Medicaid Overview Julia Paradise Associate Director, Kaiser Commission on Medicaid and the Uninsured The Henry J. Kaiser Family Foundation George Washington University Health Policy Fellows Washington, DC September 26, 2016

Entitlement Federal State Medicaid’s Origins partnership Enacted in 1965 as Title XIX of the Social Security Act Means-tested; originally focused on the public assistance population Federal State Entitlement Eligible Individuals are entitled to a defined set of benefits States are entitled to federal matching funds Sets core requirements on eligibility and benefits Flexibility to administer the program within federal guidelines partnership

Medicaid plays a central role in our health care system… Health Insurance Coverage Assistance to Medicare Beneficiaries Long-Term Care Assistance MEDICAID Support for Health Care System and Safety-Net State Capacity for Health Coverage

…and makes up a significant portion of total health coverage and spending. Total = 316.2 million Total = $2.6 trillion NOTE: Health spending total does not include administrative spending. SOURCE: Health insurance coverage: KCMU/Urban Institute analysis of 2014 data from 2015 ASEC Supplement to the CPS. Health expenditures: KFF calculations using 2014 NHE data from CMS, Office of the Actuary

Medicaid spending is mostly for the elderly and people with disabilities. SOURCE: KCMU/Urban Institute estimates based on data from FY 2011 MSIS and CMS-64. MSIS FY 2010 data were used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT, but adjusted to 2011 CMS-64.

Medicaid and private insurance provide similar access to care – the uninsured fare far less well. Children Nonelderly Adults NOTES: Access measures reflect experience in past 12 months. Respondents who said usual source of care was the emergency room are not counted as having a usual source of care. *Difference from ESI is statistically significant (p<.05) SOURCE: KCMU analysis of 2014 NHIS data.

Medicaid lowers financial barriers to care, but other access challenges remain. Among those who postponed care, share saying they did so because: NOTE: Includes adults ages 19-64. Respondents could indicate more than one reason. * Estimate statistically significantly different from uninsured estimate at the 95% confidence level. SOURCE: 2013 Kaiser Survey of Low-Income Americans and the ACA.

Medicaid costs are shared by the states and the federal government based on each state’s federal matching rate. WA OR WY UT TX SD OK ND NM NV NE MT LA KS ID HI CO CA AR AZ AK WI WV VA TN SC OH NC MO MS MN MI KY IA IN IL GA FL AL VT PA NY NJ NH MA ME DC CT DE RI MD 50.1-59.9% (12 states) 50% (14 states) 60.0-66.9% (13 states) 67.0-74.6% (12 states, including DC) FFY 2017 FMAP NOTE: FMAP percentages are rounded to nearest tenth of a percentage point. FMAPs shown reflect states’ regular FMAP in effect Oct. 1, 2016-Sept. 30, 2017; they do not reflect the 100% FMAP for persons newly eligible in states that adopted the ACA Medicaid expansion. SOURCE: The Kaiser Family Foundation, State Health Facts. Data Source: 80 Fed. Reg. 73779 – 73782 (Nov. 5, 2015) accessed September 8, 2016, http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/.

Medicaid is both a budget item and the largest source of federal revenue in state budgets. SOURCE: KCMU estimates based on the NASBO’s November 2015 State Expenditure Report (data for Actual FY 2014.)

The ACA Medicaid expansion fills historic gaps in coverage. NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,424 for an individual and $27,724 for a family of three in 2015.

32 states have adopted the ACA Medicaid expansion. As of September 2016 WY WI* WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH* NV NE MT* MO MS MN MI* MA MD ME LA KY KS IA* IN* IL ID HI GA FL DC DE CT CO CA AR* AZ AK AL Adopted (32 states, including DC) Not adopting at this time (19 states) NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, IA, IN, MI, MT, and NH have approved Section 1115 waivers. WI covers adults up to 100% FPL, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated July 7, 2016. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Medicaid eligibility for parents and other nonelderly adults remains low in non-expansion states. NOTE: Eligiblity levels for children and pregnant women reflect CHIP too. Medians are based on Medicaid expansion decisions made by Jan. 28, 2016 and include Louisiana’s decision to expand. Eligibility levels are based on the 2015 FPL for a family of three ($20,090) for children, pregnant women, and parents, and the FPL for an individual ($11,770) for childless adults. Thresholds include the standard disregard of five percentage points of the FPL. SOURCE: National survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2016.

About half of the remaining uninsured are eligible for financial assistance but are not enrolled in coverage. Eligibility for ACA Coverage Among Nonelderly Uninsured as of 2015: Eligible for Financial Assistance 49% Total = 32.3 Million Nonelderly Uninsured NOTES: Numbers may not sum to subtotals or 100% due to rounding. Tax credit-eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. SOURCE: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels, updated to reflect state Medicaid expansion decisions as of January 2016 and 2015 Current Population Survey data.

Research points to positive impacts from the Medicaid expansion. Reduction in the Number of Uninsured Increased Provider Revenue and Access to Care + ↓ Uncompensated Care Costs ↓ State-funded health programs (e.g. Mental health) Increased State Savings Federal + State Funds Increased State Economic Activity ↑ Jobs and Revenues

Over half of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs. As of July 1, 2014 WY WI WV WA VA VT UT TX TN SD SC RI PA OR OK OH ND NC NY NM NJ NH NV NE MT MO MS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL 26-50% (5 states) 51-75% (13 states, including DC) 76-100% (16 states) 0% (11 states) 1-25% (6 states) U.S. Overall = 61% SOURCE: Medicaid Managed Care Enrollment and Program Characteristics, CMS, Spring 2016. Data as of July 1, 2014.

Delivery system and payment reform activity is widespread among Medicaid programs. NOTE: Managed Care Expansions to New Groups refers to expansions to new groups, new regions, increasing the use of mandatory enrollment, and new RBMC programs. Other Delivery System Initiatives include new or expanded initiatives related to PCMH, Health Homes, ACOs, Episodes of Care, DSRIP and initiatives focused on dual eligible beneficiaries. SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2015.

Looking Ahead: Key Issues to Follow How do we reach the eligible but uninsured? Will states continue to expand and on what terms? What is the impact of the Medicaid expansion on people’s coverage and access to care? How is the rapid growth in managed care affecting access to care and costs, especially for high-need populations? How is the ACA affecting coverage and the health care safety net? How will federal state relationships reshape Medicaid coverage and financing going forward?

For more information on the Medicaid program and health reform, visit… www.kff.org