Slide 0

Medicaid/CHIP: Moving Forward

2018 GIA Annual ConferenceOctober 18, 2018

Sheila Burke, RN, MPA, FAANChair, Government Relations & Public Policy

Baker Donelson

Slide 1

Agenda

• Medicaid Origins

• Population Served

• Budget/Federal/State Share

• ACA Vision

• Who is in the Gap

• Waiver Strategies

Slide 2

Medicaid plays a central role in our health care system.

Slide 3

Medicaid’s Origins

Mandatory services and populations for participating

states with options for broader coverage

Means-tested, with focus on welfare population:-single parents with dependent children

-aged, blind, and disabled

Federal State

Entitlement

• Enacted in 1965 as title XIX of the Social Security Act• Means-tested; originally focused on the public assistance population

Eligible Individuals are entitled to a defined set

of benefits

States are entitled to federal matching

funds

Sets core requirements on

eligibility and benefits

Flexibility to administer the program within

federal guidelinespartnership

Slide 4

0

10

20

30

40

50

60

70

80

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015*

Medicaid has evolved over time to meet changing needs.

Millions of Medicaid Beneficiaries

Medicaid eligibility for womenand children is expanded

Medicaid is de-linked

from welfare

ACAenacted

HCBS waivers authorized

Medicaid enacted

SSIenacted

Section 1115 waivers expand Medicaid eligibility

SCHIPenacted

Implementation of the ACA Medicaid expansion

“Katie Beckett” option

NOTE: *Projection based on CBO March 2015 baseline.SOURCE: KCMU analysis of data from the Health Care Financing Administration and Centers for Medicare and Medicaid Services, 2011, as well as March 2015 CBO baseline ever-enrolled counts.

Slide 5

Health Insurance Coverage of the Total Population, 2016.” Kaiser Family Foundation, https://www.kff.org/other/state-indicator/total-population/.

Percent of People Covered By Medicaid/CHIP, 2016

Slide 6

Medicaid is the major source of health coverage for 20% of people in the US.

Figure 7

62%

42%

45%

20%

49%

17%

76%

38%

40%

55%

Nursing Home Residents

Nonelderly Adults with HIV in Regular Care

Nonelderly Adults with a Disability

Medicare Beneficiaries

Births (Pregnant Women)

Parents

Children Below 100% FPL

All Children

Nonelderly Between 100% and 199% FPL

Nonelderly Below 100% FPL

Percent with Medicaid Coverage

NOTE: FPL-- Federal Poverty Level. The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $19,318 in 2016.SOURCES: KFF analysis of 2017 Current Population Survey, Annual Social and Economic Supplement; Birth data -Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017, KFF, October 2016.; Medicare data -Medicare Payment Advisory Commission, Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (January 2018), 2013 data; Disability - KFF Analysis of 2016 ACS; Nonelderly with HIV - 2014 CDC MMP; Nursing Home Residents - 2015 OSCAR/CASPER data.

Medicaid plays a key role for selected populations.

Families

Elderly and People with Disabilities

Slide 8

1.7%

3.1%

-0.8%

3.1% 3.2%

4.6%

1.7%

-1.5%

-0.5%

0.5%

1.5%

2.5%

3.5%

4.5%

5.5%

Medicaidservices per

enrollee

Medicaidacute care

per enrollee

MedicaidLong-termcare perenrollee

Nationalhealth

expendituresper capita

Medical careconsumerprice index

Private healthinsurance per

enrollee

GDP percapita

NOTE: Acute Care includes payments to managed care plans. SOURCE: Medicaid estimates from Urban Institute analysis of data from the Medicaid Statistical Information System (MSIS), Medicaid Financial Management Reports (CMS Form 64), and Kaiser Commission and Health Management Associates data. NHE and private health insurance data from Centers for Medicare & Medicaid Services Office of the Actuary, National Health Statistics Group. Medical care CPI from the Bureau of Labor Statistics, Consumer Price Index Detail Report Tables. GDP data from Bureau of Economic Analysis. As featured in JAMA’s Medicare and Medicaid at 50 Years: Perspectives of Beneficiaries, Health Care Professionals and Institutions, and Policy Makers. JAMA. 2015;314(4):384-395. doi:10.1001/jama.2015.7811

Medicaid spending growth per enrollee has been slower than growth in private health spending

Perc

ent

gro

wth

Average Annual Medicaid Spending on Medical Services Growth versus Growth in Various Benchmarks, 2007-2013:

Slide 9

Inpatient11.4%

Physician, Lab & X-ray3.3%

Outpatient/Clinic5.5%

Drugs1.7%

Other Acute9.2%

Payments to MCOs37.0%

Payments to Medicare3.2%

Nursing Facilities10.5%

ICF/MR2.2%

Mental Health 0.5%

Home Health and Personal Care

11.7%

DSH3.8%

NOTE: Excludes administrative spending, adjustments and payments to the territories.SOURCE: Urban Institute estimates based on FY 2014 data from CMS (Form 64), prepared for the Kaiser Commission on Medicaid and the Uninsured.

Medicaid Expenditures by Service, with DSH Payments and Payments to Medicare, FY 2014

Total = $475.91 billion

AcuteCare

71.2%

Long-TermCare

24.9%

Slide 10

Medicaid LTSS Spending is increasingly devoted to HCBS as opposed to institutional care.

NOTE: Home and community-based care includes state plan home health, state plan personal care services and § 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals with intellectual/developmental disabilities, nursing facilities, and mental health facilities.SOURCE: Truven analysis of Centers for Medicare & Medicaid Services (CMS)-64 data supplemented by other data sources. See S Eiken, K Sredl, B Burwell, and R Woodward, “Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2015” Truven Health Analytics, April 2017.

1995 2000 2005 2010 2012 2013 2014 2015

Home and Community-Based LTSS

Institution-Based LTSS

(in billions)

82% 63% 52% 51% 49%73%

18%

27%

37%

48% 49% 51%

$57

$76

$107

$139 $142 $146

47%

53%

$153

55%

45%

$158

Slide 11

Figure 12

Figure 13

Figure 14

28.7%15.6%

57.7%

19.6%

25.3%

8.6%

51.7%59.1%

33.7%

Total State Spending(State & Federal Funds)

$1.98 Trillion

State Funds(General & Other Funds)

$1.25 Trillion

Federal Funds

$600.4 Billion

Medicaid Elementary & Secondary Education Other

SOURCE: Kaiser Family Foundation estimates based on the NASBO’s November 2017 State Expenditure Report (data for Actual FY 2016.)

Medicaid is a budget item and a revenue item in state budgets.

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NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebeliusmaintained the Medicaid expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL = $16,242 for an individual and $27,724 for a family of three in 2015.

The ACA Medicaid Expansion Filled Gaps in Coverage for Adults

Figure 16

NOTES: Current status for each state is based on KFF tracking and analysis of state activity. *AR, AZ, IA, IN, MI, MT, and NH have approved Section 1115 expansion waivers. KY’s traditional expansion continues while its expansion waiver is pending with CMS after having been invalidated by a court in June, 2018. UT passed a law directing the state to seek CMS approval to partially expand Medicaid to 100% FPL using the ACA enhanced match, and UT also has a measure on the ballot in November to fully expand to 138% FPL. ID and NE have Medicaid expansion measures on their November 2018 ballots. Expansion is adopted but not yet implemented in VA and ME. (See the link below for more detailed state-specific notes.)SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated July 27, 2018.https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

34 states including DC have adopted the Medicaid expansion.

WY

WI

WV

WA

VA*

VT

UT*

TX

TN

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NVNE*

MT*

MO

MS

MN

MI*

MA

MD

ME*

LA

KY*KS

IA*

IN*IL

ID*

HI

GA

FL

DC

DE

CT

COCA

AR*AZ*

AK

AL

Considering Expansion (3 States)

Not Adopting At This Time (14 States)

Adopted (34 States including DC)

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Some states are moving forward under an 1115 Waiver. states are moving forward under an 1115 Waiver.

• Section 1115 Demonstration waivers allow states to make changes to their Medicaid programs outside of what is otherwise allowed under Federal regulation

• 1115 waivers must be proposed by a state and approved by CMS

• Waivers vary significantly in scope

– Arkansas and Iowa have used 1115 waivers to implement premium assistance models

7 7 3

6

23

16 12

15 1

8

87

16

5

42

1

1

11

MedicaidExpansion

Eligibility andEnrollmentRestrictions

WorkRequirements

BenefitRestrictions,

Copays, HealthyBehaviors

BehavioralHealth

Delivery SystemReform

MLTSS Other TargetedWaivers

Approved (45 across 37 states)

Pending (24 across 23 states)

Invalidated by court (1 state waiver)

Most current state waiver activity relates to behavioral health,

followed by work requirements and other eligibility

restrictions, as of August 29, 2018.

NOTES: Some states have multiple approved and/or pending waivers, and many waivers cover different areas. Therefore, the

total number of pending or approved waivers across states cannot be calculated by summing counts of waivers in each category.

Pending waivers are not included until officially accepted by CMS and posted on Medicaid.gov. “MLTSS” = Managed long-term

services and supports.

SOURCE: KFF, Medicaid Waiver Tracker (Aug. 29, 2018).

Slide 19

• Coverage (Eligibility, Outreach and Enrollment)

– Will additional states decide to implement the Medicaid expansion change?

– Introduction of work requirements

• Financing and Fiscal Issues

– Continued debate on capitation block grants to replace current program. What are goals/risks?

• Access to and Delivery of Services

– What new innovations will be successful in integrating care for complex populations (duals demonstrations)

– Public charge rule concerns

• Ballot Measure in Idaho, Montana, and Nebraska in fall

Medicaid Policy Issues Going Forward

Slide 20