Transcript Slide 1

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Advocate’s Perspective:
Texas Medicaid Reforms
Health and Human Services Subcommittee,
House Committee on Appropriations
October 9, 2006
Anne Dunkelberg, Associate Director
900 Lydia Street - Austin, Texas 78702
Phone (512) 320-0222 – fax (512) 320-0227 - www.cppp.org
Center for Public Policy Priorities
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Texas Medicaid: Who it Helps
August 2006, HHSC data.
Disabled,
360,974
Elderly,
362,953
Poor Parents,
60,445
TANF Parent,
25,411
Children,
1,784,302
Maternity,
97,161
Total enrolled 8/1/2006: 2.68 million
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Who Texas Covers Defines Which
Reforms are Possible
• VERY few parents on Texas Medicaid
• Very few enrollees are “optional” coverage
under federal law
• Children, Pregnant Women, the Elderly,
and Persons with Disabilities:
– Most of Texas Program
– Special Protections in Fed law
– Special concerns for their vulnerability
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Texas Medicaid Enrollees and
Expenditures by Enrollment Group
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(2004)
Elderly &
Disabled
21%
Elderly &
Disabled
59%
Adults 9%
Children
70%
Adults 11%
Children 30%
Enrollees
Total = 2.6 million
Expenditures
Total = $14.7 billion
SOURCE: HHSC
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Children Account for Most Medicaid
Enrollment Growth (U.S. 2000-2002)
Blind/Disabled
6%
(0.4 million)
Aged
3%
(0.2 million)
Adults
35%
(2.3 million)
Children
56%
(3.7 million)
Total Enrollment
Growth = 6.6 Million
Center for
SOURCE: Urban Institute, 2003; estimates of the 2000 MSIS Annual Person Level Summary Files; 2002 data
Public Policy Priorities from the CBO March 2003 baseline. *Ever Enrolled
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Elderly & Disabled Account for Most
Medicaid Spending Growth (2000-2002)
Adults
15.4%
Disabled
34.3%
Children
20.8%
Children
and Adults
36.2%
Aged and
Disabled
58.6%
Medicare Payments 2.1%
*Other 2.5%
DSH 0.7%
Aged
24.3%
Total = $48.2 Billion
.
SOURCE: Urban Institute, 2003; estimates based on data from CMS, CMSO, Medicaid Statistical Information
System (MSIS) and HCFA/CMS-64 Reports. * Other = Administrative costs and adjustments
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What Medicare Does Not Cover:
Major Medicaid Cost Driver (FY2003)
5%
Other
Beneficiaries
60%
Medicare Premiums
14%
Prescribed Drugs
15%
Acute Care
66%
Long-Term Care
Duals 40%
Total Medicaid Spending
$262.2 billion
Total Spending on Duals
$105.4 billion
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
SOURCE: Urban Institute estimates for KCMU based on an analysis of MSIS and Financial Management reports (CMS Form 64).
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Challenge: Potential for Savings is
Greatest Among Most Vulnerable
• Cautious approach needed in cost containment
aimed at Elderly, Texans with Disabilities.
• Savings most likely to take time to manifest –
significant reforms seldom yield immediate
results.
• Key areas of Texas Medicaid pay such low rates
that ability to reduce costs further is slim.
• HHSC/Texas Medicaid currently tackling
enormous number of reforms & program
modifications enacted in 2001, 2003, and 2005.
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Medicaid is Growing Slower than
Private Health Spending, 2000-2003
12.6%
9.0%
6.9%
Medicaid Acute Care
Spending Per
Enrollee
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Center for Public Policy Priorities
Health Care Spending
Per Person with
Private Coverage1
Monthly Premiums
For EmployerSponsored Insurance2
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Strunk and Ginsburg, 2004.
Kaiser/HRET Survey, 2003.
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What Texas Spends
State "Own Source" Budget, 2006-07: $90 Billion
Sources:
LBB, SB 1
K-12 Education,
$28.6 b, 31%
Medicaid,
$14.1 b, 16%
All Other,
$7.0 b, 8%
Business/
Econ Devel.,
$9.2 b, 10%
Higher
Education,
$17.7 b, 20%
Criminal Justice,
$8.3 b, 9%
Center for Public Policy Priorities
Other Health &
Human Services,
$5.1 b, 6%
"Own Source" = Excludes Federal Funds
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Medicaid spending HAS grown
Quickly over last Decade….
BUT:
• Medicaid’s cost-per-client has been growing at about
HALF the rate of Employer-sponsored group insurance.
– Texas and the US do need to control health care costs, but not
just in Medicaid. Targeting Medicaid alone will not solve the
problems.
• Texas’ STATE DOLLAR Medicaid spending (that’s the
money YOU have to raise, NOT the federal tax dollars we
bring back home as Medicaid match) is till #3 AFTER K12 education, and Higher Ed.
• Medicaid is the #1 source of federal dollars in our state
budget, far outstripping the next highest area (usually
highways).
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HHSC/Texas Medicaid:
A
VERY
Full
Plate
As HHSC has laid out:
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• Integrated Eligibility and Enrollment/TAA take-over of CHIP
Eligibility
• Managed care Expansion: HMO, PCCM
• Preferred Drug List/Prior Authorization/Pharmacy Benefits
Manager
• Disease Management
• Integrated Care Management/STAR+PLUS
• 87 (!) SB 1188-related projects, including ER Utilization, Case
Management Optimization
• Women’s Health Waiver
• CHIP Perinatal
• Medicaid Buy-In (workers with disabilities)
• CHIP remiums assistance and 3-Share Waiver
• 5 approved and 3 proposed UPL programs
• Hospital Reimbursement Studies
• Implementing MANDATORY DRA provisions: Long Term Care
Asset restrictions (will yield some savings); US Citizenship
Documentation
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HHSC/Texas Medicaid:
A VERY Full Plate
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Many programs are underway which are likely to yield real efficiencies and
savings,
But MOST have not yet had sufficient time to reach their full potential.
No “pig in a poke”: Independent Monitoring and Evaluation of all reforms
should be required before new programs are continued and/or expanded
statewide.
Beware the “Weekend Chore List” Syndrome:
Just because I ask my husband to re-paint all the trim on our house over the
Columbus Day weekend does NOT mean he can really accomplish it in that
short time.
Overloading the agency with too many simultaneous assignments for change
risks undermining the promise and ultimate success of policies enacted in
last 5 years.
Rx for near term: Slow Down, Fix, Perfect, Study what we are already
doing. Be very selective & cautious in adding to the list we just read.
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Texas’ Limited DRA Options
Cost Sharing options (very limited)
Non-Preferred Rx:
• DOCTORS, not patients, prescribe non-preferred drugs.
Make sure Dr.s Know when they prescribe something
that will require a co-pay, and ask if family can afford.
• Monthly out-of pocket limits are needed to protect sick
children, elders, persons with disabilities.
• Denial of Rx to those who cannot pay is OPTION, not
mandate. Prescriber should be notified if patient cannot
afford co-pay.
Numbers for whom other cost share allowed so small that
not cost-effective to implement.
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Texas’ Limited DRA Options
Benchmark Benefits
• Great majority of kids in Texas Medicaid already in HMO
care, which already uses a benchmark package, and state
“wraps around” to provide comprehensive EPSDT
services.
• Unclear what, if any additional advantage this DRA
option offers Texas.
• Children on Texas Medicaid not getting enough
preventive care or care management (Frew Lawsuit).
• Could entail significant administrative costs to change
from this existing model without strong argument for
doing so.
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Texas’ Limited DRA Options
Great Opportunities to Better Serve Texans
with Disabilities, the Elderly
• Medicaid Buy-In for Children with Disabilities
• Money Follows Person Grants
• LTC Partnerships (may only reach limited group, but still
would yield savings if so)
• HCBS for mental health care
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Texas’ Limited DRA Options
Health Opportunity Accounts:
Caveats!
• Remember, HOAs were a COST, NOT savings to DRA
• MUST fully fund Account
• A real pilot: limited area, STUDY results, and make
changes
• RIGOROUS oversight of complete information for clients
about what can and cant be counted toward deductible,
paid from account is CRITICAL.
• MUST be voluntary.
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Advocates Concerns: DRA, plus other
Options under 1115 Waivers
Beware comparing “Perfect Fantasy”
to Imperfect Reality.
– In 1993, we thought HMOs would solve all our
Medicaid cost problems.
– Good ideas can be tough to implement: IE&E
sounded GREAT on paper!
– MOST waivers and DRA options have NOT
been implemented yet: still fall in the Perfect
Fantasy category.
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Advocates Concerns: DRA, plus other
Options under 1115 Waivers
• WV:
– Children should not be punished for parents’ shortcomings (e.g.,
parent, not child chooses ER; child should not lose benefits for
parental actions).
– Must doctors be “Enforcers”?
• KY:
– Too many different ESI products could be impossible for state to
monitor and guarantee kids get FULL EPSDT benefits
– Concerns about being assigned to “wrong” benefits package, and
ease/speed of transition to “right” one
– Speed of transition back to standard package if ESI benefits are
too limited
• Concerns about Florida Waiver are similar; again, these
initiatives have no real track record yet: Perfect
fantasy….
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