Medicaid Funding and Policies Is There a Medicaid Crisis? A Financial Diagnosis for State and Local Government Matt Powers Health Management Associates March 15, 2007
Main Points � Medicaid Remains a Workhorse - has Evolved into a Very Different Program � States & Health Reform – leading the charge, balancing public/private � Early lessons learned in state-based health reform initiatives � Hard Questions
Medicaid Remains the “Utility Man” … � Mental health : over half of publicly financed care � Public health and schools � Hospitals that serve the safety net : special Medicaid “DSH” payments $16 billion in 2007 � Community Health Centers: Medicaid averages 40% of CHC revenues � 7 million low-income elderly and disabled are “dual eligibles”– on both Medicaid and Medicare � “Duals” account for 40% of Medicaid spending Smith, V. Medicaid in 2007 and Beyond: Context for Medi-Cal Policy Development. Presentation for The Working Committee on Waiver Development and Medi-Cal Expansion, February 2007.
….But Medicaid Has Fundamentally Changed � Coverage @ much higher income levels � Entitlement has changed with Waivers - Florida � Match for Preventive/Wellness/Enhanced Benefits � Government subsidized commercial insurance � SCHIP
Is this a Business Cycle or is the “Defined Contribution” Having an Impact? 75% 1 4% Me dic aid � 70% 1 2% 65% 1 0% 60% 8% � E mploye r -Sponsor e d He alth Insur anc e 55% 6% 50% 4% 45% 2% 1985 1995 2005 1.8 Million E mploye e s 709,000 E mploye e s 1.3 Million E mploye e s 40% 0% 1 987 1 989 1 991 1 993 1 995 1 997 1 999 2001 2003 2005 So urc e : US Ce nsus Bure a u, Smith, V., NCSL Pre se nta tio n; F e d e ra l Re se rve Ba nk o f Da lla s; Sc o tt, J. 2005 NASMD Pre se nta tio n.
2007 State Coverage Initiatives WA ME MT ND VT MN NH OR MA WI NY SD ID RI MI WY CT PA NJ IA NE OH NV DE IN IL UT WV CA CO VA MD KS MO KY NC TN OK AZ SC AR NM GA AL MS LA TX United States - Statistical Perspective FL Non-Elderly Population 257,442,650 Employer Sponsored Coverage 61% Medicaid/SCHIP Coverage 16% Uninsured 18% Current State Individual/High-Risk Pool/Other Coverage 5% Coverage Initiatives Uninsured Population 46,118,230 Uninsured Population 18-30 15,068,735 Comprehensive Reform Population Undocumented 11,100,000 Medicaid/SCHIP Expansion Uninsured Eligible for Medicaid/SCHIP 11,391,203 2007 Total Health Care Spending $2,325,700,000,000 Premium Support/HSA Employer Sponsored Coverage Spending Currently No Major Initiative 2007 Medicaid Spending $347,300,000,000 All numbers represent the non-elderly population, age 0-64.
Early Lessons Learned � Do We Nearly Have Universal Access, Only Delivered in a Very Inefficient Way Given the Roles of EMTALA, FQHC, Charity Hospitals? � Is This a Crisis or Several Sub-Crises? � Voluntary (e.g. Maine) Helps but Individual and Business Components Help Affordable Rates and Level Playing Field � Concept to Implementation Issues
My Case for Coverage Issues Being Less of a Partisan Issue than in Past � Government routinely subsidizes commercial insurance � Individual and Business mandate are a unique blend of “big government” and “personal responsibility” � Bipartisan blend leading charge from Executive branches � Broad recognition that uninsured shift costs
Hard Questions � Ultimate Juggling–Assessment, NPRM, Payment Methodology, Cook Pressures, Community Benefit, Uninsured Plan � The Stomach to Tolerate Set-Backs and Tweaks? � Will the Beltway Trump this with a Big Plan? [Be nice to our guests – Wisconsin] � Winner Take All Mentality - Single Payor or Private? � Can we Cover More and Control Costs? � Revenue?
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