K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 0 The Role of Medicare and Medicaid in State and National Health Reform Diane Rowland, Sc.D. Executive Vice President, Henry J. Kaiser Family Foundation and Executive Director, Kaiser Commission on Medicaid and the Uninsured for National Congress on the Un and Underinsured December 12, 2007 Washington, DC

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 1 Health Insurance Coverage in the U.S., 2006 * Medicaid/Other Public includes Medicaid, SCHIP, other state programs, and military- related coverage. NOTE: Those enrolled in both Medicare and Medicaid (1.8% of total population) are shown as Medicare beneficiaries. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS. Total = million

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 2 IL Uninsured Rates Among the Nonelderly, by State, AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MOKS OH IN NY KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM 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 ( ). TX FL AL 13-17% (18 states & DC) ≥ 18% (19 states) < 13% (13 states) US Average = 18% NE

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 3 Characteristics of the Uninsured, 2006 Family IncomeFamily Work Status Total = 46.5 million uninsured 1 or More Full- Time Workers 71% No Workers 18% Part-Time Workers 11% Age % % % % The federal poverty level was $20,614 for a family of four in SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 4 The Nonelderly Uninsured, by Age and Income Groups, 2006 Total = 46.5 million uninsured Low-income includes those with family incomes less than 200% of the federal poverty level. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS. Other Adults without Children 21%

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 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 15% of national health spending Assistance to Medicare Beneficiaries 7.5 million aged and disabled — 18% of Medicare beneficiaries Long-Term Care Assistance 1 million nursing home residents; 43% of long-term care services

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 Enrollees and Expenditures by Enrollment Group, 2004 Children 17% Elderly 26% Disabled 39% Adults 12% Children 50% Elderly 10% Disabled 14% Adults 26% Total = 58 millionTotal = $274 billion DSH 6% SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on FY 2004 MSIS and CMS-64 data.

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 7 Poor Near-Poor (<100% Poverty) ( % Poverty) Poor Near-Poor Poor Near-Poor Children Parents Adults without Children Medicaid also includes SCHIP and other state programs, Medicare and military- related coverage. SOURCE: KCMU/Urban Institute analysis of March 2007 CPS. Health Insurance Coverage of Low-Income Adults and Children, 2006

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 and SCHIP Enrollment of Children, FY 1998 – FY 2005 SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of HCFA-2082, MSIS, and SEDS data, Millions of Children

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 9 Percentage of Children Without Health Insurance, By Poverty Level, * Survey method change in 2005 affects comparison with earlier years slightly. Children less than 18 years old. Source: L. Ku, “Medicaid: Improving Health, Saving Lives,” Center on Budget and Policy Priorities analysis of National Health Interview Survey data, August Children below 200% of poverty Children above 200% of poverty 23% 14% 6% 5% 21% 5%

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 10 Children’s Eligibility for Medicaid/SCHIP by Income, July 2007 AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MOKS OH IN NY IL KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA *The Federal Poverty Line (FPL) for a family of three in 2006 is $16,600 per year. **IL uses state only funds to cover children above 200% FPL SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, TX IL FL AL < 200% FPL (9 states) 200% FPL (23 states) > 250% FPL (11 states including DC) % FPL (8 states)

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 11 IL Medicaid Eligibility for Working Parents, by Income, July 2006 AZ AR MS LA WA MN ND WY ID UT CO OR NV CA MT IA WI MI NE SD ME MOKS OH IN NY KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA * Federal Poverty Level (FPL) refers here to HHS Poverty Guidelines, $16,600 for a family of three in SOURCE: Center on Budget and Policy Priorities for KCMU, 2005 TX FL AL 50% - 99% FPL (21 states) ≥100% FPL* (16 states including DC) < 50% FPL (14 states) National Average = 67% FPL

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 12 The Uninsured by Income and Eligibility for Public Coverage, 2004 SOURCE: Urban Institute analysis of 2005 CPS for KCMU. Eligible 74 % Children 8 Million Uninsured Not Eligible, 300%+ FPL 15 % Not Eligible, <300% FPL 11% *The Federal Poverty Line (FPL) for a family of three in 2004 is $15,067 per year Not Eligible, 300%+ FPL 21 % Not Eligible, <300% FPL 65% Adults 36.6 Million Uninsured Eligible 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 Renewed State Interest in Expanding Coverage Fiscal outlook improving for states –Increased tax revenues –Growth in Medicaid spending leveling off 42 states have plans to expand health coverage –States using Medicaid to support financing and enrollment –Improving Medicaid and SCHIP coverage, particularly for children –Universal coverage plans passed in 3 states, proposed in 11 others Need to address growing uninsured population –Driven by declining rates of employer-sponsored insurance –Exacerbated by rising health care costs Desire to improve the quality and efficiency of current health care system

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 14 States Moving Toward Comprehensive Health Care Reform* Proposed Universal Coverage (11 states) Enacted Universal Coverage (3 states) WA OR CA MN WI IL PA NY ME MA VT CO *as of October 1, 2007 KS CT

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 15 Role of Medicare and Medicaid in State Reform Medicare covers the elderly and some disabled Medicaid provides: –coverage through expanded eligibility and increased outreach –a financing vehicle through redirected DSH funds –a source of federal assistance through matching funds for increased coverage and provider payments

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 16 Key Elements of the Massachusetts Health Care Reform Plan 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 <100% 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 17 Proposed Coverage for Uninsured under Massachusetts Reform Subsidized coverage 38% 207,500 residents Private Insurance 39% 215,000 residents Medicaid Expansion 17% 92,500 residents Remain Uninsured 6%, 35,000 residents Total Uninsured – 550,000 Source: Massachusetts Senate

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 Reform Plan Revenues SFY 2008 Source: Massachusetts Executive Office of Administration and Finance Total Revenues = $1.725 Billion Federal Medicaid Matching Payments Insurance Surcharge Hospital Assessment State General Funds Employer Assessment Other

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 19 Massachusetts Reform Implementation Update MassHealth (Public Program Expansion) –From end of June 2006 to July 2007, MassHealth enrollment increased by nearly 56,000 Commonwealth Care (Subsidized Connector) –Commonwealth Care plans (offered by Medicaid managed care plans) became available October 2006 –As of October 2007, 127,000 have enrolled in Commonwealth Care –Vast majority of enrollees (80%) have incomes below 150% FPL Commonwealth Choice (Unsubsidized Connector) –Plans from six carriers approved, available May 1, 2007 –Plans became available to small businesses October 1, 2007 –Enrollment to date more limited

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 20 Source: Kaiser Health Tracking Poll: Election 2008 Percent naming HEALTH CARE as one of the top two issues they’d most like to hear presidential candidates talk about, by political party self-identification: National Interest in Health Care Also Rising

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 21 Presidential Candidates Differ in Approach to Health Care Reform Democrats generally favor: –universal coverage –strengthening the private employer-based system –expanding the role of existing public programs for low-income –purchasing pools and insurance market reforms –coverage mandates on employers and individuals –financing by rolling back tax breaks for wealthiest Americans Republicans generally favor: –tax incentives for the purchase of insurance –expanding the individual insurance market –limiting the role of public programs; more state flexibility –consumer-directed plans such as HSAs –deregulation of the insurance market

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 22 Hillary Clinton Barack Obama John Edwards Rudy Giuliani Mitt Romney John McCain Plan Announced: 9/17/075/29/072/18/077/31/078/24/0710/11/07 Individual Mandates For Children Only Employer Mandates Public Program Expansion New Insurance Pooling Mechanism Premium Subsidies Insurance Market Regulation More Less Change Tax Treatment of Insurance Caps for >$250,00 0 Encourage Consumer-Directed Care

K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Figure 23 Public Programs and Health Reform Medicaid provides a coverage base for low-income –Coverage could be extended to more children, parents, and other adults –Medicaid funding used to finance coverage expansions –Medicaid helps promote state reform efforts SCHIP reauthorization debate raises issues for public role –Income eligibility for public coverage –Scope of coverage and the role of private plans –Public programs vs. tax credits for coverage Medicare as a vehicle for expanded coverage –Single-payer proposals modeled after Medicare –Buy-in options for early retirees