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The Affordable Care Act: Putting Reform into Medicaid
and Medicaid into Reform
Cindy Mann, JDCMS Deputy Administrator
DirectorCenter for Medicaid, CHIP & Survey & Certification
Centers for Medicare & Medicaid Services
Texas Center for Public Policy PrioritiesTexas Center for Public Policy PrioritiesSeptember 23, 2010September 23, 2010
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CMCS: Our Mission
To help States make Medicaid and CHIP the best programs they can be and to contribute to the broader goal of improving health care for all Americans
Beneficiaries are our focus
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Implementing the Affordable Care Act
Working with States and Insurance Commissioners
Coordinating with other federal agencies
Sharing ideas about what reform means with a broad array of stakeholders
Promulgating regulations and guidance
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Progress So Far
Establishing State High Risk Pools & Federal Pre-existing Condition Insurance Plan (PCIP)
Delivering small business tax credits
Establishing a retiree reinsurance program
Accelerating efforts to reduce waste, fraud, and abuse
Implementing a new Patient’s Bill of Rights; prevention regulations
Guidance on new Medicaid options
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Building a Foundation
Consumer web portal, www.HealthCare.gov
HHS and IRS are working closely to develop a common set of standards for data exchange Reduce expenses and uncertainty in building interfaces
Working to get funding to States quickly for all of the health reform efforts including: Rate review grants to hold insurers accountable for unreasonable
insurance rate increases Consumer grants to enhance States’ ability to address consumer
inquiries, file appeals and help people enroll in coverage Exchange State planning grants to assist States in their planning for
implementation
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A System of Coverage
ExchangeEmployer Coverage
Medicaid/CHIP
Medicaid/CHIP
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Projected Changes in Coverage by 2019
-5
0
5
10
15
20
25
24M
16M
-3M -5M
Exchanges
Medicaid & CHIP
Employer
Nongroup & Other
Total new coverage = 32 million
Source: Congressional Budget Office, March 2010Source: Congressional Budget Office, March 2010
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Medicaid & CHIPEmployerNongroup & OtherUninsuredExchanges
Sources of Coverage by 2019
25m
22m24m 51m
159m
(For All Individuals under 65)
Source: Congressional Budget Office, March 2010Source: Congressional Budget Office, March 2010
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Putting Medicaid into Reform
Medicaid coverage for adults up to 133% of the federal poverty line
CHIP and Medicaid coverage for children at higher incomes (States’ March 23, 2010 levels)
Increased federal funding across the board
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Significant increase in federal support for Medicaid/CHIP
100% match for “newly eligible” group for 3 years and 95-90% match thereafter
Increased match for “childless adults” in “expansion” states (reaches 93%/90% in 2019/2020)
Increased match for CHIP in 2016 (enhanced plus 23 percentage points)
Regular federal match for remaining currently eligible groups
State Financial Impacts
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Estimated Distribution of Costs for Medicaid Coverage Changes: 2014-2019
(in billions)
Total $464.7 billion
Source: Medicaid Coverage and Spending in Health Reform, John Holahan and Irene Headen/Kaiser Commission, May 26, 2010.
Who Pays?
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Certain State-funded services may no longer be needed
Reductions in uncompensated care and cost shifting
Greater efficiencies DSH funding declines (as will State
contributions)
Other State Financial Impacts
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Not a “safety net” but a full partner in assuring coverage for all
Eligible = enrolled Law contemplates a system made up of
different components to achieve seamless coverage, quality and cost containment objectives
New Paradigm
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Creating a high performing Medicaid program
Systems upgrades and data/performance standards
Delivery and payment reforms
Focus on “dual eligibles”
Further progress (re)balancing long-term care services and supports
Close attention to program integrity
Putting Reform into Medicaid
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The “Triple Aim”
Per CapitaCost
ExperienceOf Care
PopulationHealth
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Effects of the Affordable Care Act on Per Capita National Health Expenditures
NH
E P
er
Insu
red
Pe
rso
n
US
In
sure
d P
op
ula
tion
(M
illio
ns)
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Bottom 95% Bottom 95% of Enrolleesof Enrollees
Top 5%
Elderly 16.80 %
Disabled 31.79%
Adults 1.75%Children 3.72%
Top 5%
Elderly 1.82%
Disabled 2.61%
Adult .21%
Children .36%Bottom 95% Bottom 95% of Enrolleesof Enrollees
Enrollees Total = 60.6 million
Expenditures Total = $292.9 billion
5%
54%
Source: FY MSIS 2008, FY MSIS 2007 for AZ, NC, ND, HI, UT, VT, WI
Top 5% of Enrollees Accounted forMore than Half of Medicaid Spending in
FY 2008
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2014BeginsNow!
2014BeginsNow!
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2010201020102010
Adopt NewLaws/Budgets
Provider Networks/Contracts
StaffingTraining
Federal Actions
2014201420142014
Eligibility Rules
BenefitDesigns
Systems Support
Basic Option
System Changes
NewRules/Forms
DataPerformance
Standards
Exchange/Medicaid
Org Structure
FMAP Rules
State Actions
Enrollment …
Collaboration with States is Essential
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Uninsurance rates for children have steadily dropped due to Medicaid/CHIP
Coverage levels holding steady even in economic downturn
Disparities are narrowing
Percentage of Children Without Health Insurance, By Poverty Level, 1998-2009
Children below 200% of poverty
Children above 200% of poverty
23%
16%
12%
6% 5% 5%
Lessons from Children’s Coverage Efforts:Success is Possible
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Children’s Coverage Does Not Need to WaitThe Secretary’s Challenge: Enroll the 5 million uninsured children who are currently eligible for Medicaid or CHIP
over the next five years
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Children in Texas Rate of Medicaid/CHIP Participation & Distribution
of Eligible but Uninsured Children in the Largest Counties (2008)
Source: Analysis of Urban Institute's Health Policy Center ACS Medicaid/CHIP Eligibility Model, based on data from the 2008 American Community Survey (ACS) September 17, 2010.
Rest of State 74.9% (35.4 percent of children in Texas live in counties that cannot be distinguished from other counties using the ACS.)
53 - 70%71 - 80%81 - 85%
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Key to Reaching Key to Reaching Our Goals:Our Goals:
Assuring that all Assuring that all Partners are at Partners are at
the Tablethe Table