The Future of Medicaid and Health Care Access in Ohio

A look at what’s next for the Affordable Care Act and Medicaid

a statewide coalition of over 485 organizations and thousands of individual advocates.

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Webinar Presenters

Loren AnthesPublic Policy Fellow, Medicaid Policy

CenterThe Center for Community Solutions

Brandi SlaughterChief Executive Officer

Voices for Ohio’s Children

Wendy PattonSenior Project Director

Policy Matters Ohio

Medicaid Background

Loren C. Anthes, MBAPublic Policy Fellow, Center for Medicaid Policy

1.12.17

Additional Research

When you see this…

More info is on our website!

You’ve Seen One State’s Program…

“No one designed the existing program; rather it is a perplexing Rube Goldberg of incremental adjustments and periodic enhancements or cutbacks, at both the national level and the state level, which rarely work in concert.”

What Will be Covered

• The 5 W’s

• The Money

• A Quick Review of the State’s “Group VIII Assessment”

THE 5 W’S… (AND ONE H)

Who

Children Pregnant Women

Parents Childless Adults

Disabled Workers

Disabled

Medicaid Marketplace

138% FPL

200% FPL

250% FPL

400% FPL

What

• Early and Periodic screening, diagnosis and treatment (EPSDT) for children

• Inpatient hospital• Physician• Lab and X-ray• Outpatient, including services provided by

hospitals, rural health clinics, and Federally Qualified Health Centers

• Medical and surgical vision• Medical and surgical dental• Transportation of Medicaid services• Nurse midwife, certified family nurse and pediatric

nurse practitioner• Home Health• Nursing facility• Medicare premium assistance

• Prescription drugs• Durable medical equipment and supplies• Vision, including eyeglasses• Dental• Physical Therapy• Occupational therapy• Speech therapy• Podiatry• Chiropractic services for children• Independent psychological services for children• Private duty nursing• Ambulance/ambulette• Community alcohol/drug addiction treatment• Home and Community based alternatives to facility based care• Intermediate care facilities for people with developmental

Disabilities• Hospice• Community mental health services

FEDERALLY MANDATED STATE OPTIONAL

Where

When

Ohio Medicaid spends $48,000/minute

Why

How: State PlanREASONABLE PROMPTNESS • States must promptly provide Medicaid to recipients

without delay caused by agency’s procedures

EQUAL ACCESS TO CARE • States must set payment rates that are adequate to

assure Medicaid recipients reasonable access to services of adequate quality

COVERAGE OF MANDATORY SERVICES • CMS requires state Medicaid programs to provide

certain medically necessary services to covered populations

http://www.medicaid.ohio.gov/MEDICAID101/MedicaidStatePlan.aspx

How: Waivers

Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid.

The purpose of these demonstrations is to demonstrate and evaluate policy approaches such as:

• Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible;• Providing services not typically covered by Medicaid; or• Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.• States who want to request a program under this authority must submit a written application to CMS for approval

that details the goals and operational aspects of the program, and those applications are subject to public review and comment.

Other waiver authorities include Section 1915(b) Freedom of Choice (Managed Care) Waivers and Section 1915(c) Home and Community-Based Services Waivers.

MONEY

The Money: Federal Match

Source: HPIO

The Money: Federal Match

Source: Ohio Legislative Service Commission, All-Funds Medicaid Expenditure History

FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016

$5,5

98

$5,3

22

$4,7

11

$5,2

50

$6,7

23

$6,9

50

$7,3

49

$7,3

83

$7,7

56

$8,1

39

$10,

095

$11,

279

$12,

431

$11,

678

$11,

907

$13,

511

$16,

084

$17,

538

State Federal

116%

39%

08 09 10 11 12 13 14 15 16

STATE SHARE 40.8% 34.5% 29.5% 29.7% 36.5% 36.9% 35.2% 31.5% 30.7%

FEDERAL SHARE 59.2% 65.5% 70.5% 70.3% 63.5% 63.1% 64.8% 68.5% 69.3%

The Money: Since 1975

Source: Ohio Legislative Service Commission, Total State and Federal GRF Expenditure History

FY 1

975

FY 1

977

FY 1

979

FY 1

981

FY 1

983

FY 1

985

FY 1

987

FY 1

989

FY 1

991

FY 1

993

FY 1

995

FY 1

997

FY 1

999

FY 2

001

FY 2

003

FY 2

005

FY 2

007

FY 2

009

FY 2

011

FY 2

013

FY 2

015

FY 2

017

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000 EXPENDITURES

FY 1

975

FY 1

977

FY 1

979

FY 1

981

FY 1

983

FY 1

985

FY 1

987

FY 1

989

FY 1

991

FY 1

993

FY 1

995

FY 1

997

FY 1

999

FY 2

001

FY 2

003

FY 2

005

FY 2

007

FY 2

009

FY 2

011

FY 2

013

FY 2

015

FY 2

0170%

10%20%30%40%50%60%70%80%90%

100%SHARE OF BUDGET

The Money: Spending

Enrol lme nt Expe nditure

12.1%

47.3%

57.2%

28.4%

22.6%21.3%

8.0% 3.0%

ABD CFCMedicaid Expansion Other

• Most of the resources consumed by Aged, Blind and Disabled (ABD)

• Question: How do you become efficient?

MEDICAID EXPANSION

Ohio Expansion Cost

Source: Ohio Legislative Service Commission, Budget Footnotes

Ohio Expansion Results

ACCESS• Uninsured rates for low-income Ohioans at

an all-time low• 64.3% of enrollees reported better access• Mostly benefited white, unmarried men with

a highschool diploma or less

OUTCOMES• Half reported an improvement in health• Ability to manage disease increased

http://medicaid.ohio.gov/

Ohio Expansion Results

RURAL IMPACT• 43.5% of population in small hubs were

covered by Medicaid (compared to 38.5% in big cities)

• 35 of the 47 small towns also had a hospital as one of the major employers

CREATES ECONOMIC MOBILITY• National Bureau of Economic Research

– Does not create job-lock– Children who were covered are healthier,

living longer, and working

SUPPORTED WORKING• 22.9% reported financial situation improved• 58.6% stated coverage made it easier to purchase food• 48.1% said is was easier to pay mortgage• 44.8% said it eliminated their medical debt

INCENTED WORKING• 40% working• 50% stated it was easier to secure and maintain work• 75% of unemployed stated it would be easier to find a

job• Of the unemployed, half had a mental health issue

(compared to 28% of those without)

Ohio Expansion Cost

Source: Ohio Legislative Service Commission, Budget Footnotes

THANK YOU

Additional Resources:www.communitysolutions.com/Medicaid

Follow me! @lorenanthes

@CCSPolicy

Repeal of the ACA will hurt Ohio – especially

MedicaidWendy Patton, Senor Project Director

Policy Matters Ohiowpatton@policymattersohio.org

The Affordable Care Act has Helped Ohio

•900,000 more have health coverage•5,000,000 with pre-existing

conditions are protected• Lifetime caps, limits on care,

are eliminated• Free preventative care in all

health coverage

Where Americans Get Health Coverage

Source: New York Times, January 3, 2017

3%

1.2% other

Repeal Would Hurt Financially

• State loses billions of federal $$$$• Indigent care swamps hospitals • Insurers lose customers

• Families and individuals lose coverage• Seniors lose help paying for prescriptions• 117,000 children lose insurance in 2019

Repeal Would Hurt Low-Income Workers

Hotels/motels

Building services (janitor, extermination, cleaning)

Department and discount stores

Grocery stores

Child day care services

Home health care services

Employment services (temp agencies)

Nursing care facilities

Construction

Restaurants and other food services

0 10,000 20,000 30,000 40,000 50,000 60,000 70,000

7,070

8,490

8,770

9,190

9,320

13,530

14,000

16,090

18,010

60,030

Number of adult workers by sector enrolled in Medicaid expansion.

These are the ten sec-tors with the largest numbers of workers enrolled in Medicaid expansion.

Source: Analysis of the 2015 American Community Survey. Adults are those aged 19 through 64. Workers are those who have worked within the past year. The ten industries above are those with the largest number of Medicaid enrolled workers in the Medicaid expansion income-eligibility range in Ohio. All figures are rounded to the nearest ten workers.

Current Medicaid Structure

•Entitlement

•Federal/state match (FMAP)

•Flexible

•Countercyclical

Danger of Proposed Structures

• Block grant• Per-capita Cap• Premiums• Lock-outs• Reduction in

eligibility What happened under block grant structure in TANF illustrates danger

Erosion of Value Would Further Reduce Health Services Over Time

VoiceOhioKids

Voices for Ohio’s Children

Medicaid is a Critical Health Social Support

• Children and Families• People with Disabilities• Seniors

The U.S. and Ohio Have Achieved Historic Low Uninsured Rates Among Children

2008 2009 2010 2011 2012 2013 2014 20150.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0% 9.3%

4.8%

6.8%

4.4%

Child Uninsured Rate in the U.S. and Ohio Over Time

United States Ohio

Largely Thanks to Increased Participation in Medicaid and CHIP

2008 2009 2010 2011 2012 2013 201476.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

81.7%

84.3%85.8%

87.2%88.1% 88.3%

91.0%

83.3%

86.6%

88.5% 87.8%89.5%

90.2%

92.1%

Participation in Med-icaid/CHIP

Close to half of Medicaid enrollees in Ohio are children

* Source: CMS Medicaid and CHIP Enrollment Report, October 2016

Children42%

Adults58%

• For every 1 child enrolled in CHIP there are 6.5 enrolled in Medicaid in Ohio

• CHIP = Healthy Start• CHIP in Ohio is an expansion of Medicaid but

children must be uninsured

CHIP Rests on the Shoulders of Medicaid

Source: MACPAC “Child Enrollment in CHIP and Medicaid in 2015”

Snapshot of CHIP History

Bipartisan support created CHIP

CHIP was reauthorized with funding extended

through 2013

ACA strengthened CHIP by extending funding through

September 2015 and boosting CHIP match

rate by 23 percentage points in

2016

Congress must act to extend CHIP funding beyond September

2017

1997 2009 2010 2017

Going forward, renewing CHIP funding is essential for maintaining our gains in coverage and ensuring quality, affordable care for kids.

CHIP: Federal-State Partnership

Federal Government States

Administration Oversight Direct administration

FinancingPays 65% to 85% of costs; with a 23% point bump in 2016

Pays non-federal share of cost

Program Rules Fewer minimum standards than Medicaid

• Set provider payment rates• Determine eligibility rules,

benefits, and cost sharing within guidelines

Coverage Guarantee None required Can freeze or cap enrollment or require waiting periods

CHIP: Federal-State Partnership

What do we know about past

restructuring proposals and the

impact of ACA repeal?

Potential Risks to Children in Restructuring Proposals

Cuts to Medicaid in exchange for state flexibility could eliminate core protections for children in federal standards:

• Guarantee of coverage• Comprehensive benefits through EPSDT• Cost-sharing limitations

Repeal of ACA Direct Impact on Children and Families• Maintenance of Effort provision (MOE) requiring states to

hold children’s eligibility levels steady• Coverage of former foster youth up to age 26• Loss of parent expanded coverage and impact on:• Parent health• Family economic security• Welcome mat effect on child enrollment

• Loss of Marketplace coverage for 1 million kids in the U.S.; approximately 30,000 in Ohio.

Other Policy Changes Proposed in the Past

• Substantial changes through waiver activity

• Elimination of 23% point e-FMAP increase for CHIP

• Mandated vs. optional 5 year waiting period for lawfully present immigrant children

Healthy Start is Still EssentialDesigned specifically to meet the needs of kids

More comprehensive benefits for kids compared to Marketplace plans

More affordable for families: Healthy Start does not require premiums or cost-sharing for children

Not all families will qualify for financial assistance to purchase Marketplace plans

Healthy Start federal funding provides state budget stability and predictability

Contact Uswww.raiseyourvoiceforkids.org

Brandi Slaughter, CEObrandi@raiseyourvoiceforkids.org

Dana Dunlap, Policy Directordanaj@raiseyourvoiceforkids.org

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• Join the conversation on social media:

• @Advocates4OH• Facebook.com/advocatesforohio

• @PolicyMattersOH• Facebook.com/policymattersohio

Next Steps

• @CommunitySols• Facebook.com/CommunitySols

• @VoiceOhioKids• Facebook.com/voicesforohioschildren

Call Ohio Senators Rob Portman (202-224-3353) and Sherrod Brown (202-224-2315) and tell them not to repeal the Affordable Care Act without a replacement.

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Thank you for joining us today!