Changes in Health Care Policy: How Could Florida be Affected? Joan - - PowerPoint PPT Presentation

Changes in Health Care Policy: How Could Florida be Affected?

Joan Alker Executive Director, Research Professor Georgetown University Center for Children and Families March 7, 2017

Childr Children’ en’s Uninsur s Uninsured Rate in Florida ed Rate in Florida and US, 2008-2015 and US, 2008-2015

9.3% 4.8% 16.7% 6.9% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 2008 2009 2010 2011 2012 2013 2014 2015 United States Florida

2

Source: CCF analysis of single-year estimates of summary data from the American Community Survey (ACS).

Rate of Childr Rate of Children’ en’s Uninsurance by s Uninsurance by State State

3

Source: Source: J. Alker, A. Chester, “Children’s Health Coverage Rate Now at Historic High of 95 Percent,” Georgetown University Center for Children and Families, October 2016.

Long-T Long-Term Ef erm Effects of Childhood fects of Childhood Medicaid Coverage Medicaid Coverage

Healthier Adults Greater Academic Achievement Greater Economic Success

Gover Government Savings (ROI) nment Savings (ROI)

4

Source: A. Chester and J. Alker. “Medicaid at 50: A Look at the Long-Term Benefits of Childhood Medicaid.” Georgetown University Center for Children and Families. July 2015.

5

Source: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families. January 2017.

Childr Children’ en’s Coverage in Florida, 2016 s Coverage in Florida, 2016

400% of the FPL

(Family of 3) $80,360/year

Exchange Subsidies

(Premiums Based on Sliding Scale, Ranging from 2%-9.5%

• f Income)

138% of FPL

(Family of 3) $27,724/year

255% of FPL

(Family of 3) $51,230/year

CHIP Medicaid

138% of FPL (Family of 3) $27,821/year 215% of FPL (Family of 3) $43,334/year 400% of FPL (Family of 3) $80,640/year

Public Coverage for Childr Public Coverage for Children in Florida en in Florida

6

Medicaid Medicaid

2,264,000

Medicaid CHIP Medicaid CHIP

135,000

Separate CHIP Separate CHIP

293,000

Marketplace Marketplace

122,000

Sources: “Child Enrollment in CHIP and Medicaid by State, FY 2015.” MACPAC. “Health Insurance Marketplaces 2016 Open Enrollment Period: March Enrollment Report.” ASPE. March 11, 2016.

Medicaid Eligibility in Florida, 2017 Medicaid Eligibility in Florida, 2017

Source for children, pregnant women, parents and other adults: The Kaiser Family Foundation, "Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey", January 2017. Source for seniors and individuals with disabilities: The Kaiser Family Foundation State Health Facts, "Medicaid Eligibility, through the Aged, Blind, Disabled Pathway", January 2017 Source for medically needy: MACPAC, MACSTATS, 2016.

7

211% 211% 145% 145% 138% 138% 196% 196% 33% 33% 0% 0% 88% 88% 88% 88% 18% 18% 215% 215% 215% 215% Childr Children, 0-1 en, 0-1 Childr Children, 1-5 en, 1-5 Childr Children, en, 6-18 6-18 Pr Pregnant egnant women women Par Parents ents Other adults Other adults Seniors Seniors Disabled Disabled Medically Medically needy needy Medicaid Medicaid Separate CHIP Separate CHIP

Enr Enrollees and Expenditur

• llees and Expenditures in

es in Florida, FY 2013 Florida, FY 2013

Source: MACPAC, "MACSTATS", 2016.

8

49.7% 19.0% 21.9% 21.9% 14.0% 14.0% 15.3% 15.3% 40.9% 40.9% 13.1% 13.1% 26.1% 26.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Enrollees Expenditures Child Adult Disabled Aged

Medicaid and CHIP Cover 41% of Medicaid and CHIP Cover 41% of Florida’ Florida’s Childr s Children en

41% 37% 8% 7% 7% Medicaid/CHIP ESI Direct Purchase Other Uninsured 9

Source: CCF analysis of 2015 ACS data.

Medicaid and CHIP Cover Mor Medicaid and CHIP Cover More than e than Half of Florida’ Half of Florida’s Childr s Children Age 0-5 en Age 0-5 and Half of All Births and Half of All Births

52% 48%

Medicaid/CHIP Other/Uninsured

10

Sources: Georgetown CCF analysis of monthly November 2016 CMS Medicaid & CHIP Enrollment. “Births Financed by Medicaid.” Kaiser Family Foundation. Florida data is from 2014.

50% 50%

Medicaid Other

Medicaid and CHIP Coverage, Medicaid and CHIP Coverage, Ages 0-5 Ages 0-5 Medicaid Financed Births Medicaid Financed Births

11

Source: Single-year estimates of summary data from the 2015 American Community Survey (ACS). The U.S. Census Bureau publishes ACS summary data on American Fact Finder. Percent estimates were computed.

39% 39% – 70% 70% 30% 30% – 39% 39% 9% 9% – 30% 30%

Per Percent of Childr cent of Children in Medicaid/ en in Medicaid/ CHIP by Congr CHIP by Congressional District, US essional District, US

1 2 3 4 6 11 5 8

7

10 12 9 15 13 14 17

16

18 20

19

25 26

21 22 23 24 27

12

Source: Single-year estimates of summary data from the 2015 American Community Survey (ACS). The U.S. Census Bureau publishes ACS summary data on American Fact Finder. Percent estimates were computed.

57-65% 49-57% 41-49% 33-41% 24-33%

Per Percent of Childr cent of Children on Medicaid/CHIP by Congr en on Medicaid/CHIP by Congressional District, FL essional District, FL

Impact of ACA Repeal Impact of ACA Repeal

13

What Do W What Do We Know About ACA e Know About ACA Repeal? Repeal?

• Budget reconciliation process will be used; simple majority

needed

• Future of marketplace is uncertain
• Florida has 1.7 million enrollees
• Tax credits replacing subsidies
• Entire Medicaid program will be capped
• Medicaid expansion being phased down

14

What Does ACA Repeal Mean for Childr What Does ACA Repeal Mean for Children in en in Florida W Florida Without Medicaid Cap? ithout Medicaid Cap?

Source: The Urban Institute. “Partial Repeal of the ACA through Reconciliation: Coverage Implications for Florida Residents.” Analysis using HIPSM 2016.

15

How Quickly Could Repeal and How Quickly Could Repeal and Replace Happen? Replace Happen?

• House committees starting tomorrow
• Senate may bypass committees and take House bill to the Floor

which is extremely unusual.

• No CBO score yet.
• No hearings on proposed bill.
• Senate has to comply with “Byrd Rule.”
• This limits the “flexibilities” that can be included in the bill
• Goal is to be done by April recess

16

What Changes ar What Changes are Pr e Proposed for

• posed for

Medicaid? Medicaid?

17

Medicaid/CHIP Medicaid/CHIP

• House bill imposes a per capita cap on Medicaid with

a base year of FY 2016 and an inflator of Medical CPI

• This cap applies to the entire program!
• Expansion funding reduced starting on January 1,

2020 – applies only for those who are continuously

• covered. Everyone else gets regular match.
• Small new fund for non-expansion states ($2B a year)
• CHIP funding expires on September 30, 2017 unless

Congress acts.

18

What Does A Medicaid Cap Mean What Does A Medicaid Cap Mean for Florida? for Florida?

19

A Per Capita Cap Shifts Risk to A Per Capita Cap Shifts Risk to States States

• If a new treatment becomes available
• If costs per person go up more than expected –

especially for expensive populations like the elderly

• Aging of the population
• If a new epidemic occurs like HIV, Zika, opioids
• If a natural or manmade disaster occurs.

20

Medicaid is the Primary Sour Medicaid is the Primary Source of ce of Federal Funds to Florida Federal Funds to Florida

Source: Kaiser Family Foundation analysis of National Association of State Budget Officers (NASBO), State Expenditure Report: Fiscal 2014-2016, November 17, 2016.

21

• Federal government pays state-

specific share of total Medicaid costs (FMAP).

• FMAP higher for poorer states,

lower for wealthier states.

• Florida match hovers around the

median at about 60%. In FY 2018, it’s 61.79%.

• Mandatory entitlement funding.

Federal Gover Federal Government Pays the nment Pays the Majority of Medicaid Costs Majority of Medicaid Costs

22

Source: Office of the Assistant Secretary for Planning and Evaluation. “FY 2017 Federal Medical Assistance Percentages.” ASPE. December 19, 2015.

58.5% 50.0% 74.5% Median State Lowest FMAP States (13) Highest FMAP (MS) State Share Federal Match

$50 $60 $50 $60

50% FMAP State Higher spending (unexpected cost growth)

Current Medicaid Financing System

Federal Share State Share

$50 $40 $40 $50 $60 $80

50% FMAP State Expected spending with cap Higher spending (unexpected cost growth)

Capped Federal Medicaid Funding

Federal Share State Share

$100 $120 $100 $120 $100

Federal cap VS

Medicaid Per Capita Caps Shift Medicaid Per Capita Caps Shift Costs to States Costs to States

23

Graphic Credit: Center on Budget and Policy Priorities.

• The onset of the HIV/AIDS

epidemic in the 1980s and early 1990s led to unexpected Medicaid costs.

• Anti-retroviral prescriptions

increased from 170,000 to 3 million from 1991 to 2005.

• Anti-retroviral prescription

spending increased from $31 million to $1.6 billion.

Medicaid Anti-Retr Medicaid Anti-Retroviral Drug Spending/

• viral Drug Spending/

Use Mor Use More Than Doubled e Than Doubled

24

Graphic Credit: Center on Budget and Policy Priorities. Source: Yonghua Jing, et. al. “Utilization and Spending Trends for Antiretroviral Medications in the US Medicaid Program from 1991 to 2005.” AIDS Research and Therapy. October 2007.

Would State Flexibility do the T

• uld State Flexibility do the Trick?

rick?

• States already have flexibility over many things

like: delivery system; provider rates.

• Medicaid is already very efficient and has low

administrative costs (6%) which is less than that of private insurance.

• Provider rates are already low

25

• Urban Institute modeled if

Medicaid enrollees instead enrolled in ESI.

• Spending $1,700 higher

(28 percent) in ESI.

• Beneficiary out-of-pocket

spending more than three times higher in ESI.

Medicaid Is Efficient Medicaid Is Efficient

26

Chart based on 2009 costs per enrollee Source: T.A. Coughlin et. al. “What Difference Does Medicaid Make? Assessing cost Effectiveness, Access, and Financial Protection Under Medicaid for Low-Income Adults.” The Urban Institute. May 2013.

$6,052 $257 $7,752 $784 Health Care Spending (excluding OOP) Out-of-Pocket Spending (OOP) Medicaid ESI

What Does State Flexibility Really What Does State Flexibility Really Mean? Mean?

• New flexibility would come in areas like:
• Entitlement/guarantee of coverage (waiting lists, caps,

time limits);

• Eligible populations i.e. limiting eligibility
• Benefits (EPSDT) and cost sharing;
• Other barriers to coverage i.e. work requirements,

lockouts.

27

Why Florida Should be Especially Why Florida Should be Especially Worried About Caps

• rried About Caps

28

Image Source: Habitat Florida

Florida Medicaid Spending Per Full Florida Medicaid Spending Per Full Benefit Enr Benefit Enrollee, FY 2013

• llee, FY 2013

Source: MACPAC, MACSTATS, 2016 Note: Total excludes four states. Florida's ranking is out of 46 states and the District of Columbia.

29

$1,880 $3,978 $15,048 $14,733 $5,420 $2,884 $5,138 $20,091 $19,912 $7,766 $0 $5,000 $10,000 $15,000 $20,000 $25,000 Child (ranked last) Adult (ranked 44/47) Disabled (ranked 41/47) Aged (ranked 43/47) Total (ranked 46/47) Florida National

Low-Income Elderly Population Low-Income Elderly Population Gr Growth, 2006-2015

• wth, 2006-2015

Source: 2006 and 2015 1-year estimate of the American Community Survey Note: Low-Income refers to income less than 200% of the federal poverty level

30

25% 14% Florida National

Florida Also Has High Gr Florida Also Has High Growth in SSI

• wth in SSI

Population Population

• Florida Ranks 6th in the U.S. for increase in

SSI beneficiaries; 35% increase over the past ten years compared to US average of 17%.

• All SSI beneficiaries automatically eligible for

Medicaid

31

Incr Increase in SSI Beneficiaries, by ease in SSI Beneficiaries, by Category Category, 2005-2015 , 2005-2015

Source: Social Security Office of Retirement and Disability Policy, "SSI Recipients by State and County, 2015"; Social Security Office of Retirement and Disability Policy, "SSI Recipients by State and County, 2005"

32

35% 36% 32% 21%

• 5%

22%

• 10%
• 5%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Blind and disabled Blind and disabled Aged Aged Child Child

Florida National

Top 10 Florida Counties with Largest Incr

• p 10 Florida Counties with Largest Increase

ease in SSI Beneficiaries, 2005-2015 in SSI Beneficiaries, 2005-2015

• Aged:

– Lee – Collier – Indian River – Osceola – Palm Beach – Broward – Orange – Miami-Dade – Hillsborough – Hernando

• Blind and Disabled:

– Osceola – Indian River – Flagler – Lake – Lee – Charlotte – Hernando – Collier – Manatee – Citrus

33

Source: Social Security Office of Retirement and Disability Policy, "SSI Recipients by State and County, 2015"; Social Security Office of Retirement and Disability Policy, "SSI Recipients by State and County, 2005"

Want to Lear ant to Learn Mor n More? e?

• Visit our website

ccf.georgetown.edu and sign up for our newsletter!

• Follow us on Twitter:

@GeorgetownCCF @JoanAlker1

• Facebook: Georgetown

University Center for Children and Families

34