –Single parents with dependent children –Aged, blind, disabled Included mandatory services and gave states options for broader coverage

3 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 2 Medicaid Today Medicaid provides health and long-term care coverage for over 52 million low-income people: –Comprehensive, low-cost health coverage for 39 million people in low-income families –Acute and long-term care coverage for over 13 million elderly and persons with disabilities, including over 6 million Medicare beneficiaries Guarantees entitlement to individuals and federal financing to states Federal and state expenditures of $300 billion—with federal government funding 57% Pays for nearly 1 in 5 health care dollars and 1 in 2 nursing home dollars

4 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 3 Medicaid’s Role for Selected Populations Note: “Poor” is defined as living below the federal poverty level - $14,680 for a family of three in 2003. SOURCE: KCMU, KFF, and Urban Institute estimates; Birth data: NGA, MCH Update. Percent with Medicaid Coverage: Families Aged & Disabled Poor Near Poor All Children Low-Income Children Low-Income Adults Births (Pregnant Women) Medicare Beneficiaries People with Severe Disabilities People Living with HIV/AIDS Nursing Home Residents

5 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 4 Minimum Medicaid Eligibility Levels, 2004 Note: The federal poverty level was $9,310 for a single person and $15,670 for a family of three in 2004. SOURCE: Cohen Ross and Cox, 2004 and KCMU, Medicaid Resource Book, 2002. Income eligibility levels as a percent of the Federal Poverty Level:

6 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 5 Medicaid Benefits Physician services Laboratory and x-ray services Inpatient hospital services Outpatient hospital services Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 Family planning Rural and federally-qualified health center (FQHC) services Nurse midwife services Nursing facility (NF) services for individuals 21 or over Prescription drugs Clinic services Dental services, dentures Physical therapy and rehab services Prosthetic devices, eyeglasses Primary care case management Intermediate care facilities for the mentally retarded (ICF/MR) services Inpatient psychiatric care for individuals under 21 Home health care services Personal care services Hospice services “Mandatory” Items and Services“Optional” Items and Services

7 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 6 Medicaid Expenditures by Service, 2003 Total = $266.1 billion SOURCE: Urban Institute estimates based on data from CMS (Form 64), prepared for KCMU. Inpatient Hospital 13.6% Physician/ Lab/ X-ray 3.7% Outpatient/Clinic 6.7% Drugs 10.0% Other Acute 6.3% Payments to MCOs 15.6% Nursing Facilities 16.8% ICF/MR 4.4% Mental Health 1.8% Home Health and Personal Care 13.0% Payments to Medicare 2.3% DSH Payments 5.4% Acute Care 58.2% Long- Term Care 36.0%

8 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 7 Medicaid Enrollees and Expenditures by Enrollment Group, 2003 Note: Total expenditures on benefits excludes DSH payments. SOURCE: KCMU estimates based on CBO and OMB data, 2004. Children 19% Elderly 26% Disabled 43% Adults 12% Children 48% Elderly 9% Disabled 16% Adults 27% Total = 52.4 millionTotal = $252 billion

9 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 Payments Per Enrollee by Acute and Long-Term Care, 2003 $1,700 $1,900 $12,300 $12,800 SOURCE: KCMU estimates based on CBO and Urban Institute data, 2004. Long-Term Care Acute Care

10 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 9 Federal Medical Assistance Percentages (FMAP), FY 2005 50 percent (13 states) 61 to <71 percent (15 states & DC) 51 to <61 percent (13 states) 71 + percent (9 states) SOURCE: Federal Register, December 3, 2003

11 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 10 Poor Near-Poor (<100% Poverty) (100-199% Poverty) Poor Near-Poor (<100% Poverty) (100-199% Poverty) Poor Near-Poor (<100% Poverty) (100-199% Poverty) Children Parents Adults without children Note: Medicaid/Other Public includes SCHIP and other state programs, Medicare, and military-related coverage. The federal poverty level was $14,680 for a family of three in 2003. SOURCE: KCMU and Urban Institute analysis of March 2004 Current Population Survey. Medicaid’s Role for Children and Adults, 2003

12 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 11 Medicaid’s Impact on Access to Health Care Percent Reporting Did Not Receive Needed Care No Pap Test in Past Two Years No Regular Source of Care AdultsWomenChildren SOURCES: The 1997 Kaiser/Commonwealth National Survey of Health Insurance; Kaiser Women’s Health Survey, 2004; Dubay and Kenney, Health Affairs, 2001.

13 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 12 Medicaid Enrollees are Poorer and Sicker Than The Low-Income Privately Insured Population Percent of Enrolled Adults: Poor Health Conditions that limit work Fair or Poor Health SOURCE: Coughlin et. al, 2004 based on a 2002 NSAF analysis for KCMU. Medicaid Low-Income and Privately Insured

14 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 13 Average Annual Medicaid Spending Growth Compared to Growth in Private Health Spending, 2000-2003 Medicaid Acute Care Spending Per Enrollee Health Care Spending Per Person with Private Coverage 1 Monthly Premiums For Employer- Sponsored Insurance 2 SOURCES: 1 Strunk and Ginsburg, 2004. 2 Kaiser/HRET Survey, 2003.

15 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 14 Total Medicare Beneficiaries = 40 million SOURCE: KCMU estimates based on CMS data and Urban Institute analysis of data from MSIS. Total Duals = 7.2 million Medicaid Status of Medicare Beneficiaries, FFY 2002

16 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 15 Medicaid Eligibility & Benefits for Medicare Beneficiaries, 2005 PathwayIncome Eligibility Asset Limit Individual /Couple Medicaid Benefits Medicare Premiums & Cost-sharing SSI Cash Assistance < 74% of poverty (SSI income eligibility) $2,000 $3,000 XX Qualified Medicare Beneficiary (QMB) < 100% of poverty$4,000 $6,000 X Specified Low-Income Beneficiary (SLMB) 100-120% of poverty $4,000 $6,000 Premium only Mandatory Populations

17 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 16 Medicaid Eligibility & Benefits for Medicare Beneficiaries, 2005 (cont’d) PathwayIncome Eligibility Asset Limit Individual/ Couple Medicaid Benefits Medicare Premiums & Cost-sharing Medically Needy Individuals who spend income down to a specified level $2,000 $3,000 X*X Poverty Level < 100% of poverty$2,000 $3,000 XX Special Income Rule for Nursing Home Residents Institutionalized individuals with income < 300% of the SSI level $2,000 $3,000 XX HCBS Waivers Must be eligible for institutional care XX Optional Populations *Medicaid benefits may be more limited than for SSI.

18 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 17 Dual Enrollees are Poorer and Sicker Than Other Medicare Beneficiaries *Community-residing individuals only. SOURCE: KCMU estimates based on analysis of MCBS Cost & Use 2000.

19 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 18 Spending on Dual Eligibles as a Share of Medicaid Spending on Benefits, FY2002 Total Spending on Benefits = $232.8 Billion SOURCE: Urban Institute estimates prepared for KCMU based on an analysis of 2000 MSIS data applied to CMS-64 FY2002 data. Spending on Dual Eligibles 42% Prescription Drugs ($13.4 Billion) Non- Prescription ($82.7 Billion) Spending on Other Groups ($136.7 Billion) 36% 59% 6%

20 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 19 National Spending on Nursing Home and Home Health Care, 2003 Total = $110.8 billion SOURCE: CMS, National Health Accounts, 2005. Total = $40 billion Nursing Home CareHome Health Care Medicaid 46% Medicare 12% Out-of- Pocket 28% Private Insurance 8% Other 6% Medicaid 25% Medicare 32% Out-of- Pocket 17% Private Insurance 21% Other 5%

21 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 20 Growth in Medicaid Long-Term Care Expenditures, 1991-2003 $34 $52 $75 86% 79% 71% SOURCE: Burwell et al. 2004, HCFA-64 data. In Billions: 14 % 21% 29% 31% 69% $82 $84 33% 67% Home & community- based care Institutional

22 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 21 Average Annual Growth in Medicaid Expenditures, 1991-2003 SOURCE: Urban Institute, 2005; data from HCFA Financial Management Reports, 2004 (HCFA-64/CMS-64).

23 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 22 Growing Pressure on Government Spending SOURCE: CBO, Baseline Budget Outlook, January 2005; National Association of State Budget Officers, 2003 State Expenditure Report, 2004. State General Fund Spending Total = $499 BillionTotal = $2.3 Trillion Federal Outlays

24 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 23 What’s at Stake in Medicaid Reform Health Insurance Coverage 25 million children and 14 million adults in low- income families; 6 million persons with disabilities State Capacity for Health Coverage 43% of federal funds to states MEDICAID Support for Health Care System 17% of national health spending Assistance to Medicare Beneficiaries 7 million aged and disabled — 18% of Medicare beneficiaries Long-Term Care Assistance 1 million nursing home residents; 43% of long- term care services


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