Figure 0 The Role of Medicaid and the

Figure 0 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 1 Number of Nonelderly Uninsured Americans, 2004 - 2007 Uninsured in Millions 43. 0 44. 4 46. 5 45. 0 K A I S E R SOURCE: KCMU/Urban Institute analysis of March CPS for each year. C O M M I S S I O N Medicaid and the Uninsured

Figure 2 Uninsured Rates Among the Nonelderly, by State, 2006 -2007 NH VT WA MT MN OR ID SD MI RI CA CO IL KS OK AZ NM OH IN WV DE VA MD KY MO NC TN AL DC SC AR MS TX CT NJ PA IA NE NE NV MA NY WI WY UT ME ND GA LA AK FL HI US Average = 18% ≥ 18% (18 states) 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 (2006 -2007). K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 3 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. K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 4 Medicaid Today Health Insurance Coverage Assistance to Medicare Beneficiaries Long-Term Care Assistance 29 million children & 15 million adults in low-income families; 14 million elderly and persons with disabilities 7. 5 million aged and disabled — 18% of Medicare beneficiaries 1 million nursing home residents; 43% of long-term care services MEDICAID Support for Health Care System and Safety-net State Capacity for Health Coverage 15% of national health spending 43% of federal funds to states K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 5 Health Insurance Coverage of Low-Income Adults and Children, 2007 Poor Children (<100% Poverty) Near-Poor (100 -199% Poverty) Parents Poor Near-Poor Adults without Children Poor Near-Poor SOURCE: KCMU/Urban Institute analysis of March 2008 CPS. K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 6 Medicaid Enrollees and Expenditures by Enrollment Group, 2005 Elderly 10% Disabled 14% Elderly 28% Adults 26% Disabled 42% Children 50% Total = 59 million SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2005 MSIS data. Adults 12% Children 18% Total = $275 billion K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 7 Percentage of Children Without Health Insurance, By Poverty Level, 1997 -2005 Children below 200% of poverty 23% 21% 14% Children above 200% of poverty 6% 5% 5% * Survey method change in 2005 affects comparison with earlier years slightly. Children less than 18 years old. K A I S E R C O M M I S S I O N Source: L. Ku, “Medicaid: Improving Health, Saving Lives, ” Center on Budget and Policy Medicaid and the Uninsured Priorities analysis of National Health Interview Survey data, August 2005.

Figure 8 The Uninsured by Income and Eligibility for Public Coverage, 2004 Not Eligible, 300%+ FPL 15% Not Eligible, <300% FPL 11% Not Eligible, 300%+ FPL 21% Eligible 14% Eligible 74% Not Eligible, <300% FPL 65% Children 8 Million Uninsured Adults 36. 6 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. K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 9 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 10 Challenges to Building on Medicaid and SCHIP • Medicaid: – 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 17 th directive limited expansion efforts – Reauthorization debate raises questions about future of program • States must still raise matching funds K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 11 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 12 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 13 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 14 Massachusetts: Medicaid as Foundation for Broader Reform • Mass. Health – 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured

Figure 15 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 K A I S E R C O M M I S S I O N Medicaid and the Uninsured