Florida's Medicaid Florida's Medicaid Program: Looking Program: Looking

Ahead to 2012Ahead to 2012Joan Alker and Jack HoadleyGeorgetown University Health Policy

Institute

Webinar, December 7th, 2011

Looking Ahead to 2012, Looking Ahead to 2012, What Changes Are In Store What Changes Are In Store for Florida's Medicaid for Florida's Medicaid Program?Program?

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What is an 1115 waiver?What is an 1115 waiver?

o A provision in the Social Security Act which allows the Secretary discretion to waive certain federal rules

o The proposal must assist in promoting the objectives of the Act

o Must be experimental, pilot or demonstration – can’t just be designed to save $.

Medicaid EnrollmentMedicaid Enrollment

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66.7%

33.3%

Cost of Florida’s Medicaid Cost of Florida’s Medicaid ProgramProgram

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o Total annual costs slightly less than $20.3 billion

o FMAP= 55.94% in SFY 11-12o FMAP is projected to rise to 59.14%

in SFY 14-15

Medicaid’s Budget: Putting Costs Medicaid’s Budget: Putting Costs in Context, SFY 2008- SFY 2009in Context, SFY 2008- SFY 2009

Source: Kaiser Commission on Medicaid and the Uninsured, "Policy Brief Update: State Budgets in

Recession and Recovery," October 20116

Florida’s Budget, Florida’s Budget, SFY 2008- SFY 2009SFY 2008- SFY 2009

Source: 2008 and 2009 Annual Survey of State Government Finances. U.S. Census Bureau and 2009

NASBO State Expenditure Report7

Florida’s Medicaid SpendingFlorida’s Medicaid Spending

State Medicaid Spending, as a Share of the State General Fund

State Medicaid Spending, as a Share of the State General Fund and Other State Fund Expenditures

Florida 14.49% 15.98%

National Average 14.73% 11.33%

Source: Georgetown University Center for Children and Families calculations based on National Association of State Budget

Officers, "2009 State Expenditure Report" (December 2010).8

Growth in Florida Medicaid Growth in Florida Medicaid Enrollment and Spending, 2006-Enrollment and Spending, 2006-

2011 2011

Source: Georgetown University calculations of “Social Services Estimating Conference - Medicaid Services Expenditures" (March 1 and October 17, 2011); and "Social Services Estimating Conference - Basic Medicaid Caseloads, Historical and Forecasted” (September 9, 2011).

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Per-Person Five Year Growth in Per-Person Five Year Growth in Health Care Costs, 2006-2011 Health Care Costs, 2006-2011

Source: Georgetown University calculations of Kaiser Family Foundation & Health Research & Educational Trust, "Employer Health Benefits 2011 Annual Survey" (September 2011); 2006-2009 and Projected 2010-2011 National Health Expenditure Data; "Social Services Estimating Conference - Medicaid Services Expenditures" (March 1, 2011); and "Social Services Estimating Conference - Basic Medicaid Caseloads, Historical and Forecasted" (January 24, 2011).

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What’s in the 2011 What’s in the 2011 Legislation?Legislation?

o Required enrollment in managed care for most Medicaid beneficiaries

o Managed long-term care programo $10 monthly premium requiremento $100 copay for non-emergency use of

ERo Enhanced benefits program: credits for

healthy behaviorso Opt-out to purchase private, employer-

sponsored insurance11

Mandatory Managed Care Mandatory Managed Care PopulationsPopulations

o Children and parents who are eligible because of their incomes

o Aged and Disabled persons receiving SSI disability (except those with developmental disabilities)

o Children eligible because they are disabled (SSI)o Pregnant womeno Children with chronic conditions who participate in

Children’s Medical Services Networko Children in foster care and/or receiving adoption

subsidieso Individuals eligible for hospice-related serviceso Individuals eligible for both Medicaid and Medicare

(“dual eligibles”)o “Medically Needy”

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Voluntary Managed Care Voluntary Managed Care PopulationsPopulations

o Individuals residing in an institution, such as a nursing home, sub-acute inpatient psychiatric facility for those under the age of 21, or an Intermediate Care Facility for the Developmentally Disabled

o Individuals with developmental disabilitieso Individuals that have other creditable health care

coverage, excluding Medicareo Individuals residing in residential commitment facilities,

operated through the Department of Juvenile Justice or mental health treatment facilities

o Refugeeso Individuals with developmental disabilities enrolled in

the home and community based services waiver program, those on the waiting list for this program, or those who are residents of developmental disabilities centers

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Exempt Managed Care Exempt Managed Care PopulationsPopulations

o Women who are eligible for family planning services

o Women who are eligible through the breast and cervical cancer program

o Persons who are eligible for emergency Medicaid only

o Children receiving services in a pediatric extended care facility

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What Will the Federal What Will the Federal Government Do?Government Do?

o Negotiations have been underway all year on extension of five-pilot county waiver• Some of those issues will carry over

o CMS could act on some parts of the waiver and not others (1915 (b) and (c), SPA)

o A lot of negotiations!!

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Proposed Medicaid Proposed Medicaid Premiums Challenge Premiums Challenge Coverage for Florida’s Coverage for Florida’s Children and ParentsChildren and Parents

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FL

NC

SC

GA

LATX

AL

AR

KS

OKAZ

TN

MS

NV

UT

NM

CA

WY

ID

WA

ORND

SD

NE

MT

MO

IN

MI

WI

IL

ME

OH

KY

HI

AK

WV VA

CTNJ

DE

MD

RI

NHVT

DC

MA

CO

IA

NY

MN

Uninsured rate higher than national rate(16 states)

Uninsured rate lower than national rate (30 states including DC)

No statistically significant difference (5 states)

PA

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How is Florida doing in How is Florida doing in covering children?covering children?

Florida=12.7%US=8%

Increase in Child PovertyIncrease in Child Poverty

Source: US Census Bureau, American Community Survey ACS18

Florida Still Has Many Florida Still Has Many Uninsured ChildrenUninsured Children

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Florida had largest decline in Florida had largest decline in number of uninsured children number of uninsured children

in 2008-2010in 2008-2010

Source: Georgetown University Center for Children and Families, “Despite Economic Challenges, Progress Continues: Children's Health

Insurance Coverage in the United states fro m2008-2010”20

Florida led nation in decline of Florida led nation in decline of uninsured rateuninsured rate

Source: Georgetown University Center for Children and Families, “Despite Economic Challenges, Progress Continues: Children's Health

Insurance Coverage in the United states fro m2008-2010”21

Proposed New PremiumsProposed New Premiums

o $10 monthly premium on Medicaid beneficiaries, regardless of income• Primary exception: those living in nursing

homes

o Premium would be a condition of eligibility

o $10 premium far exceeds allowable limits under federal law

o Thus requires federal government waiver

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Illustrative Premiums under Illustrative Premiums under ProposalProposal

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Assumed Family Income

Yearly Premiums

Premiums as Percent of Income

Family with 1 parent, 2 children

$11,000 $360 3%

Family with unemployed parent, 2 children

$4,000 $360 9%

Family with 2 covered children

$13,000 $240 2%

Pregnant woman, no children

$14,000 $120 1%

Premiums in Other StatesPremiums in Other States

o States currently charging premiums• For children: 34

• For adults: 23

o Only 8 states have premiums that reach families with incomes as low as 101% of FPL

o No other state currently charges premiums to children under the poverty line

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Case Study in OregonCase Study in Oregon

o Higher premiums for adults below poverty• $6 to $20 per month, based on income

o Enrollment dropped from 104,000 in February 2003 to 24,000 in November 2005.

o One-third cited premiums as key factoro Two-thirds became uninsuredo Total state premium revenues declined25

Other State ExperiencesOther State Experiences

o Missouri: 30% enrollment decline over two years

o Maryland: 28% of children disenrolled• $37 monthly premium at higher income

levels

o Urban Institute study: even small premiums (as share of income) decrease enrollment

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Expected Effect of Increasing Expected Effect of Increasing Premiums on Participation RatesPremiums on Participation Rates

27Source: Leighton Ku and Teresa Coughlin, “Sliding-Scale

Premium Health Insurance Programs: Four States’ Experiences,” Inquiry 36(4): 471-480, Winter 1999-2000.

Applying the Model to FloridaApplying the Model to Florida

o Estimates made for different eligibility groups, based on income levels• Families with TANF-based eligibility ≤ 59%

FPL

• Families with unemployed parent ≤ 22% FPL

• Children based, on age and income

• Pregnant women, based on age and income

o 807,000 children and parents projected to drop coverage

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Over 80% of Those Expected to Over 80% of Those Expected to Lose Enrollment are ChildrenLose Enrollment are Children

Source: Georgetown Health Policy Institute Analysis29

Most Beneficiaries Projected to Lose Most Beneficiaries Projected to Lose Enrollment are Below PovertyEnrollment are Below Poverty

30 Source: Georgetown Health Policy Institute Analysis

What Happens to Children and What Happens to Children and Families Who Disenroll?Families Who Disenroll?

o Many will have no other option for coverage• Those working at low-paid jobs often have

no employer health insurance offered

• When offered, insurance has much higher premiums than proposed in Medicaid

• Those without jobs have few insurance options

o The result: many likely to become uninsured

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Reliance on the Safety NetReliance on the Safety Net

o Without insurance, people turn to emergency rooms and safety net clinics and hospitals• Neglected preventive care

• Added burden for safety net clinics, hospitals

• Higher costs for state and localities

o Increased cycling on/off coverage• Greater administrative costs

• Adverse selection

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For More InformationFor More Information

o Visit the Jessie Ball duPont Fund website• www.dupontfund.org

o Visit the Winter Park Health Foundation website• http://www.wphf.org/

o The Georgetown University project website• http://hpi.georgetown.edu/floridamedicaid

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