1. Affordable Care Act Summit
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Countdown to 2014: Texas Medicaid, CHIP, and the Uninsured Coverage Gap
Anne Dunkelberg, Associate Director –
Affordable Care Act Summit
Irving, TX
Wednesday, August 7, 2013
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CPPP.org

2. Marketplace and Medicaid: Building Blocks of
ACA’s 2014 Reforms
Build on current system: Most Americans still get coverage through their employer.
Medicaid expansion: US citizens to 133% FPL ($14,856 individual; $30,657 for 4 in 2012). State option.
Reform private health insurance: standard minimum benefits, can’t charge more based on health status, limits on premium differences by age, no denial of coverage, no excluding pre-existing conditions, no annual or lifetime maximums.
New Health Insurance Marketplace where private insurers’ options can be compared and purchased.
Sliding scale help with premiums in the exchange from 100% up to 400% of FPL ($92,200 for family of 4).
Sliding scale help with deductibles/co-pays and out-of-pocket caps in the exchange
Individual mandate to have coverage (with major exemptions for lowest-income).
Employer penalties possible if employees get sliding-scale help in Marketplace, but exemption for all employers with 50 or fewer FTE workers.

3. 2014: ACA Provides Public Support Fitted to Income
>$89,400 for a family of four;
>400% of FPL
Job-based coverage, or
Full-cost coverage in the exchange
$67,100-$89,400;
% of FPL
Subsidized exchange coverage: premiums capped at 9.5% of income
$44,700-$67,100;
% of FPL
Subsidized exchange coverage: premiums capped at 6.3 – 9.5% of income
$29,700-$44,700;
% of FPL
CHIP
Subsidized exchange coverage: premiums capped at 3% - 6.3% of income
<$29,700 for a family of four;
< 133% FPL
Medicaid
???Medicaid???
Children
Adults
(non-disabled adults,
not eligible for Medicare)
Family Income
Next going to see which Texans are covered by what part of Affordable Care Act.
Family income based on 2011 federal poverty income levels for a family of four

4. Texas Enrollment Opportunity
As of 2010, 6.2 million Texans were uninsured. This is how those individuals could gain coverage under the ACA:
Marketplace with help
Marketplace at full cost
Medicaid adults: newly eligible
Medicaid/CHIP kids:
eligible now but not enrolled
Left uninsured

5. About 1.5 million Texans would gain insurance with Medicaid expansion
Experts and Texas HHSC estimate million uninsured US citizen adults in Texas will be eligible for the Medicaid option in 2014,
HHSC projects just over a million of these adults would actually enroll by 2016 (note the difference between who is eligible, versus who actually signs up).
HHSC also estimates that over 400,000 more children— already eligible today, but unenrolled—will sign up for Medicaid by 2016 because of higher public awareness: called the “welcome mat” effect.

6. But, If Texas Opts Out
ACA sliding-scale premium help is available only to persons above 100% FPL (exception: legal immigrants excluded from Medicaid) , so:
Uninsured Texas adults below 100% FPL would have NO assistance available in
Those from % FPL would be eligible for premium assistance, but because the system was designed assuming poorest would have Medicaid, some of these near-poor will have difficulty affording the coverage even with premiums capped at 2% of family income.
So, costs of care for uninsured poor Texas adults will continue to be carried primarily by local property taxpayers, secondarily by other charity care providers, and without benefit of the 90%+ federal matching dollars.

8. Share of Nonelderly Uninsured <138% FPL by State, 2010-2011:
There is significant variation in the share of the uninsured that is below the Medicaid expansion limit across states.
Share of Nonelderly Uninsured <138% FPL by State, : WA VT ME MT ND NH MN OR NY MA WI ID SD MI RI CT WY PA IA NJ NE OH DE NV IL IN MD UT CO WV CA VA KS MO DC KY NC TN AZ OK AR SC NM MS AL GA AK TX
53% LA FL HI
34% – 47% (17 states)
United States:
51% Uninsured <138% FPL
48% – 51% (18 states, including DC)
52% - 61% (16 states)
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements).

9. Texas Uninsured: Without Medicaid Expansion, Only half as many gain coverage
6.1 million uninsured
Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D. , Rice University, Estimates of the Impact of the Affordable Care Act on Counties in Texas, April 2012.

10. Texas Uninsured by Income 2011…
89% of the 6.1 million uninsured have incomes <400% FPL
656K
501K
6.1 million includes 1.7 million non-US citizens; ~2/3 of these (about 1.1 million) likely undocumented
1.912 Million
421K
626K
614K
921K
525K
Annual income limits given for a family of four, 2011 federal poverty level U.S. Census, 2012 CPS

11. Texas Medicaid/CHIP: Who is Helped Today
January 2013, HHSC data
Total enrolled 1/1/2013:
3.6 million Medicaid;
592,000 CHIP
1 in 7 Texans,
but 42% of Texas kids 11 11

12. Why So Few Poor Parents Covered in Texas Medicaid
Texas Medicaid has VERY low coverage of parents (must live below 12% of poverty; work less than 10 min wage; must be under $308 a month for family of 3).
This dollar limit set by Texas legislature 1985 and never updated.
Today, about 226,000 poor Texas parents get Medicaid, even though there are about 2.6 million children enrolled.
Medicaid Maternity coverage income limit is much higher, but coverage ends 2 months after birth.
Medicaid does not cover undocumented at any age.
LEGAL immigrant adults NOT covered in Texas Medicaid (state choice, AL, VA, ,MS, ND, OH, WY also exclude). (Legal immigrant kids through age 18 are covered in Texas Medicaid and CHIP)
60% of adult Texans below poverty are uninsured (1.4 million)

13. Income Caps for Texas Medicaid and CHIP, 2012
$25,128
$35,317/yr
$35,317/yr
$38,180
$25,390/yr
225%
200%
$19,090
185%
185%
$8,376
$3,696
$2,256
100%
75%
133%
19%
12%
“Optional” indicates Texas Choices to go ABOVE federal minimum
Income Limit as Percentage of Federal Poverty Income
Annual Income is for a family of 3,
except Individual Incomes shown for SSI and Long Term Care

14. The Medicaid expansion will significantly increase eligibility for parents in many states.
Medicaid Eligibility Levels for Parents, January 2013:
138%*
25%
NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL .
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013.

15. In states that do not expand Medicaid, there will be large gaps in coverage, leaving millions of low-income adults with no affordable options.
NOTE: Applies to states that do not expand Medicaid. The current median state Medicaid eligibility limit for parents is 48% FPL in the 21 states that are not moving forward with the Medicaid expansion at this time.

16. Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013
Source: KFF.org

17. What does Texas pay, and what does federal government pay if we expand Medicaid to adults under the ACA?
Federal government picks up 100% of the costs for the first three years of Texas’ expansion to the adults,
95% in 2017, 94% in 2018, 93% in 2019, and no less than 90 percent every year after that.
Texas will also see increased enrollment—known as the “welcome mat” effect—by already-eligible but currently uninsured children.
Federal government picks up 100% of the costs for the first three years of Texas’ expansion to the adults, 95% in 2017, 94% in 2018, 93% in 2019, and no less than 90 percent every year after that.
Texas will also see increased enrollment— known as the “welcome mat” effect—by already-eligible but currently uninsured children.
So, Texas’ costs for children’s Medicaid would also be expected to increase, and the state’s share of that growth would be our “regular” state Medicaid share (just under 42 cents per dollar in 2012, updated by Congress every year).

18. Range of Official Cost Estimates
HHSC (Texas Medicaid agency) estimates the state-budget (GR) Medicaid costs to cover these new adults at $1.3 billion GR for the first 4 years, drawing another $23.9 billion in federal match.
HHSC projects in first 4 years, Texas would spend an average of $784 million a year, drawing over $6.8 BILLION federal match (net gain over $6 billion/year)
Legislative Budget Board (LBB) often has different opinion of Medicaid caseload and cost per enrollee from THHSC; projects only $482 million state GR costs for 4 years.

19. 5 Tools on Medicaid Expansion and Texas:
Choices and Challenges: How Texas County Uninsured Rates Will Drop Under Health Care Reform Cline & Murdock, of Rice U. (former Texas State Demographer and Director of the US Bureau of the Census)  includes estimates of the much smaller reduction in uninsured rates expected if Texas does not accept the Medicaid Expansion. (see
Your County and the ACA Medicaid Expansion. CPPP compiled data for all 254 Texas counties on impact of ACA on uninsured, and the new federal dollars by county, based on Rice data above and the Texas Health and Human Services Commission’s latest official Medicaid expansion estimates.   (see
Texas Has Only One Rational Choice: Expanding Medicaid Under the Affordable Care Act: Study by The Perryman Group Finds that Expanding Medicaid More than Pays for Itself. Analysis by The Perryman Group, every $1 spent by the State of Texas to expand Medicaid coverage under the Affordable Care Act (ACA) returns $1.29 in dynamic State government revenue over the first 10 years of the expansion.
Government Effectiveness and Efficiency Report 2013 (January 2013). This biennial report to the Legislature by Legislative Budget Board staff includes a chapter analyzing the costs and benefits of the ACA Medicaid expansion and recommending that counties be enabled to finance and implement the expansion.
Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income Adults (January 2013). This new report from Billy Hamilton Consulting provides a comprehensive model estimating the costs and benefits to local taxing authorities (including cities, counties and hospital districts) and state government. Using the Cline-Murdock model data, the authors conclude that state match needed for the Medicaid expansion are far less than current state, local, and hospitals spending on health care for low-income adults, and project $1.8 billion in new state revenue will be generated by the expansion from 2014 through 2017, offsetting about half of the required state match.

21. Large Urban Counties & Medicaid Expansion Estimated # Gaining Medicaid
El Paso
Dallas
Harris
Lubbock
Travis
Yearly Avg.
$222 million
$ million
$935.3 million
$77.7 million
$224.1 million
NEW Fed $
Uninsured NOW
208,379
601,492
1,025,922
66,405
233,067
Estimated # Gaining Medicaid
51,462
131,042
223,165
19,693
55,676
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, Cline & Murdock estimates of ACA insurance gains by county.

22. Largest South Texas Metro Counties Estimated # Gaining Medicaid
& Medicaid Expansion:
Bexar
Cameron
Hidalgo
Nueces
Webb
One-year Avg.
$ million
$ million
$ million
$ million
$92.0 million
NEW Fed $
Estimated # Gaining Medicaid
179,654
27,987
50,509
22,403
16,031
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, Cline & Murdock estimates of ACA insurance gains by county.

23. What’s Happened?
13 House and 6 Senate billed filed to expand Medicaid per ACA; each chamber included a bill authored by a Republican in a leadership role (Rep. Zerwas; Senator Deuell).
Also Senate budget “rider” by Finance committee Chairman Tommy Williams
Widespread Support, Executive Opposition. Statewide support for Medicaid expansion from doctors, hospitals, county officials, chambers of commerce, and even the Texas Association of Business eventually supporting the Zerwas coverage option.
Polling by Texas and national firms found 58-59% of Texas voters support accepting federal ACA funds to cover the poorest uninsured adults.
Twenty-two chambers of commerce have called on the state to accept this funding, and new chambers continue to add their names to the list.
Despite this support, the Legislature did not move the very-conservative, market-based “Texas Solution” alternative offered by Rep. John Zerwas HB 3791.
There was more than sufficient support by House members for Zerwas’ “Texas Solution” bill. But the Governor’s office began to communicate a veto threat

24. What’s Next? Texas’ decision means that in January 2014:
Texas adults above the poverty line will begin to get publicly funded sliding-scale help with health insurance,
but Texans below poverty will qualify for nothing.
Estimates of the number of uninsured Texas adults who will be left without a coverage option in the near term range:
from around 935,000 (HHSC, out of 1.1 million below 138% of poverty)
to as high as 1.3 million (Urban Institute/Kaiser Family Foundation, out of about 1.7 million below 138% of poverty).
A Diverse network of Texans and Texas Organizations will keep working to find health care for the Texans in the “Gap Group,” to tell their stories, and to seek inclusion of Texas’ working poor in the ACA’s health reform.

25. INFORMATION NOW: HealthCare.gov
Available 24/7: ; TTY:
Or, Chat Online

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