Arkansas’s Journey through Medicaid Expansion Craig Wilson, JD, MPA Health Policy Director Families USA Health Action Conference February 5, 2016

Workforce Payment System Insurance Coverage Health IT Transparency Population Health Arkansas System Transformation Strategy

Arkansas: Fed Min for Parents = 13% FPL Jobless Parents = 13% FPL Working Parents = 17% FPL Medicaid Income Eligibility Limits as a Percent of Federal Poverty Level Source: Kaiser Family Foundation’s statehealthfacts.org. Based on a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families, 2012, with data updates.

Emanated from 100 – 138% FPL discrepancy in ACA Alternative approach to Medicaid expansion (commonly called “Private Option”) Neither managed care nor traditional Medicaid coverage Use Medicaid funding through premium assistance to purchase private coverage through the Health Insurance Marketplace for those <139% FPL Majority of newly insured placed with private carriers; medically frail better served in traditional Medicaid Arkansas Health Care Independence Program (HCIP)

Consumer Entry- Initiate Application 187,246 Private Coverage 21,634 Traditional Medicaid 53,271 Actively Enrolled in Marketplace Plan 240,517 in Private Coverage through Marketplace Health Care Needs Questionnaire 208,880 Eligible from State & Federal Portals Consumer Entry- Initiate Application Eligibility and Enrollment for Health Insurance Marketplace and the Health Care Independence Program (HCIP) Federal Health Insurance Marketplace Arkansas Eligibility & Enrollment Framework Updated October 2015

Percentage Uninsured, by County 2015 Source: The New York Times, October 30, 2015

92% of Arkansans originally estimated to be eligible have signed up for program Anecdotal evidence of improved access to specialists Increased competition in Health Insurance Marketplace from 2 to 6 insurance carriers Decreased premiums by average 2% for 2015 and less than 5% increase for 2016 Other Positive Impacts of HCIP

Arkansas Marketplace Enrollment Private Option Enrollment by Age Marketplace Enrollment without Private Option Total Marketplace Enrollment

Rural Hospital Closings in Surrounding States Source: Adapted from the North Carolina Rural Health Research Program, “56 Rural Hospital Closures Map.” Accessed August 2015.

Losses incurred by hospitals caring for low income Arkansans decreased by $149M Arkansas Hospital Association, April 2015 Uninsured Admissions Down 48.7% Uninsured ER Visits Down 38.8% Uninsured Outpatient Visits - Down 45.7%

Challenges and Opportunities Marriage of Medicaid and insurance worlds –State insurance vs federal Medicaid rules –Plan certification timing and policymaking Legislative restrictions on outreach & enrollment Implementation of cost-sharing (50-100% FPL) –Health independence accounts Limits on non-emergent transportation Requirements for carrier participation in delivery/payment reforms

Changes with New Administration Terminate Health Care Independence Program by end of 2016 Create Health Reform Legislative Task Force and Governor’s Advisory Council Focus on direction of entire Medicaid program Eliminate requirement for cost-sharing/health independence accounts for % FPL Special session likely in coming months

Task Force Report (HCIP Findings) HCIP enrollees represent 80% of total enrolled through Marketplace HCIP participants have better access to providers than traditional Medicaid ~$9 billion in federal Medicaid match payments to AR over next 5 years 40% of PO enrollees had no annual income; 54% had income had income below 50% FPL, 15% between % FPL $438M negative budget impact w/o program

Governor’s Proposed Changes Mandating participation in employer-based premium assistance program Referral of unemployed to work training; 5-year cap on length of private coverage for failure to participate Dental benefits (dental) for achieving wellness requirements (assessments/prevention) Premiums for those with incomes above 100% FPL (may be offset by wellness achievement) Elimination of 90-day retroactive coverage

HCIP Waiver Evaluation