Transcript Title
PRELIMINARY DRAFT
Behavioral Health Transformation
March 15, 2014
PRELIMINARY WORKING DRAFT, SUBJECT TO CHANGE
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Today, we face major health care challenges in Arkansas
▪ The health status of Arkansans is poor: the
state is ranked at or near the bottom of all states
on national health indicators
▪ The health care system is hard for patients to
navigate, and it does not reward providers who
work as a team to coordinate care for patients
▪ Health care spending is growing
unsustainably:
– Insurance premiums doubled for employers
and families in past 10 years (adding to
uninsured population)
– Often unnecessary costs are created in
Medicaid due to duplication of services and
lack of care coordination
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There are many challenges specifically within the current behavioral
health system
Current challenges
Prevention
▪ Awareness of available services can be improved
▪ Gaps in services for behavioral health needs (mental health and
▪
Early intervention
substance abuse)
Need for additional training programs
▪ Gaps in early intervention services, including crisis intervention
▪ Existing early intervention can be enhanced
▪ Areas for improvement in current referral and awareness programs
▪ Gaps in current treatment delivery system (inc. provider training
Treatment
Recovery /
resilience
and workforce limitations)
Treatment is not always delivered in a guideline concordant manner
Care integration and coordination is limited
Outcomes are not tracked effectively
▪
▪
▪
▪ There are gaps in the ways providers address recovery and
▪
▪
Screenings and
assessments
resilience today
Opportunity to improve consistency in existing recovery / resilience
efforts
Consumer, peer, family, and community supports are not always
leveraged most effectively
▪ Inconsistent screening and assessment process
▪ Need to improve the use of data
▪ Arkansas has a high prevalence of SED/SMI designations
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Key facts in behavioral health for the Medicaid population
Early facts in Arkansas
Definitions of key terms
Total Medicaid behavioral
health beneficiaries
~110,000
recipients
“Core” behavioral health
spend (38% IP, 62% OP)
~$550 M
“Halo” spend
~$380 M
Pharmacy spend of
behavioral health clients
(BH and halo)2
~$150 M
“Core” behavioral health spend1:
▪ Includes behavioral health
services delivered to the client,
(e.g., services for ADHD or
depression)
▪ Does not include direct dementia
or DD costs, but does includes
BH spend from these populations
Halo:
▪ Includes non-behavioral health
services (e.g., medical, support
services) delivered to people who
also use BH services
NOTE: Does not include those funded solely from state general revenue. Analysis underway to incorporate broader behavioral health programs
1 Details of BH spend: ICD9 291 – 314 excluding autism (299) and dementia codes in 294, excludes pharmacy
2 Pharmacy includes some spend from some DD and dementia clients that has not yet been excluded
SOURCE: 2011 Medical claims for behavioral health diagnosis codes. Does not include pharmacy, crossover or third party liability
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Behavioral health core spend is concentrated amongst the highest need
clients
Distribution of clients1,2 by cost of core care for behavioral health
Millions of dollars
Youth3
Adults
200
52% of total
costs are
covered by the
top 5% of
clients
155
81% of total costs
are covered by the top
20% of clients
53
Each bar represents:
5% of clients
~5,000 clients
2
1
5% least costly clients
3
1
34
19
41
25
3
45
29
11 14
21
4 5 6 8
9 12 16 4 5 12
6
4
3
1 1 2 2 2 3
5% most costly clients
1 Includes all clients with at least one core related claim
2 Excludes clients with DD and LTSS because this group is likely to have multiple health home options
3 Youths are clients<21 years of age; Adults are clients ≥ 21 years of age
SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims
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Diagnostic profiles for adult BH clients by level of core spend
Breakdown of diagnoses by behavioral health spend rank for adults in top 50% of core spend
Percentage, Number of clients = 10,303 1
Core
spend
rank (05% = top) Adults
0 – 5%
Schizophrenia
Other
Anxiety / phobia
Bipolar
Adj. Disorder
ADHD
Depression
SA
ODD
Unspecified
PTSD
68
13
40
5 - 10%
20
27
10 - 15%
22
23
15 - 20%
20 - 25%
20
25 - 30%
21
30 - 35%
19
35 - 40%
19
40 - 45%
16
45 - 50%
14
21
27
19
19
18
1,300
8
4 32
1,023
6 2 4 2 718
6 4 22
7
30
9
21
29
7
23
31
17
6 2
8
33
22
9
8
7
30
11
7
692
5 4 2 773
9
4 5 2
6
5 3 3 2 956
▪
Majority of top 5% adults
have a diagnoses of
schizophrenia
834
6 3
2 1,223
29
10
9
7 2
3 1,298
31
10
8
6 4
3 1,478
1 Excludes clients with DD and LTSS because this group is likely to have multiple health home options
SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and
crossover claims; each client must have at least one core related claim
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Diagnostic profiles for youth BH clients by level of core spend
Breakdown of diagnoses by behavioral health spend rank for youth in top 25% of core spend
Percentage, Number of clients = 18,605 1,2
Core
spend
rank
0 – 5%
ADHD
Bipolar
Adj. Disorder
ODD
Other
Schizophrenia
Unspecified
Anxiety / phobia
Substance abuse
Depression
PTSD
Youths
13
20
28
11
14
5 - 10%
38
13
18
8
4
10 - 15%
38
13
16
9
3 5
15 - 20%
37
20 - 25%
35
▪
▪
12
11
17
16
3 5
9
10
2 5
3 2 2 3,321
5
5
10
2 2 3,598
10
1 3 3,903
12
14
1 4 3,932
2 5 3,851
Both ADHD and ODD will be covered by episodes
Over 1,000 clients in top 5% of spend are diagnosed with
ADHD or ODD
1 Excludes clients with DD and LTSS because this group is likely to have multiple health home options
2 Youths are clients<21 years of age; Adults are clients ≥ 21 years of age
SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and
crossover claims; each client must have at least one core related claim
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Our vision to improve care for Arkansas is a comprehensive,
patient-centered delivery system
Improve the health of the population
For
patients
▪
▪
▪
For
providers
▪
▪
Reward providers for high quality, efficient care
Objectives
How care is
delivered
Five
aspects of
broader
program
Focus today
Enhance the patient experience of care
Enable patients to take an active role in their care
Reduce or control the cost of care
Population-based care
▪ Medical homes
▪ Health homes
Episode-based care
▪ Acute, post-acute, or
select chronic conditions
▪
Results-based payment and reporting
▪
Health care workforce development
▪
Health information technology (HIT) adoption
▪
Consumer engagement and personal responsibility
▪
Expanded coverage for health care services
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Potential payment initiatives to address issues within the BH system
Initiative
1
Health homes (& link to medical
homes)
Description
Focus today
PRELIMINARY
Deliver integrated care management to facilitate quality care and positive
outcomes through:
– Ensuring effective treatment of BH conditions
– Integrating care coordination across BH, medical, developmental
disabilities, and long-term supports
Episode-based care delivery
Increase adoption of evidence-informed practices by creating
accountability for all services related to a specific BH condition (e.g.,
ADHD, and potentially ODD, depression and bipolar disorder)
Reimbursement adjustments
Modify reimbursement rules to encourage appropriate diagnosis and
utilization of services (e.g., placing appropriate time limits on
unspecified diagnoses)
4
Reimbursement for new services
Add reimbursement for selected new services that are known to be costeffective and evidence-informed (e.g., crisis intervention, substance
abuse treatment services, medication management and communitybased services)
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Reimbursement for pharmacy
(including polypharmacy)
Build on recent work in pharmacy management utilization rules to ensure
appropriate use of medications (includes polypharmacy, therapy
interactions, and dosage)
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Policy changes/enabling
initiatives
Develop policy changes or initiatives that enable or compliment the
payment initiatives (e.g., changes to certifications for all BH providers,
specialty certifications, new screenings)
2
3
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Contents
▪
Behavioral health homes
▪
Proposed behavioral health services
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Health Home Model
What is a health home?
The Affordable Care Act of 2010, Section 2703, created an
optional Medicaid State Plan benefit for states to establish
Health Homes to coordinate care for people with Medicaid
who have chronic conditions by adding Section 1945 of the
Social Security Act. CMS expects states health home
providers to operate under a “whole-person” philosophy.
Health Homes providers will integrate and coordinate all
primary, acute, behavioral health, and long-term services and
supports to treat the whole person.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html
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Goals of the behavioral health home
PRELIMINARY
To deliver integrated care management in a manner
that facilitates quality care and positive outcomes
through:
Providing care coordination
▪ Providing clients with integrated care coordination
within and across BH, medical health, developmental
disabilities, long-term supports, and other systems
Managing core care delivery
▪ Ensuring effective treatment of behavioral health
conditions, including pharmacy effects
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Guiding principles for health home development
Health homes must address comprehensive needs of individuals by
utilizing a “whole person” and “person centered” approach while
ensuring personal choice assurances through service planning and
delivery
Health homes will provide services that address issues of access to
care, accountability, and active participation on behalf of both
providers and individuals/families receiving services, continuity of
care across all medical, behavioral, and social supports, and
comprehensive coordination/integration of all needed services
Health homes will provide services that seek to align a fragmented
system of needs assessment, service planning, care management,
transitional care, and direct care service delivery
Health homes must demonstrate the use of health information
technology as a means to improve service delivery and health
outcomes of the individuals served
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Introduction to a health home
What a BH health home is…
▪ A behavioral health agency
▪ Extra support for people who need an
increased level of care management or who
face greater challenges in navigating the
healthcare system
▪ Enhanced support for clients who have
needs in multiple areas, including DD,
LTSS, housing, justice system, etc.
▪ Opportunity to promote quality in the core
What a BH health home is not…
▪ NOT a direct provider of medical services
▪ NOT a gatekeeper restricting a client’s
choice of providers
▪ NOT a physical “house” where all health
home activities take place
▪ NOT an organization that is required to
contract with other providers (e.g., medical
providers) to serve their clients
provision of behavioral health care
▪ Encourage providers to work in teams to
improve outcomes for the clients
▪ A way of aligning financial incentives
around evidence-informed practices,
wellness promotion, and health outcomes
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The new behavioral health system will be conscious of varying
ILLUSTRATIVE
severity of needs as well as intensity of care management
Care managed by health
required for the different tiers BH client population
homes
Care mgmt.
performed by PCMH
Care mgmt.
performed by BHH
Health home
PCMH
BH
provider
PCMH
BH
provider
Intensive care
mgmt. performed by BHH
Health home
PCMH
BH
provider
Prevention
Prevention
Prevention
Recovery
Recovery
Recovery
Tier 1 (low-needs)
PCMH care mgmt.
adequate for BH care
Tier 2 (medium-needs)
BHH required to manage
frequent BH services
Tier 3 (high-needs)
BHH intensely manages
BH & support services
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1IP=Inpatient OP= Outpatient; SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Example profiles of children in different tiers
ILLUSTRATIVE
Tier 1 client: Ben
Ben, age 6, has been
diagnosed for 1 year with level I
ADHD.
Ben’s family is engaged in
treatment and he resides with
his family including one sibling.
Ben’s performance in school
has been average and he
meets the typical cognitive
development of a 6 year old.
Ben is known to be easily
distracted in school, tends to be
the class clown, and he has
difficulty keeping friends. He is
generally friendly but he is often
impulsive and socially
immature. His teacher has
reported some improvement in
his behavior over the past few
months.
Tier 2 client: Tom
Tom, age 8, has been
diagnosed comorbid for 2 years
with depression and ODD.
Tom continues to display very
oppositional behavior at home
and school which is beginning
to impact academic
performance and result in
disciplinary issues.
Tom’s family is very involved in
his treatment, regularly
attending family therapy
sessions with Tom’s therapist.
However, the family has not
been successful in
implementing therapeutic
strategies in the home.
Tom’s parents would like
additional supports in the home
and teacher supports and
education in the school.
Tom’s therapist and his parents
agree he does not need to be
placed in a residential treatment
facility.
Tier 3 client: Annie
Annie, age 14, has been
diagnosed with Bipolar Disorder
and presents with oppositional
symptoms as well. She has
recently started to make
suicidal statements.
Annie is currently living in foster
care and has been with her
current family for 2 years.
Annie has had multiple acute
inpatient stays in the recent
months due to her suicidal
threats.
Annie’s academic performance
has also significantly declined
over the past 2 years.
Annie’s family service worker
and her therapist are
considering admission into a
psychiatric residential treatment
facility.
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Example profiles of adults in different tiers
ILLUSTRATIVE
Tier 1 client: George
George, age 26, was diagnosed
with depression 2 years ago.
George had previously been in
a Tier 2 health home but has
greatly improved.
George now manages his
depression through regular
medication appointments and
occasional clinic-based therapy
appointments; he does not need
a case manager.
George is living independently
and maintaining a steady job.
Tier 2 client: Roy
Roy, age 32, has been
diagnosed with depression and
drug addiction, but he is on a
path of recovery.
During his recovery, Roy
experienced a crisis event. He
relapsed, lost his job, and lost
his apartment. He was
undergoing intensive outpatient
substance abuse treatment at
the time of his relapse.
Roy and his therapist are of the
opinion that his recovery would
likely be successful if he was
provided with the opportunity to
enter a partial hospitalization
program and had a peer
specialist working with him in
the community.
Tier 3 client: Liz
Liz, age 44, has been diagnosed
with schizophrenia and has
substance abuse issues.
Liz had recently been
hospitalized and she is currently
in a residential substance abuse
program.
Liz needs ongoing behavioral
health and substance abuse
treatment after she discharges
from residential treatment.
Liz will also need housing
support, assistance with her
budget, and help meeting her
nutritional needs including meal
planning.
Liz has a history with the
criminal justice system and is at
risk of returning to jail is she
relapses.
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Tier 2 and 3 clients will receive care management services
from health homes
Care
management
Care
plan
support
activities
Comprehensive
transitional care
Care coordination
Health promotion
Support services
▪TextSupport and enable
▪ Arrange for /
▪ Match individuals ▪ Establish process to
▪
▪
▪
▪
care plan adherence by
providing assistance
with referrals,
scheduling and getting
to appointments, etc.
Regularly check-in with
client to understand
barriers to plan
adherence
Maintain client
documentation
Monitor chronic disease
indicators and
performance metrics
Integration of care
plans across systems
▪
provide clientspecific health
education
services
Educate and
support client on
selfmanagement
plans and routine
clinical care
▪
(and families) to
support services
and advocate on
their behalf for
participation
Maintain
awareness of
and interact with
key services to
ensure they are
meeting client
needs
▪
▪
▪
ensure prompt
informing on unplanned
care
Coordinate and share
transition planning with
relevant coordinators
Provide regular
education on client
access to services,
especially at transition
points
Develop crisis
intervention plan,
including creating
options for increased
access
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Contents
▪
Behavioral health homes
▪
Proposed behavioral health services
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Guiding principles for Behavioral Health system changes
We will optimize our system to ensure that behavioral health care…
Is family/consumer-driven and person-centered;
Supports and promotes evidence-based, recovery-oriented practices that
guide service delivery and payment efficiency;
Provides customized, culturally and linguistically competent, communitybased services;
Offers the least restrictive care;
Utilizes a team-based approach to treatment decisions to address service
needs; and
Ensure services are high quality based on data from outcomes and
evaluation tools
These principles will support our “Triple Aim” of improving health,
increasing quality, and lowering the growth of health care costs.
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1915(i) and Home and Community Based Services
This Federal state plan option allows states to offer Home and
Community Based Services under a Medicaid state plan to
individuals who are Medicaid-eligible.1
With the intent of improving 1915(i) home and community based
services, the ACA broadens the scope of covered services and
requires services be provided statewide with no waiting lists.
New community and evidence-based practices will be reimbursed
through the 1915(i)1 Medicaid funding mechanism
1915(i) allows drawing down federal funds to support reimbursement
of needed services for the first time
Benefits can be targeted to a specific population, services can differ in
amount, duration, and scope
1 States have the option to offer home and community-based services (HCBS) as part of the state plan benefits package, as authorized by the
Deficit Reduction Act (2005), which added § 1915(i) of the Social Security Act (SSA). Prior to § 1915(i), states could receive federal Medicaid
matching funds for HCBS only through waiver or demonstration projects.
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In addition to care management, the new behavioral health system will
reimburse new, tier-specific services to deliver necessary care
New community and evidence-based
practices will be reimbursed through the
1915(i)1 Medicaid funding mechanism
1915(i) allows drawing down federal funds
to support reimbursement of needed
services for the first time
Benefits can be targeted to a specific
population, services can differ in amount,
duration, and scope
1 This Federal state plan option allows states to offer Home and Community Based Services under a Medicaid state plan to individuals who are
Medicaid-eligible.
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1915(i) requires an Independent Assessment and Individualized Care Plan
Requirements
Independent
Assessment
Face-to-face
Determines necessary level of services & supports
Evaluates functional needs
Consults individual as well as family/significant others & treating
providers as well as individual
Reviews patient history
Establishes individualized plan of care
Integrated
Care Plan
Person-centered care plan development
Based on the independent assessment
Developed in consultation with individual, treating providers or others
Identifies necessary home & community based services to be delivered
Should prevent inappropriate care
Beneficiaries must be re-evaluated at least every 12 months to see if
service needs have changed
Provider of the services may not conduct evaluation, assessment or
care plan development
SOURCE: Medicaid CHIP Program Documentation; www.medicaid.gov
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Referral
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This integrated system includes health homes, behavioral health
services, independent assessments and care plans
BH client population
ILLUSTRATIVE
Independent
Assessment
Report
Independent
assessment
Integrated
Care plan
Care mgmt.
performed by PCMH1
Care mgmt.
performed by BHH2
Intensive care
mgmt. performed by BHH
Health home
PCMH1
BH
provider
PCMH1
BH provider
PCMH1
Prevention
Prevention
Tier 1 PCMH1 care mgmt.
adequate for BH care
Tier 1 - Total: ~90,000
Tier 2 - Total: ~10-15,000
Tier 3 - Total: ~5,000
Recovery
Tier 2 BHH2 required to manage
frequent BH services
Population by Tier
BH provider
Prevention
Recovery
Recovery
1 Patient centered medical home
2 Behavioral health home
Health home
Tier 3 BHH2 intensely manages
BH & support services
Core Spend by tier
70% youth
82%youth
72%youth
30%adult
18%adult
28% adult
Tier 1 - 79%OP
Tier 2 - 83%OP
Tier 3 - 44%OP
21% IP
17% IP
56% IP
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Preliminary: new behavioral health services to be offered
BH client population
Existing Services
Expanded Services
Proposed Services (including 1915i)
Tier 1
Clinic-Based
Individual behavioral health counseling
Group behavioral health counseling
Marital/family behavioral health counseling
Multi-family behavioral health counseling
Psychoeducation
Mental health diagnosis
Interpretation of diagnosis
Substance abuse assessment
Psychological evaluation
Psychiatric assessment
Pharmacologic management
Tier 21
Tier 31
Includes low needs services +…
Includes medium needs services +…
Home/Community-Based
▪ Master treatment plan
▪ Home and community individual
psychotherapy
▪ Community group psychotherapy
▪ Home and community marital/family
psychotherapy
▪ Home and community family
psychoeducation
▪ Partial hospitalization
▪ Peer support
▪ Family support partners
▪ Behavioral assistance
▪ Intensive outpatient substance abuse
treatment
▪ Aftercare recovery services
Home/Community-Based
▪ Individual life skills development
▪ Group life skills development
▪ Child and youth support services
▪ Individual recovery support
▪ Group recovery support
Residential
▪ Planned respite
▪ Residential treatment unit and center
▪ Crisis residential treatment
▪ Therapeutic communities
Clinic/Home/Community-Based
▪ Psychiatric diagnostic assessment
Health Home services available in Tiers 2 & 3
Care management (Tier 2)
Crisis services available to all Tiers1
Acute psychiatric hospitalization
Mobile response and crisis stabilization
Intensive care management (Tier 3)
Wraparound facilitation (Tier 3)
Acute crisis units
Substance abuse detoxification
1 Services are cumulative; any service available in Tier 1, will also be available in Tiers 2 and 3. Similarly, any service available in Tier 2 will also be available in Tier 3 24
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2011 (Pre-Reform)
Medicare w/Coverage
Disability
Arkansas Health Insurance
Availability
Employer-Based Coverage or
Private Plan
Income
400%
FPL
300%
FPL
>60% of all
AR children
200%
FPL
ARKids
First B
133% FPL
100%
FPL
ARKids
First A
(Medicaid)
(Medicaid)
0
10
Medicare
Medicare
Medicare
Uninsured: ~500,000
>60% of all AR
pregnancies
Medicaid for
Pregnant
Women/Family
Planning
Medicaid w/Disability
20
30
40
50
60 65 70
Age
25
January 1, 2014 (Marketplaces Operational)
Arkansas Health Insurance
Coverage Availability
Medicare w/ Disability
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Medicare w/Disability
Employer-Based Coverage, Private Plan
Income
400%
FPL
Employer-Based Coverage or
Marketplace Plus Tax Credits
19-26
(sliding scale)
300%
FPL
yrs of
150,000age
- 200,000
Lives Covered
~$1.5 Billion Estimated New Federal
Dollars for Arkansas
200%
FPL
ARKids
First B
133% FPL
100%
FPL
ARKids
First A
(Medicaid)
(Medicaid)
0
10
Pregnant
Women/Family
Planning
Medicare
Medicare
Medicare
Private Insurance
Private Insurance
Medicaid Expansion
250,000Medicaid
Lives Covered
Expansion
$1 - $1.5 Billion Federal per Year
Medicaid w/Disability
20
30
40
50
60 65
70
Age
26
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QUESTIONS
27
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THANK YOU
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