OverviewoftheMedicaidExpansionand ImpactsforCommunitiesofColor

SamanthaArtiga TheHenryJ.KaiserFamilyFoundation For FamiliesUSATeleconference AftertheElection: MovingFullSteamAheadwithObamaCare Implementation November29,2012

FIGURE1

Medicaidhasmanyvitalrolesinourhealthcaresystem
HealthInsuranceCoverage
31millionchildren&16million adultsinlowincomefamilies; 16millionelderlyandpersons withdisabilities

AssistancetoMedicare Beneficiaries
9.4millionagedanddisabled 20%ofMedicare beneficiaries

LongTermCare Assistance
1.6millioninstitutional residents;2.8million communitybasedresidents

MEDICAID
SupportforHealthCareSystem andSafetynet
17%ofnationalhealthspending; 41%oflongtermcareservices

StateCapacityforHealth Coverage
Federalsharecanrangefrom5083%; ForFFY2012,rangesfrom5074.2%

FIGURE2

TheMedicaidmatchingstructureprovidesfundsonanas neededbasisandmorefederalassistancetopoorerstates.
StatutoryFederalMedicalAssistancePercentages(FMAP),FFY2012
WA MT
OR

VT ND MN ID WY NE IA IL CO KS OK MO TN AZ NM TX AR MS LA FL AL GA IN SD WI NY MI PA OH WV KY VA NC SC

ME NH MA CT NJ DE MD DC RI

NV
CA

UT

AK HI

50percent (15states) 51 59percent(11states) 60 66percent(13states) 67 74percent(12statesincludingDC)

SOURCE:FederalRegister,Nov,10,2010(Vol.75,No.217),pp.6908269083. http://edocket.access.gpo.gov/2010/pdf/201028319.pdf

FIGURE3

Medicaidhelpstogeneratejobsinstateeconomies.
FederalMedicaidMatching DollarsInjectionofNew Money StateMedicaidDollars
Direct Effects

HealthCareServices

JOBS

Vendors
(ex.MedicalSupplyFirm)

Indirect Effects

EmployeeIncome
Induced Effects ConsumerGoodsand Services Taxes

FIGURE4

ExpandingMedicaidisakeyelementinhealthreform.
UniversalCoverage

MedicaidCoverage ForLowIncome Individuals

Individual Mandate HealthInsurance MarketReforms

ExchangesWithSubsidies forModerateIncome Individuals

EmployerSponsoredCoverage

FIGURE5

TheACAexpandsMedicaideligibilityandsimplifies enrollmentprocesses.
Establishesanationalfloorofeligibilityat138%FPL
Fillslongstandinggapsincoverageforlowincomeadults

Providesadditionalfederalfinancingfornewlyeligible
100%federalfinancingforfirstthreeyears,phasingdownto90% overtime

Simplifieseligibilitycategoriesandstreamlinesenrollment andrenewalprocess
Multipleenrollmentoptions,includingonlineandphone Useofelectronicdataexchangeinsteadofpaper Goalofrealtimedetermination CoordinationbetweenMedicaidandExchangeCoverage

FIGURE6

TheSupremeCourtdecisionmayimpactstatedecisionsto implementtheMedicaidexpansion.
ThedecisionlefttheMedicaidexpansionforadultsintactbutlimitedthe Secretarysauthoritytoenforceit. Stateshavefinancialincentivetocomplywiththeexpansion,butthepenalty fornoncomplianceislimitedtolossofMedicaidexpansionfunds.
SecretarymaynotwithholdexistingfederalMedicaidfundsifastatedoesnotexpand. SecretarysauthoritytowithholdfederalMedicaidfundsifastatedoesnotcomply withotherprogramrequirementsremainsinplace.

OtherMedicaidprovisionsintheACAremaininplaceregardlessofwhether statesexpand.
Enrollmentsimplifications/coordinationwiththeExchanges Newoptionsforlongtermcareandcarecoordination Primarycarephysicianfeeincrease DisproportionateShareHospitalpaymentreductions

FIGURE7

TheMedicaidexpansionwouldincreaseeligibilityfor parentsandchildlessadults.
MedianMedicaid/CHIPEligibilityThresholdasofJanuary2012 250%

185%

MinimumMedicaidEligibilityunderHealthReform 138%FPL ($26,344forafamilyof3in2012)

63% 37% 0%
Children PregnantWomen WorkingParents JoblessParents ChildlessAdults

SOURCE:BasedontheresultsofanationalsurveyconductedbytheKaiserCommissiononMedicaid andtheUninsuredandtheGeorgetownUniversityCenterforChildrenandFamilies,2012.

FIGURE8

Theexpansionwouldresultinsignificanteligibility increasesforparentsinmanystates.
CurrentMedicaidLimit
138%

ACAMedicaidExpansionFloor

100%

50%

0% AR AL IN LA TX VA KS WV MO ID OR MS UT PA GA NH NC WY SD OK MT NE FL KY ND MI WA AK IA NM NV OH SC HI AZ CA CO MD DE TN
NOTE:Tenstates(CT,IL,ME,MA,MN,NJ,NY,RI,VT,WI)andDCalreadyoffercoveragetoparents>133%FPL. SOURCE:BasedontheresultsofanationalsurveyconductedbytheKaiserCommissiononMedicaidandthe UninsuredandtheGeorgetownUniversityCenterforChildrenandFamilies,2012,withstateupdates.

FIGURE9

Potentialcoveragegainsforchildlessadultsareevenlarger.
MedicaidCoverageofAdults,January2012
WA OR*
(closed)

VT* MT ID WY NE IA IL CO KS OK MO AR MS TX LA FL HI*
(closed)

ME NH MA CT* RI NJ DE MD DC*

ND MN SD WI
(closed)

MI
(closed)

NY PA WV

NV CA

IN
(closed)

OH VA NC SC GA KY

UT*
(closed)

AZ (closed)

(closed)

TN

NM
(closed)

AL

AK

NoorLimitedCoverage(42states) MedicaidComparableCoverage(9states,includingDC) Closeddenotesenrollmentclosedtonewapplicants

SOURCE:BasedontheresultsofanationalsurveyconductedbytheKaiserCommissiononMedicaidandthe UninsuredandtheGeorgetownUniversityCenterforChildrenandFamilies,2012withstateupdates.

FIGURE10

WithouttheMedicaidexpansion,manypooruninsured adultscouldbeleftoutofcoverage.
400%FPL+ 11% Parents 11% 139399%FPL 39% ChildlessAdults 26% 100 138%FPL 13%

Eligibilityfor InsuranceAffordabilityPrograms

Medicaid Expansion <100%FPL Exchange Subsidies

0 40.3million NonelderlyUninsuredAdultsasof2011

100

200

300

400

%FederalPovertyLevel

TheFPLforafamilyofthreein2011was$18,530.Nonelderlyadultsisadultsage1964. SOURCE:KCMU/UrbanInstituteanalysisof2012CPS.

FIGURE11

Statedecisionstoexpandwillhavesignificantimpacts onindividualshealthandwellbeing.
WhenI'msittingonthesideofthebedat3:00 inthemorning[theprescription]saystake twoeverysixhoursforpain,butIdonthave enoughI'mcryinganditshurting,butI'm tryingtomakeitstretchuntilthenexttime. Roosevelt,uninsuredman,Houston. Itsnotfunlivinginfearyoufearthatyouwill getsickandthatyoucantdoanythingabout itbecauseyourenotcoveredandyoudont haveoptions. Christine,uninsuredwoman,Cincinnati. Iwouldwant[healthinsurance]becauseofthe preventionfactorthenIwoulddefinitelygo andgetmymammogram,myPapsmear Valerie,uninsuredwoman,Tampa.

SOURCE:ForthcomingKCMUreportbasedonfocusgroupswithuninsuredlowincomeadults.

FIGURE12

Theimpactofstatedecisionswillvarysignificantlyacross states.
UninsuredRatesAmongNonelderlyAdultsWithIncome138%FPL,byState,20102011
WA MT OR ND MN ID WY NE NV
CA

VT

ME NH MA CT NJ DE MD DC RI

SD IA

WI

NY MI PA OH WV VA NC SC GA KY TN

UT

IL CO KS OK MO AR MS TX LA

IN

AZ

NM

AL

AK HI

FL

12%35%Uninsured(13states,includingDC) 36%41%Uninsured(17states) >41%Uninsured(21states)

SOURCE:KCMU/UrbanInstituteanalysisof2012ASECSupplementtotheCPS.

Stateswillconsideranumberoffactorsinevaluating whethertoimplementtheMedicaidexpansion.
FiscalImpactoftheMedicaidExpansion(i.e.spendingrelativetospendingin theabsenceoftheACAandnewfederalfunds) FiscalOffsetstoMedicaidExpansion(i.e.uncompensatedcarecosts) MacroEffectsoftheMedicaidExpansion(i.e.effectsonthestateeconomy andfinancialsecurityforindividuals) ConsequencesofNotImplementingtheMedicaidExpansion
Manypooradultswillremainuninsured HighuncompensatedcarecostsandcutsinDSH Participationofthoseeligiblebutnotenrolled

FIGURE13

FIGURE14

Morethanhalfofthenonelderlyuninsuredaremembersof communitiesofcolor.
Nonelderlyuninsuredbyrace/ethnicity,2011:

Hispanic 32% White 45% 55%FPL Black 15% Other 8%

TotalUninsured:47.9Million
Note:OtherincludesAsian/PacificIslander,AmericanIndian/AlaskaNative,andtwoormoreraces. Source:UrbanInstituteandKCMUestimatesbasedontheCensusBureau'sMarch2012Current PopulationSurvey AnnualSocialandEconomicSupplement.

FIGURE15

Communitiesofcolorareathigherriskofbeinguninsured.
Distributionofcoverageamongnonelderlybyrace/ethnicity,2011:
Employer/OtherPrivate White Medicaid/OtherPublic Uninsured

161.6M

71% 67% 47% 40% 39% 32% 30% 32%

15% 15%

13% 18% 21% 27%

14.7M

Asian

33.5M

Black

AmericanIndian
1.9M

Hispanic
49.2M

32%

AsiangroupincludesPacificIslanders.AmericanIndiangroupincludesAleutianEskimos.Twoormore racesexcluded.Datamaynottotal100%duetorounding. SOURCE:KCMU/UrbanInstituteanalysisof2012ASEC SupplementtotheCPS.

FIGURE16

Roughly60%ofuninsuredHispanics,Blacks,andAmericanIndians haveincomebelowtheMedicaidexpansionlimit.
Distributionofcoverageamongnonelderlyuninsuredbyrace/ethnicity,2011:
400%FPL+ 139399%FPL(EligibleforSusbsidies) Atorbelow138%FPL(MedicaidExpansionLimit)

15% 41%

13% 41%

5% 38%

6% 31%

9% 27%

44%

46%

57%

62%

63%

White

21.4M

2.6M

Asian

Hispanic
15.5M

Black

7.0M

AmericanIndian
0.5M

Thefederalpovertylevelwas$18,530forafamilyofthreein2011.AsiangroupincludesPacific Islanders.AmericanIndiangroupincludesAleutianEskimos.Twoormoreracesexcluded.Datamay nottotal100%duetorounding. SOURCE:KCMU/UrbanInstituteanalysisof2012ASEC SupplementtotheCPS.

FIGURE17

Forsomecommunitiesofcolor,immigrantsaccountfora significantshareoftheuninsured.
Distributionofcoverageamongnonelderlyuninsuredbycitizenshipstatus,2011:
U.S.BornCitizens 4% 3% NaturalizedCitizens NonCitizens

7% 4% 42% 46%

94%

88%

29%

11%

29%
White 21.4M Black 7.0M Asian 2.6M

43%

Hispanic 15.5M

Note:Twoormoreracesexcluded. SOURCE:KCMU/UrbanInstituteanalysisof2012ASECSupplementtotheCPS.

FIGURE18

Noncitizenimmigrantswillfacespecificeligibility restrictionsforMedicaidunderreform.
Medicaid Eligibilityin2014 Expandstonearlyallindividuals withincomesupto133%FPL ExchangeCoverage Individuals withoutaffordableemployer coveragecanbuycoveragethroughexchanges Taxcreditsavailableupto400%FPL Naturalized Citizens SameeligibilityasU.S.borncitizens SameeligibilityasU.S.borncitizens Individualswithoutaffordableemployer coveragecanbuycoveragethroughexchanges Tax creditsavailableupto400%FPL,including thosebelow133%FPLwhocannotenrollin Medicaidduetofiveyearwait Prohibitedfrompurchasingexchange coverageandapplyingfortaxcredits

Lawfully Residing Manyremainsubject tofiveyear Immigrants waitbeforetheymayenroll Statesmaychoose towaivethe fiveyearwaitforchildrenand pregnantwomen Undocumented Immigrants RemainineligibleforMedicaid

FIGURE19

Communitiesofcolorareatriskforbarriersto enrollmentandcare.
EnrollmentBarriers Burdensomeandconfusingapplication processes Languageandliteracyissues Fearsamongimmigrantandmixed immigrantstatusfamilies
Publicchargerelatedfears Fearsamongmixedstatusfamilies

BarrierstoCare Transportation Language

Navigatingtoappointments Providerinterpretationservices

Confusion
ObtainingcarethroughanMCO Identifyingparticipatingproviders PrimaryCareProviderassignment

Documentationrequirements Limitedaccesstotechnology

Challengesaccessingspecialtycare
Findingparticipatingspecialists Lengthyreferralprocesses

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FIGURE20

LookingAhead
TheMedicaidexpansionhasthepotentialtosignificantlyexpandcoverageandimprove accesstocareforuninsuredadults.
Disproportionatelyimportantforcommunitiesofcolor,whohavehigheruninsuredratesand lowerincomes. Keyforhelpingtoreducelongstandingdisparitiesincoverageandaccesstocare.

Conductingoutreachandaddressingenrollmentandaccessbarrierswillbeimportant forachievingincreasedcoverageandcare.
Usingtrustedcommunityorganizationsandindividuals. Assuringeffortsarelinguisticallyandculturallyappropriate. Providingasimpleandwelcomingapplicationandenrollmentprocesses. Strengtheningandreinforcingmessagestodispelfears.

IfastatedoesnotexpandMedicaid,pooruninsuredadultsinthatstatewillbeleft withoutanynewcoverageoptionsandlikelyremainuninsured. FiscalcliffcouldhaveimportantimplicationsforMedicaidandtheMedicaidexpansion.

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