Medicaid Solutions

7/29/2019 Medicaid Solutions

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illinois Policy institute March 4, 2013

research rePort health care

Medicaid Solutions:Floridas Medicaid cure for Illinois ailing programJonathan Ingram, Director of Health Policy and Pension Reform

For more than a decade, Illinois Medicaid program has ailed tomeet the needs o the states most vulnerable residents. Accessto high-quality care has deteriorated, even as record amountso taxpayer dollars are spent on the ballooning program.

Over the years, eligibility standards have loosened toincreasingly include amilies earning ever-higher incomes.Today, only 40 percent o Medicaid patients are in poverty,meaning that scarce budget money is being siphoned awayrom those most in need. To cope with ballooning enrollmentand higher costs, the state has opted to ration the ees it pays

or each service.

Sadly, the states mismanagement o the Medicaid programhas orced many doctors to opt out o the Medicaid programaltogether. These actors have created an environment in whichMedicaid enrollees are given a medical card, but very littleaccess to care.

In many cases, Medicaid patients have a more dicult timending a doctor and suer worse health outcomes than eventhe uninsured. The problems were so bad that a ederal judgeordered state ocials to study them. The results o that study,detailed more thoroughly later in this report, were published in

the New England Journal o Medicine.Illinois Medicaid program is a one-size-ts-all model thatsbroken, and its ailing Illinoisans on three ronts: costs, accessto quality care and health outcomes. Illinois should ollow thelead o states such as Florida and Louisiana and undamentallytransorm how the program operates. To address theseproblems, Illinois should:

Give Medicaid patients meaningul choices or their healthplans rom a variety o provider service networks andmanaged care organizations.

Allow plan providers to customize their plans to meet the

individual needs o their enrollees, which will help ensureplans compete on value.

Pay plan providers a xed, risk-adjusted monthly rate basedon enrollment in a particular plan.

Additional resources: illinoispolicy.org

190 s. ls s., s 1630, cg, il 60603 | 312.346.5700 | 802 s. 2d s., spgd, il 62704 | 217.528.8800

Floridas reorm pilot is a proven success. It has improvedaccess to quality care and delivered better health outcomesto its patients than the traditional Medicaid program. Betteryet, the reorm pilot has seen average annual savings o morethan 20 percent when compared to per-person spending inFloridas traditional program.

These reorms can be implemented without a waiver rom theederal government, and similar reorms have already beenimplemented in Florida and Louisiana.

Transorming how Medicaid operates is the only solution thatdoes right by both patients and taxpayers.

The Medicaid program was created asa temporary safety net for the poor anddisadvantaged

Medicaid is a joint state and ederal program that aimsto provide medical care to the poor and disadvantaged.It is nanced by ederal, state and local taxes and isadministered by state governments. Each state receivesederal reimbursement o Medicaid expenditures according

to their Federal Medical Assistance Percentage, or FMAP,rate. This rate can range rom 50 percent to 83 percento expenditures, depending upon the states per capitapersonal income. Historically, hal o all Medicaid spendingin Illinois has been paid or with ederal money.1

In Illinois, Medicaid serves both the nondisabled low-incomepopulation and the elderly, blind and disabled populations.While there might be some overlap between these twogroups, each might require dierent policies tailored to theirspecic needs. Children and nondisabled adults account or84 percent o enrollees in Illinois.2


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illinoispolicy.org | 2

Children and nondisabled adults make up amajority of Medicaid patients in Illinois

61%

23%

6%

10%

Elderly Disabled adults Nondisabled adults Children

Source: Illinois Department of Healthcare and Family Services

The size of Illinois Medicaid program hasalmost doubled since 2000

The number o people in Illinois Medicaid program has

increased signicantly in recent years. In 2000, about 1.7million people were enrolled in the program.3 That numberalmost doubled to 3.1 million Illinoisans by 2011.4 To put thisin perspective, the states population grew by only 3.5 percentduring that same time period.5

Medicaid enrollment almost doubled duringthe course of a decade

Total number o Medicaid enrollees in Illinois by year, in millions

Source: Medicaid Statistical Information System

Additionally, as Medicaid grew, the composition o Medicaidenrollees changed. Medicaid historically has ocused onindividuals and amilies in poverty. As recently as 2003, amajority o Medicaid patients in Illinois had incomes at obelow the ederal poverty level.6 But, over the years, eligibilitystandards were loosened to include amilies with ever

higher incomes than previously allowed. Today, ater years oexpanding eligibility, almost 60 percent o Medicaid enrolleesare above the ederal poverty level.7

Most people on Medicaid are not in povertyEnrollment in Illinois Medicaid program by poverty level in 2012

59% 41%

Below poverty level Above poverty level

Source: U.S. Census Bureau

1999 2001 2003 2005 2007 2009 2011

1.71.8

2.22.4

2.9

2.4

3.1

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Medicaid expansions have not reduced thenumber of uninsured

Number o uninsured people in Illinois, in millions

1.6 1.61.7

1.5

1.9 1.9

2002 2004 2006 2008 2010 2012

Source: U.S. Census Bureau

Medicaid patients often have coverage, butlack access to quality care

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Otolaryngology Endocrinology Neurology

100%

37%

91%

57%

89%

46%

Medicaid patients are far less likely tosee a specialistLikelihood o scheduling appointment, by insurance status and specialist type

Private insurance Medicaid Source: Bisgaier and Rhode

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Medicaid patients must wait longer toreceive care

Length o wait times (days), by insurance status and specialty type

Otolaryngology Endocrinology Neurology

Private insurance Medicaid Source: Bisgaier and Rhodes

5.8

52.7

47.3

103.4

23.3

38.8


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Access barriers force Medicaid patients to useemergency rooms for preventable conditions

Number o emergency department visits or preventable conditions per 1,000people in 2007, by insurance status

Private insurance No insurance Medicaid

12

28

84

Source: Tang et al.

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Medicaid patients often face worse healthoutcomes

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Medicaid patients are more likely to die afterheart surgeryLikelihood o in-hospital death ater percutaneous coronary intervention, by

insurance type


Source: Tang et al

1.5%

5.1%

6.2%

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Medicaid patients are diagnosed at later, lesstreatable stages

Odds ratio o being diagnosed with late-stage melanoma by insurance type


Source: Roetzheim et al

1.0

2.6

4.7


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Florida fundamentally transformed howMedicaid operates

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Floridas reforms empower patients with realchoices

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Floridas reforms improve health outcomesfor Medicaid patients

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Floridas reforms save money

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Floridas Medicaid reform pilot spends lessthan traditional Medicaid

Spending per-person in reorm counties and statewideChildren and families

0

$500

$1,000

$1,500

$2,000

2007 2008 2009 2010 2011

Statewide Reform counties

Spending per-person in reorm counties and statewideElderly and disabled

0

$3,000

$6,000

$9,000

$12,000

$15,000

2007 2008 2009 2010 2011

Statewide Reform counties

Source: Medicaid Statistical Information System; Florida Agency for HealthCare Administration

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Illinois could have saved $1.1 billion if it hadimplemented Floridas Medicaid cure in 2011Illinois actual Medicaid spending in 2011 and estimated spending based onthe Florida reorm pilots historical savings

Without reform With reform Savings

Targeted populations

Total spending $5.22 billion $4.13 billion $1.09 billion

Spending per person $2,367 $1,874 $493

Non-targeted populations

Total spending $6.66 billion $6.66 billion -

Spending per person $7,192 $7,192 -

Combined

Total spending $11.88 billion $10.79 billion $1.09 billion

Spending per person $3,795 $3,447 $348

Source: Medicaid Statistical Information System; Florida Agency for HealthCare Administration; Illinois Policy Institute

Illinois can implement reforms without federawaivers

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Why this works

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aPPenDix

Medicaid patients are more likely to die orhave another heart attack after heart surgeryLikelihood o major adverse cardiac events within 30 days ater percutaneouscoronary intervention


2.2%

8.1%

9.7%

Source: Gaglia et al.

Medicaid patients experience the longest

hospital staysNumber o days spent in hospital or cardiac valve operations,by insurance type


9.7

13.915.1

Source: LaPar et al.

Medicaid patients experience the mostcomplicationsLikelihood o pulmonary complications ater cardiac valve operations, byinsurance type


Source: LaPar et al

12.1% 12.3%

13.8%

Medicaid patients are diagnosed at later, less

treatable stagesOdds ratio o being diagnosed with late stage cancer, by cancer type

Non-Hodgk in lymphoma O var y Urinar y bla dde r Ut erus

1.0

1.51.7

1.0 1.0

1.3

1.0 1.0

2.3

2.8

1.71.8

Source: Halpern et al


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aPPenDix

Floridas Medicaid reform plans outperform Illinois plans on several measuresComparison o select HEDIS measures or the Medicaid program in Florida and Illinois

Performance measure Florida (traditional) Florida (reform) Illinois

Childhood immunization (combo 2) 71.4% 70.0% 71.6%

Childhood wellness visits (3-6 years) 74.9% 72.7% 74.6%

Adolescent wellness visits 45.7% 46.3% 41.6%

Adult access to preventative care (20-44) 67.9% 71.2% 66.9%

Adult access to preventative care (45-64) 81.2% 84.9% 68.1%

Breast cancer screening 50.1% 56.9% 33.8%

Postpartum care 52.7% 52.1% 44.3%

Blood pressure control 53.0% 53.4% 38.0%

Diabetes management (HbA1c testing) 76.4% 82.8% 69.3%

Diabetes management (LDL screening) 77.9% 83.5% 60.6%Appropriate asthma medications 87.0% 87.6% 87.4%

Source: Florida Agency for Health Care Administration; Illinois Department of Healthcare and Family Services


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enDnotes

1 Authors calculations based upon annual FMAP rates or scal years 1961 through 2011. See, e.g., Assistant Secretary or Planning and Evaluation, Federalpercentages and ederal medical assistance percentages, FY 1961 - FY 2011, Department o Health and Human Services (2011), http://aspe.hhs.gov/health/mapearly.htm.

2 Authors calculations based upon Title XIX and Title XXI enrollment data provided by the Department o Healthcare and Family Services.

3 In 2000, there were 1,736,185 unique individuals with personal identication numbers in Illinois Medicaid program. Approximately 1,519,313 o these had

a paid amount adjudicated during the scal year. See, e.g., Medicaid Statistical Inormation System, State Summary Datamart: FY 2000 Quarterly Cube,Department o Health and Human Services (2001), http://msis.cms.hhs.gov/.

4 In 2011, there were 3,130,791 unique individuals with personal identication numbers in Illinois Medicaid program. Approximately 2,917,389 o these had apaid amount adjudicated during the scal year.

See, e.g., Medicaid Statistical Inormation System, State Summary Datamart: FY 2011 Quarterly Cube, Department o Health and Human Services (2001),http://msis.cms.hhs.gov/.

5 Authors calculations based upon ederal population estimates rom the U.S. Census Bureau. According to census data, Illinois had 12.4 million residents in2000 and nearly 12.9 million residents in 2011.

6 Authors calculations based upon 2003 census data disaggregated by Medicaid enrollment and by income-to-ederal poverty level ratio. See, e.g., CensusBureau, Current Population Surveys Annual Social and Economic Supplement, Department o Commerce (2003).

7 Authors calculations based upon 2012 census data disaggregated by Medicaid enrollment and by income-to-ederal poverty level ratio. See, e.g., CensusBureau, Current Population Surveys Annual Social and Economic Supplement, Department o Commerce (2012).

8 Authors calculations based upon 2003-12 census data disaggregated by health insurance status. See, e.g., Census Bureau, Current Population Surveys

Annual Social and Economic Supplement, Department o Commerce (2012).9 The crowd-out eect is urther evidenced by the act that the number o impoverished Illinoisans who are employed increased over the same time period, thatemployer-sponsored insurance oer rates remained relatively stable and that the number o Illinoisans with private insurance decreased in each o these incomebrackets.

10 Authors calculations based upon 2003-12 census data disaggregated by health insurance status, income-to-poverty ratio and employment status. See,e.g., Census Bureau, Current Population Surveys Annual Social and Economic Supplement, Department o Commerce (2012). See also, Gary Claxton et al.,Employer health benets: 2011 annual survey, The Kaiser Family Foundation (2011), http://ehbs.k.org/pd/2011/8225.pd.

11 In scal year 2011, approximately $10.4 billion o the states $11.9 billion Medicaid budget was billed as ee-or-service. See, e.g., Medicaid StatisticalInormation System, State Summary Datamart: FY 2011 Quarterly Cube, Centers or Medicare and Medicaid Services (2012), http://www.cms.gov/ResearchStatistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenIno/MSIS-Mart-Home.html.

12 Joanna Bisgaier & Karin V. Rhodes, Auditing access to specialty care or children with public insurance, New England Journal o Medicine 364: 2324-33(2011), http://www.nejm.org/doi/ull/10.1056/NEJMsa1013285.



15 Katherine Iritani, Most physicians serve covered children but have diculty reerring them or specialty care, Government Accountability Oce (2011),http://www.gao.gov/new.items/d11624.pd.

16 Only 45 percent o primary care physicians are accepting most or all new Medicaid patients. See, e.g., Center or Studying Health System Change,Health tracking physician survey, 2008, Inter-university Consortium or Political and Social Research (2010), http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/27202.

17 Brent R. Asplin et al., Insurance status and access to urgent ambulatory care ollow-up appointments, Journal o the American Medical Association 294(10)1248-54 (2005), http://jama.ama-assn.org/content/294/10/1248.

18 Approximately 77 percent o primary care physicians accept at least some uninsured patients who are unable to pay or services, while 46 percent accept allor most o them. See, e.g., Center or Studying Health System Change, Community tracking study physician survey, 2004-2005, Inter-university Consortiumor Political and Social Research (2008), http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/4584.

19 Joanna Bisgaier & Karin V. Rhodes, Auditing access to specialty care or children with public insurance, New England Journal o Medicine 364: 2324-33

(2011), http://www.nejm.org/doi/ull/10.1056/NEJMsa1013285.20 Joanna Bisgaier & Karin V. Rhodes, Auditing access to specialty care or children with public insurance, New England Journal o Medicine 364: 2324-33(2011), http://www.nejm.org/doi/ull/10.1056/NEJMsa1013285.


22 Amy B. Bernstein et al., Health, United States, 2010: With special eature on death and dying, National Center or Health Statistics (2011), http://www.cdcgov/nchs/data/hus/hus10.pd

23 Ellen J. Weber et al., Does lack o a usual source o care or health insurance increase the likelihood o an emergency department visit? Results o a nationalpopulation-based study, Annals o Emergency Medicine 45(1): 4-12 (2005), http://www.annemergmed.com/article/S0196-0644(04)01168-0/.


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24 Ning Tang et al., Trends and characteristics o US emergency department visits, 1997-2007, Journal o the American Medical Association 304(6): 664-70(2010), http://jama.ama-assn.org/content/304/6/664.

25 For ease o reading, this report uses preventable conditions in place o ambulatory care sensitive conditions, which are conditions that generally shouldnot require hospitalization i treated in a timely ashion with adequate primary care and managed properly on an outpatient basis.

26 Joel S. Weissman et al., Rates o avoidable hospitalization by insurance status in Massachusetts and Maryland, Journal o the American Medical Association

268(17): 2388-94 (1992), http://jama.ama-assn.org/content/268/17/2388.27 Eduardo LaCalle & Elaine Rabin, Frequent users o emergency departments: The myths, the data, and the policy implications, Annals o EmergencyMedicine 56(1): 42-48 (2010), http://www.annemergmed.com/article/S0196-0644(10)00105-8.

28 Michael A. Gaglia, Jr. et al., Eect o insurance type on adverse cardiac events ater percutaneous coronary intervention, American Journal o Cardiology107(5): 675-80 (2011), http://www.ajconline.org/article/S0002-9149(10)02234-4.

29 Damien J. LaPar et al., Primary payer status aects mortality or major surgical operations, Annals o Surgery 252(3): 544-51 (2010), http://journals.lww.com/annalsosurgery/ulltext/2010/09000/Primary_Payer_Status_Aects_Mortality_or_Major.16.aspx.

30 Damien J. LaPar et al., Primary payer status aects mortality or major surgical operations, Annals o Surgery 252(3): 544-51 (2010), http://journals.lww.com/annalsosurgery/ulltext/2010/09000/Primary_Payer_Status_Aects_Mortality_or_Major.16.aspx.

31 Rachel Rapaport Kelz et al., Morbidity and mortality o colorectal carcinoma surgery diers by insurance status, Cancer 101(10): 2187-94 (2004), http://onlinelibrary.wiley.com/doi/10.1002/cncr.20624/ull.

32 John D. Birkmeyer et al., Hospital volume and surgical mortality in the United States, New England Journal o Medicine 346: 1128-37 (2002), http://www.nejm.org/doi/ull/10.1056/NEJMsa012337.

33 Jerome H. Liu et al., Disparities in the utilization o high-volume hospitals or complex surgery, Journal o the American Medical Association 296(16): 1973-80 (2006), http://jama.ama-assn.org/content/296/16/1973.ull.

34 Richard G. Roetzheim et al., Eects o health insurance and race on early detection o cancer, Journal o the National Cancer Institute 91(16): 1409-15(1999), http://jnci.oxordjournals.org/content/91/16/1409.ull.

35 Michael T. Halpern et al., Association o insurance status and ethnicity with cancer stage at diagnosis or 12 cancer sites: A retrospective analysis, LancetOncology 9(3): 222-31 (2008), http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(08)70032-9.

36 Michael T. Halpern et al., Insurance status and stage o cancer at diagnosis among women with breast cancer, Cancer 110(2): 403-11 (2007), http://onlinelibrary.wiley.com/doi/10.1002/cncr.22786/abstract.

37 Floridas Medicaid reorm pilot passed the Senate on May 6, 2005, by a vote o 39-1. See, e.g., Faye W. Blanton, Journal o the Senate, Florida Senate(2005), http://archive.fsenate.gov/data/Historical/Senate%20Journals/2000s/2005/sj050605.pd.

38 The reorm pilot passed the House o Representatives on May 6, 2005, by a vote o 88-24. See, e.g., John B. Phelps, Journal o the House oRepresentatives, Florida House o Representatives (2005), http://www.myforidahouse.gov/FileStores/Adhoc/Journals/data/session/2005/2005%20RS%20-%20Journal%2031.pd.

39 For a more detailed analysis o the Florida reorm pilot, see Tarren Bragdon, Floridas Medicaid reorm shows the way to improve health, increase satisactionand control costs, Heritage Foundation (2011), http://www.medicaidcure.org/wp-content/uploads/2012/09/Medicaid-Cure-Floridas-Medicaid-Reorm-Pilot.pd.

40 Legislation to implement the reorms statewide passed the Senate on May 6, 2011, by a vote o 28-11. See, e.g., R. Philip Twogood, Journal o the Senate,Florida Senate (2011), http://www.fsenate.gov/usercontent/session/2011/journals/2011-sj-bound-vII.pd.

41 Legislation to implement the reorms statewide passed the House o Representatives on May 6, 2011, by a vote o 79-39. See, e.g., Robert L. Ward,Journal o the House o Representatives, Florida House o Representatives (2011), http://www.myforidahouse.gov/Sections/Documents/loaddoc.aspx?PublicationType=Session&DocumentType=Journals&Session=2011&FileName=Bound_House%20Journal%20No.42,%20May%2006,%202011%20(Friday).pd.

42 Justin M. Senior, Florida Medicaid reorm: Year 6 annual report, Florida Agency or Health Care Administration (2012), http://ahca.myforida.com/medicaid/medicaid_reorm/pd/FL_1115_YR_6_Final_Annual_Report_07-01-11_06-30-12.pd.






enDnotes continued


12/14


enDnotes continued

48 More than 86 percent o reorm pilot patients in urban counties and more than 82 percent o reorm pilot patients in rural counties reported having noproblem nding a personal doctor that they liked. Approximately 8.5 percent o reorm pilot patients in urban counties and 10 percent o reorm pilot patientsin rural counties reported minor problems nding a doctor that they liked. See, e.g., R. Paul Duncan et al., Medicaid reorm enrollee satisaction: Year twoollow-up survey, Florida Agency or Health Care Administration (2010), http://ahca.myforida.com/Medicaid/quality_management/mrp/contracts/med027/Medicaid_Reorm_Enrollee_Satisaction-Year2_Follow_Up_Survey_Vol1_County_Estimates.pd.

49 Approximately 91 percent o reorm pilot patients in urban counties and nearly 93 percent o reorm pilot patients in rural counties reported that theirpersonal doctors usually or always explained matters to them in a way that was easy to understand. See, e.g., R. Paul Duncan et al., Medicaid reorm enrolleesatisaction: Year two ollow-up survey, Florida Agency or Health Care Administration (2010), http://ahca.myforida.com/Medicaid/quality_management/mrp/contracts/med027/Medicaid_Reorm_Enrollee_Satisaction-Year2_Follow_Up_Survey_Vol1_County_Estimates.pd.

50 Nearly 85 percent o reorm pilot patients in urban counties and nearly 88 percent o reorm pilot patients in rural counties reported that their personaldoctors usually or always spent enough time with them. See, e.g., R. Paul Duncan et al., Medicaid reorm enrollee satisaction: Year two ollow-up survey,Florida Agency or Health Care Administration (2010), http://ahca.myforida.com/Medicaid/quality_management/mrp/contracts/med027/Medicaid_Reorm_Enrollee_Satisaction-Year2_Follow_Up_Survey_Vol1_County_Estimates.pd.

51 Nearly 93 percent o reorm pilot patients in both urban and rural counties reported that their personal doctors usually or always listened to them. See,e.g., R. Paul Duncan et al., Medicaid reorm enrollee satisaction: Year two ollow-up survey, Florida Agency or Health Care Administration (2010), http://ahca.myforida.com/Medicaid/quality_management/mrp/contracts/med027/Medicaid_Reorm_Enrollee_Satisaction-Year2_Follow_Up_Survey_Vol1_County_Estimates.pd.

52 Justin M. Senior, Florida Medicaid reorm: Year 5 annual report, Florida Agency or Health Care Administration (2012), http://ahca.myforida.com/medicaid/medicaid_reorm/pd/FL_1115_YR_5_Final_Annual_Report_07-01-10_06-30-11_sent_11-18-11.pd.



55 Health Services Advisory Group, External quality review technical report: HEDIS 2010 Medicaid rates, Illinois Department o Healthcare and FamilyServices (2010), http://www2.illinois.gov/hs/ManagedCare/Documents/112811_hedis.pd.

56 Authors calculations based upon reported HEDIS measures.

57 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System. Statewide spending per person includes individuals andexpenditures or patients who are over the age o 1 with a basis o eligibility o children, adults, unemployed adults, children o unemployed adults and ostercare children. Statewide spending per person excludes individuals and expenditures or patients who are under the age o 1, dual-eligibles or medically needy.Statewide spending per person also excludes individuals and expenditures or patients receiving medical care at intermediate care acilities or individualswith mental retardation. See, e.g., Medicaid Statistical Inormation System, State Summary Datamart: FY 2011 Quarterly Cube, Centers or Medicare andMedicaid Services (2012), http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenIno/MSIS-Mart-Home.html.

58

Authors calculations based upon capitated monthly rates or low-income children and amilies in the ve reorm counties, weighted by each countiesenrollment in the pilot. See, e.g., Justin Senior, Medicaid Reorm HMO capitation rates by area, age and eligibility category/population, Florida Agency orHealth Care Administration (2010), http://www.dhc.state.f.us/mchq/managed_health_care/mhmo/docs/MCAID/1011_Rates/Attach-I_Exhibit2-R_rates-eective_2010-09-01.pd.

59 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System. Statewide spending per person includes individuals andexpenditures or patients who are over the age o 1 with a basis o eligibility o aged, blind or disabled. Statewide spending per person excludes individualsand expenditures or patients who are under the age o 1, dual-eligibles or medically needy. Statewide spending per person also excludes individuals andexpenditures or patients receiving medical care at intermediate care acilities or individuals with mental retardation. See, e.g., Medicaid Statistical InormationSystem, State Summary Datamart: FY 2011 Quarterly Cube, Centers or Medicare and Medicaid Services (2012), http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenIno/MSIS-Mart-Home.html.

60 Authors calculations based upon capitated monthly rates or aged and disabled patients in the ve reorm counties, weighted by each countiesenrollment in the pilot. See, e.g., Justin Senior, Medicaid Reorm HMO capitation rates by area, age and eligibility category/population, Florida Agency orHealth Care Administration (2010), http://www.dhc.state.f.us/mchq/managed_health_care/mhmo/docs/MCAID/1011_Rates/Attach-I_Exhibit2-R_rates-eective_2010-09-01.pd.

61 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System and rom the capitated rates in the Medicaid reorm pilot.

62 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System and rom the capitated rates in the Medicaid reorm pilot orscal years 2007 through 2011.

63 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System. Statewide spending per person includes individuals andexpenditures or patients who are over the age o 1 with a basis o eligibility o children, adults, unemployed adults, children o unemployed adults and ostercare children. Statewide spending per person excludes individuals and expenditures or patients who are under the age o 1, dual-eligibles or medically needy.Statewide spending per person also excludes individuals and expenditures or patients receiving medical care at intermediate care acilities or individualswith mental retardation. See, e.g., Medicaid Statistical Inormation System, State Summary Datamart: FY 2011 Quarterly Cube, Centers or Medicare andMedicaid Services (2012), http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenIno/MSIS-Mart-Home.html.


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64 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System. Statewide spending per person includes individuals andexpenditures or patients who are over the age o 1 with a basis o eligibility o aged, blind or disabled. Statewide spending per person excludes individualsand expenditures or patients who are under the age o 1, dual-eligibles or medically needy. Statewide spending per person also excludes individuals andexpenditures or patients receiving medical care at intermediate care acilities or individuals with mental retardation. See, e.g., Medicaid Statistical InormationSystem, State Summary Datamart: FY 2011 Quarterly Cube, Centers or Medicare and Medicaid Services (2012), http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenIno/MSIS-Mart-Home.html.

65 Authors calculations based upon ederal data rom the Medicaid Statistical Inormation System and Floridas reorm pilot savings. I these reorms had beenenacted in scal year 2011, the state could have seen savings o $1.09 billion.

66 For a similar estimate o savings, see Tarren Bragdon and Christie Herrera, Floridas Medicaid cure: Big taxpayer savings or every state, Foundation orGovernment Accountability (2012), http://www.medicaidcure.org/wp-content/uploads/2013/01/Medicaid-Cure-Policy-Brie-1.pd.

67 States may generally require individuals to enroll with a managed care entity as a condition o receiving Medicaid assistance. Federal law exempts patientswho are eligible or both Medicare and Medicaid, certain children with special needs and members o Indian tribes rom this requirement. See, e.g., 42 U.S.C.1396u2(a)(1)(A).

68 The ederal government can le a ormal request or additional inormation, which stops the 90-day clock until the state provides a written response. Theederal government is then given up to an additional 90 calendar days to act upon the state plan amendment.

69 Bill Brooks, Letter to Louisiana Department o Health and Hospitals regarding State Plan Amendment Transmittal No. 11-21, Centers or Medicare andMedicaid Services (2011), http://downloads.cms.gov/cmsgov/archived-downloads/MedicaidGenIno/downloads/LA-11-21-Ltr.pd.

70 Cindy Mann, Letter to Florida Agency or Health Care Administration regarding Project No. 11-W-00206/4, Centers or Medicare and Medicaid Services(2011), http://ahca.myforida.com/medicaid/medicaid_reorm/pd/CMS_Approval_Letter_12-15-2011.pd.

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