1. The Role of Medicaid and the State Children’s Health Insurance Program in State Health Reform
Jennifer Tolbert,
Principal Policy Analyst
Kaiser Commission on Medicaid and the Uninsured
for
National Congress on the Un and Underinsured
September 23, 2008
Washington, DC

2. Number of Nonelderly Uninsured Americans,
Uninsured in Millions
46.5
44.4
45.0
43.0
The reasons we are focused on health care during this presidential election are twofold: the number of uninsured continues to rise and skyrocketing health care costs jeopardize coverage for many Americans, including those in the middle class.
In 2006, 46.5 million people in the U.S. lacked health insurance, an increase of 2.2 million from In a disturbing trend, the number of uninsured children continued to rise. Importantly, over 70% of the increase in uninsured children occurred among children with family incomes between % FPL.
SOURCE: KCMU/Urban Institute analysis of March CPS for each year.

3. Uninsured Rates Among the Nonelderly,
by State, NH VT ME WA MT ND MN MA OR NY ID SD WI MI RI WY CT PA IA NJ NE OH NE IN NV IL DE WV UT VA CO MD CA KS MO KY NC DC TN OK SC AR AZ NM GA MS AL TX LA
TWO YEAR POOLED ESTIMATES FOR US RATE AK FL HI
≥ 18% (18 states)
US Average = 18%
13-17% (19 states)
< 13% (13 states & DC)
SOURCE: Urban Institute and KCMU analysis of the March 2007 and 2008 Current Population Survey. Two-year pooled estimates for states and the US ( ).

4. The Nonelderly Uninsured, by Age and Income Groups, 2007
Other Adults without Children 21%
Total = 45.0 million uninsured
Low-income includes those with family incomes less than 200% FPL.
SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.

5. Medicaid Today MEDICAID Health Insurance Coverage
29 million children & 15 million adults in low-income families; 14 million elderly and persons with disabilities
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
MEDICAID
Data in boxes may need to be updated—unsure of source.
Support for Health Care System and Safety-net
15% of national health spending
State Capacity for Health Coverage
43% of federal funds to states

6. Health Insurance Coverage of Low-Income Adults and Children, 2007
Poor
Near-Poor
(<100% Poverty)
( % Poverty)
Children
Poor
Near-Poor
Parents
corrected near poor child data
Adults without Children
Poor
Near-Poor
SOURCE: KCMU/Urban Institute analysis of March 2008 CPS.

7. Medicaid Enrollees and Expenditures by Enrollment Group, 2005
Elderly
10%
Elderly
28%
Disabled
14%
Adults
26%
Disabled
42%
Children
50%
Adults 12%
Children 18%
Total = 59 million
Total = $275 billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data.

8. Percentage of Children Without Health Insurance, By Poverty Level, 1997-2005
23%
Children below
200% of poverty
21%
14% 6%
Children above
200% of poverty 5% 5%
* 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 2005.

9. The Uninsured by Income and Eligibility for Public Coverage, 2004
Not Eligible, 300%+ FPL 15%
Not Eligible, 300%+ FPL 21%
Eligible 14%
Not Eligible, <300% FPL
11%
Eligible 74%
Not Eligible, <300% FPL 65%
Children Million Uninsured
Adults Million Uninsured
*The Federal Poverty Line (FPL) for a family of three in 2004 is $15,067 per year
SOURCE: Urban Institute analysis of 2005 CPS for KCMU.

10. Medicaid and SCHIP as Building Blocks
Medicaid provides:
Mechanism for expanding coverage to children and some adults
Source of federal assistance through matching funds for increased coverage and provider payments
Delivery system on which to build
Additional financing vehicle through redirected DSH funds
SCHIP provides:
Successful model for covering children
Enhanced federal financing, though amount is fixed

11. Challenges to Building on Medicaid and SCHIP
Federal rules limit coverage options (childless adults excluded except with waiver)
Budget neutrality requirements
Partnership with federal government sometimes uncertain
SCHIP
Federal funding capped
August 17th directive limited expansion efforts
Reauthorization debate raises questions about future of program
States must still raise matching funds

12. Medicaid and SCHIP Expansions for Children
25 states plus DC expanded eligibility for children
Several states expanded eligibility up to 300% FPL
Focus on outreach and simplifying enrollment processes
Ten states enacted universal coverage for children
Hawaii, Illinois, Iowa, Maine, Massachusetts, New Jersey, Pennsylvania, Vermont, Washington, Wisconsin
Universal coverage builds on Medicaid/SCHIP coverage
Full buy-in for families with higher incomes
Connecticut: automatic enrollment of all uninsured newborns

13. Leveraging Medicaid/SCHIP to Expand Coverage for Adults
Raising eligibility levels for parents (Maryland, New Jersey)
Using/expanding waivers to cover childless adults (Wisconsin, Minnesota)
Using Medicaid funding to purchase private insurance (Indiana, Vermont)
Targeting small businesses (Oklahoma, New Mexico)
New group insurance options for small employers
Premium subsidies for low-income workers
Financed with Medicaid funds

14. Using Medicaid to Address Other Health System Reforms
Access to care
medical homes model
Chronic care management
development of chronic care programs
advancing HIT
Quality improvement
paying for performance
non-payment for medical errors
Focus on prevention, consumer responsibility

15. Massachusetts: Medicaid as Foundation for Broader Reform
MassHealth
Expanded eligibility for children up to 300% FPL
Enrollment increase – 90,000
Commonwealth Care
New public coverage option for adults up to 300% FPL
Care provided by Medicaid managed care plans
Financed with state and federal Medicaid funds
Enrollment – 175,000
Other components
Individual and employer mandates
Commonwealth Connector

16. Public Programs and Health Reform
Recent public program expansions show opportunities for gains in coverage
States continuing to implement enacted expansions
Poor fiscal outlook for states may limit future efforts
Problems with health care system remain
uninsured, rising health care costs, quality and access issues
public programs offer states mechanism for addressing some of these problems
Despite challenges to health reform, states are not waiting on federal action