Medicaid and the 4 A’s: Use of 1115 Waivers and State Plan

Amendments

American Cancer SocietyWashington, Dc

June 5, 2008Erin Reidy

Erin.Reidy@cancer.org

Why a Medicaid Evaluative Tool?

• ACS 4A’s campaign

• Recent 1115 and SPA activity

• Uncertainty about Medicaid reform among ACS state advocates

3

We cannot reach our goals without addressing Access to Care

8090

100110120130140150160170180190200210220

'75 '78 '81 '84 '87 '90 '93 '96 '99 '02 '05 '08 '10 '13

Year

Ra

te

2015 Goals – Reduce Mortality by 50 Percent

2003 Rate 190.1

1991 Baseline 215.1

2015 Goal 107.6

2015 Rate 160.5

Why the Cancer Lens

• The cancer community can play a greater role in influencing what public policy approaches are followed than they do today

• It is difficult to understand all the complexities of health care reform proposals, but people do understand cancer

• If it works for cancer patients, then it can work for almost any condition

Why do we care about Medicaid?

• Increases access to care

• Cancer screening

• Cancer treatment

40%

83%

56%48%

88%

75%

19%

68%

38%

Medicaid Private UninsuredPercent

Received recommended colorectal cancer screening in

past 10 years, 2005

Pap Test in Past Three Years, 2005

Mammogram in Past Two Years, 2005

Adults, 50-64Women, 18-64 Women, 40-64

SOURCES: Ward, Elizabeth, et al. "Association of Insurance with Cancer Care Utilization and Outcomes." CA: A Cancer Journal for Clinicians 58.1 (2008): 9-31.

Why do we care about Medicaid?

Why do we care about Medicaid?

• Increases access to care

• Cancer screening

• Cancer treatment

• Health disparities

• Low-income

• Racial/ethnic minorities

• Smoking

• Higher rate of smoking in the Medicaid population

Odds of More Advanced Stage at Diagnosis Breast Cancer, NCDB, 1998-2004

*Odds ratio is significant at the 95% confidence level.Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of diagnosis, and facility type.Source: Halpern et al, 2007 (manuscript in preparation)

Insurance Stage II vs. IStage III or IV

vs. I Private 1.0 (Ref.) 1.0 (Ref.) Uninsured 1.5* 2.4* Medicaid 1.5* 2.5* Medicare Age 65+ 0.9* 1.0

Race Non-Hispanic White 1.0 (Ref.) 1.0 (Ref.) Non-Hispanic Black 1.5* 1.9* Hispanic 1.3* 1.4*

What’s behind poor Medicaid outcomes?

• Retroactive enrollment

• Social Determinants of Health

• High rates of co-morbidities

• Continuities in care

The 4 A’s

• Available

• Affordable

• Adequate

• Administratively Simple

Illustration of the 4 A’s and Medicaid

•Available

• Must meet specific eligibility criteria

• Affordable

• Premiums and co-pays may be high

• Adequate

• Benefits, providers may not meet needs of cancer patients

• Administratively Simple

• Awareness and transparency may be lacking

• Appeals may be burdensome

Medicaid- Availability

• Eligibility

• “optional” groups

• Spend-down/pay-in programs

• Application

• Face to face interviews

• Self-declaration of income

• Enrollment

• Presumptive eligibility

• Enrollment caps

• Waiting periods

Medicaid- Affordability

• Premiums

• Premiums charged to beneficiaries greater than 150% FPL

• Multiple payment options

• Cost-sharing

• Under the DRA, co-payments to 20% of cost of services, or 10% of cost for lower-income beneficiaries.

• Total cost sharing can exceed 2-3% of a family’s income

• Can be denied at point of service

Medicaid- Adequacy

• Covered benefits

• “Benchmark” benefits

• Tiered benefits

• “Optional” services

• Benefit limits

• Annual/lifetime benefit limit

• Limited number of prescriptions

• Limits on number of treatments, visits, etc.

Medicaid- Administrative Simplicity

• Awareness

• Widely advertised

• Use of community organizations for enrollment

• Transparency

• Written in clear, simple language

• Materials in multiple languages

• Access to a live person for benefit explanations

• Plan Assignment

• Simple, publicized methods for switching

• Reassign enrollees to same plan after break in coverage

Conclusion

• Evaluative Tool can help advocates better questions about Medicaid reform proposals

• Provides the basis for developing practical and more specific evaluative criteria in the four main areas: adequacy, availability, affordability, and administrative simplicity

• The Society is not currently offering its own plan, but rather will evaluate proposals put forth by others and decide whether to support them

Thank you!