Transcript Medicaid Under Fire: Is the Pressure Going to Let Up?

Figure 1
Getting Ready for Health Reform:
An Overview of Health Coverage
for People with HIV/AIDS
ADAP Advocacy Association
December 4, 2008
Jeffrey S. Crowley, M.P.H.
Senior Research Scholar
Health Policy Institute, Georgetown University
[email protected] / (202) 687-0652
Figure 2
Goals for this session
• Provide a background on how people with HIV/AIDS
obtain health insurance coverage
• Describe the role of private insurance--and key
issues as we approach a national debate on health
care reform
• Describe the role of Medicaid and Medicare and
discuss current policy issues
• Discuss the role of the Ryan White programs in filling
in gaps left by private insurance, Medicaid, and
Medicare
Figure 3
How Americans Obtain Health
Insurance Coverage, 2007
Population = 298 Million
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute
analysis of March 2008 Current Population Survey.
Figure 4
People with HIV/AIDS: Insurance
Coverage (HIVRN), 2002
Of those in care
M edicaid
36%
Uninsure d
29%
Private
17%
Duals
4%
M edicare
14%
SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient
Health Services Utilization Among HIV-Infected Adults in Care 2000-2002, Medical Care, Vol 43
No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006
Figure 5
Health Insurance Coverage of the Low-Income
Nonelderly Population by Race/Ethnicity, 2005
28%
28%
21%
36%
44%
32%
45%
9%
33%
3%
20%
42.8 million
5%
4%
Hispani c
23.7 million
17.8 million
Employer
1%
24%
Afr ican
Amer ican,
Non-Hispani c
M edicaid or
Othe r Public
Indiv idual
35%
33%
32%
White, NonHispani c
49%
22%
10%
Uninsure d
43%
21%
Asian or
Paci fic
Islander
3.8 million
Amer ican
Indian/Alaska
Native
0.9 million
26%
Two or Mor e
Races
1.7 million
Notes: Low-income is defined as family income less than 200% of the federal poverty level, or
$39,942 for a family of four in 2005. Nonelderly includes individuals up to age 65. “Other Public”
includes Medicare and military-related coverage. Data source is the March 2005 Current
Population Survey.
Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates.
Figure 6
Health Insurance Coverage of
Low-Income Adults and Children, 2005
M edicaid/Othe r Public Employer/Othe r Private
Uninsure d
Poor
Children
(<100% Poverty)
Near-Poor
(100-199% Poverty)
Poor
Near-Poor
43%
41%
17%
50%
17%
33%
18%
40%
42%
(<100% Poverty)
Parents
17%
61%
22%
(100-199% Poverty)
Adults
without
children
Poor
(<100% Poverty)
Near-Poor
39%
25%
28%
47%
18%
43%
(100-199% Poverty)
Notes: Medicaid also includes SCHIP and other state programs, Medicare and military-related
coverage. The federal poverty level was $19,971 for a family of four in 2005. Data may not total
100% due to rounding.
Source: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of
March 2006 Current Population Survey.
Figure 7
Non-Elderly Uninsured, by Age
and Employment Status, 2005
At Le ast 1 Full
Time Worker
70%
Adults 19-64
84%
Part Time
Workers
11%
Children 18
and Under
16%
Non Workers
19%
Age
Employment Status
46.1 Million Uninsured
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured
estimates based on the Census Bureau's March 2005 and 2006 Current Population
Survey (CPS: Annual Social and Economic Supplements).
Figure 8
U.S. Population and People with
HIV/AIDS: Income & Unemployment
62%
US Population
45%
People with
HIV/AIDS
8%
5%
Income
<$10,000
Unemploye d
SOURCE: Kaiser Family Foundation based on US Census Bureau, 2006; Kaiser State Health
Facts Online; Cunningham WE et al. “Health Services Utilization for People with HIV Infection
Comparison of a Population Targeted for Outreach with the U.S. Population in Care.” Medical
Care, Vol. 44, No. 11, November 2006. NOTE: US income data from 2005, US unemployment
data from 2006. 1998 estimates were also 8% and 5%, respectively, rounded to nearest decimal;
HCSUS data from 1998.
Figure 9
In & Not in Care: Receipt of HAART by
Those Eligible for HAART, 2003
Of those aged 15-49 estimated
to be eligible for HAART
In Care /
No HAART
15%
In Care /
HAART
55%
Not In Care
30%
SOURCE: Teshale EH et al., “Estimated Number of HIV-infected Persons Eligible for and
Receiving HIV Antiretroviral Therapy, 2003--United States”, Abstract #167, 12th
Conference on Retroviruses and Opportunistic Infections; February 2005.
Figure 10
Dynamics of Health Coverage
• Health insurance coverage is not static
• 45 million uninsured in 2004, vs. 80 million uninsured over
two-year period
• Approximately 2 million Americans lose health insurance
every month – often for a short period
• Coverage options can change with…
–
–
–
–
–
Loss or change of job
Change in family status (e.g. divorce, death of spouse)
Birthday (e.g. 19th)
Move
Change in health status
SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from
www.KaiserEDU.org.
Figure 11
Many Policy Makers Seek to Expand
Access to Private Coverage
…but not all health insurance is created equal
• Employer-sponsored coverage:
– Often comprehensive, but not always
– Variation in benefits covered as well as premium and deductible
costs
• Individually-purchased policies:
– Typically less comprehensive
• Less coverage of maternity, mental health and prescription
drugs
• Can have high deductibles as well
– Generally unavailable or unaffordable to people with HIV/AIDS
SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from
www.KaiserEDU.org.
Figure 12
Health Conditions Denied by
Individual Market Insurers
• Always denied
o Cancer
o HIV/AIDS
o Diabetes
o Multiple Sclerosis
o Pregnancy
o Stroke
• Often denied
o Overweight
o Cancer history
o High blood pressure
o Asthma
• Sometimes denied
o Acne
o Hay fever
Pollitz, K., Sorian, R., and Thomas, K. How Accessible is Individual Health Insurance for
Consumers in Less Than Perfect Health?, Kaiser Family Foundation, June 2001.
Figure 13
Take Aways on Private Insurance
• Private insurance is mainstay of health coverage for most
Americans, but…
– Access, affordability, adequacy of coverage not
guaranteed
– Complex, with high administrative costs
• Difficulty of getting/keeping private coverage increases
with health problems, especially during coverage
transitions
• Regulation to limit risk selection involves tradeoffs: access
vs. adequacy vs. affordability
• Additional public policy responses needed to subsidize
and expand coverage
SOURCE: Karen Pollitz “Private Health Insurance 101” Tutorial, available from
www.KaiserEDU.org.
Figure 14
Public Coverage is Often More Efficient
and Targeted than Private Coverage
Kaiser Commission on Medicaid and the Uninsured (KCMU)
conducted an extensive review of research literature on
health coverage for low-income Americans. Key findings
include:
• Role of Public Coverage: Expanding publicly sponsored
health insurance offers the most targeted and efficient
strategy for expanding health coverage among low-income
populations
• Eligibility: Basing eligibility for publicly sponsored health
coverage on having a low income, without categorical
restrictions, could substantially reduce the number of
uninsured
Americans
SOURCE:
Health Coverage
for Low-Income Americans: An Evidence-Based Approach to
Public Policy, Kaiser Commission on Medicaid and the Uninsured, January 2007.
Figure 15
Role of Public Coverage (continued)
• Use of Premiums: Premiums can be expected to depress
participating among people living at or near poverty
• Use of Cost-Sharing: Even at low levels, cost-sharing can
adversely affect access to care for low-income people
• Scope of Benefits: The relatively poor health status of lowincome Americans, combined with their limited ability to pay
for care out-of-pocket mean that comprehensive benefits are
important to meet the diverse needs of this population
• Financing: A federal-state financing partnership that takes
into account national trends, countercyclical pressures at the
state level, and the federal government’s greater fiscal
capacity could provide a strong and sustainable source
of support for a health coverage program for
low-income Americans
SOURCE: Health Coverage for Low-Income Americans: An Evidence-Based Approach to Public
Policy, Kaiser Commission on Medicaid and the Uninsured, January 2007.
Figure 16
The Institute of Medicine Endorsed
Expanded Public Coverage for HIV/AIDS
• Many individuals with HIV/AIDS experience delays in
treatment access … there are missed opportunities to
reduce mortality, morbidity, and disability among
individuals with HIV infection
• The Committee’s principal recommendation to address
system deficiencies is the establishment of a new federal
program for financing HIV care … the program would
entitle individuals based on HIV infection rather than AIDS,
and by specifying a set of benefits that meet the standard
of care for HIV.
SOURCE: Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White,
Institute of Medicine, 2004.
Figure 17
Key Messages
• The HIV/AIDS community must be part of the campaign to
achieve universal coverage
• Recent state efforts to achieve universal coverage are
encouraging—but likely insufficient
– Federal leadership and new resources are needed
– Close attention to low-income populations is needed
• Access to coverage alone, however, is not a solution
– Coverage also must be adequate and affordable
– Many current state efforts appear to fudge the
affordability issue and do not fully address the
adequacy issue
• Protecting public coverage–as the anchor of the health
system must be a key goal
Figure 18
Medicaid Anchors the Rest of the
Health System
• Nation’s largest health care program in terms of enrollment:
• In FY 2005, covered 59 million low-income Americans
• 29.4 million non-disabled children,
• 15.2 million non-disabled adults,
• 6.1 million seniors, and
• 8.3 million children and adults with disabilities
• Largest source of health coverage for people with HIV/AIDS
(≈195,000 Medicaid beneficiaries with HIV/AIDS, at a federal cost of
$5.4 billion in 2004)
• Provides health and long-term services coverage to 15% of
the U.S. population
SOURCE: Urban Institute analysis of CMS MSIS data for the Kaiser Commission on
Medicaid and the uninsured.
Figure 19
Medicaid Eligibility Pathways for
People Living with HIV/AIDS
Category
Criteria
Mandatory/Optional
SSI beneficiaries
Severely disabled AND low-income
(74% of FPL)
Mandatory
Parents, children, pregnant
women
Low income; income & asset criteria
vary by category & state
Mandatory; states may offer higher
income thresholds
Medically Needy
Severely disabled and low income
(median = 56% of FPL) after subtracting
incurred medical expenses
Optional (35 states use this option for
people with disabilities)
Workers with Disabilities
Severely disabled; low-income; for
persons returning to workforce
Optional
Poverty-level expansion
Allows for income above SSI levels up
to FPL
Optional (19 states use this option)
State Supplementary
Payment (SSP)
Allows for coverage of those receiving
SSP
Optional (21 states use this option)
SOURCE: Kaiser Family Foundation.
Figure 20
Medicaid is a Major Source of
Financing for Health Services
• Second largest health care program (after Medicare) in terms
of spending:
– Federal government matches states spending under a formula
based on state per capita income. Federal share can vary from
50-83% of total costs. In FY 2008, 13 states have a federal
share of only 50%, and MS has the highest match, with the
federal government paying 76.29% of total costs.
– In FY 2006, the program spent $303.9 billion, with the federal
government paying 57% of the cost and the states paying the
remainder.
• Responsible for 15% of national health expenditures in 2006.
SOURCES: Urban Institute analysis for the Kaiser Commission on Medicaid and the Uninsured of CMS64 Reports, July 2007 and National Health Expenditure Accounts, 2008, CMS Office of the Actuary.
Figure 21
Medicaid has a unique role in relation to
private coverage and Medicare
• Catastrophic needs: Assists people with extensive needs
at all stages of life
• Essential public role: Shoulders uniquely public
responsibilities, such as covering children in foster care
• Integrates acute and long-term services: By contrast,
private insurance and Medicare mostly cover acute care or
short-term rehabilitation
• Critical safety net: Private insurance and Medicare not
designed to meet the needs of some populations with
extensive needs
Figure 22
Medicaid Serves a Diverse Population
Percent with Medicaid:
Poor
Near Poor
40%
22%
Families
All Children
26%
Low-Income Children
Low-Income Adults
50%
20%
Births (Pregnant Women)
41%
Seniors and People with Disabilities
Medicare Beneficiaries
People with Severe Disabilities
People Living with HIV/AIDS
Nursing Home Residents
19%
20%
44%
60%
Note: “Poor” defined as <100% of federal poverty level, which was $19,971 for a family of four in
2005.
Source: Estimates by Kaiser Commission on Medicaid and the Uninsured and Urban Institute; birth
data from MCH Update, National Governors Association.
Figure 23
A large share of Medicaid spending
is for dual eligibles
(2003)
Medicaid Enrollment
Long-Term Care
Spending on Other
Groups
Adults
25%
Children
50%
Medicaid Spending
27%
Dual
Eligibles
14%
58%
6%
10%
Other
Acute Care
6%
Prescription
Drugs
Medicare Premiums
Other Aged &
Disabled
Total = 51 Million
2%
Total = $232.8 Billion
(42% on Duals)
SOURCE: Kaiser Commission on Medicaid and the Uninsured estimates based on CMS
data and Urban Institute analysis of data from MSIS.
Figure 24
Small Share of Population Accounts for
Large Share of Expenditures
<$25,000
in Costs
52%
<$25,000
in Costs
96%
>$25,000 in
Costs
Children 3%
Adults 1%
Disabled
25%
>$25,000 in
Costs
3.6%
Children 0.2%
Adults 0.1%
Disabled 2%
Elderly 2%
Elderly
20%
Enrollees
Total = 46.9 million
Expenditures
Total = $180.0 billion
SOURCE: Sommers and Cohen, Medicaid’s High Cost Enrollees: How
Much Do They Drive Program Spending? Kaiser Commission on Medicaid
and the Uninsured, March 2006. Based on MSIS 2001 data.
49%
Figure 25
Medicare Today
• Covers 44 million people
– ~37.4 million seniors
– ~6.6 million non-elderly people with disabilities
– Second largest source of HIV/AIDS coverage (≈85,000 Medicare
beneficiaries with HIV/AIDS, includes ≈ 55,000 dual eligibles; at a
cost of ≈ $2.5 billion in 2004)
• Net Federal cost of $459.4 billion in 2008
• Program now has 4 parts A,B,C, and D
– Part A – Hospital and skilled nursing care
– Part B – Physician and outpatient hospital care
– Part C – Medicare Advantage (voluntary managed care alternative
to Parts A and B)
– Part D – Outpatient prescription drug coverage
Source: CBO Medicare Baseline, March 2008.
Figure 26
Medicare Eligibility Pathways for
People Living with HIV/AIDS
Category
Criteria
Individuals age 65 and over
Sufficient number of work credits to qualify for
Social Security payments
Individuals under age 65 with
permanent disability
Sufficient number of work credits to qualify for
SSDI payments due to disability; also includes
spouses and adults disabled since childhood
Have been receiving SSDI payments for at least
24 months
Individuals with End-Stage Renal
Disease, any age
SOURCE: Kaiser Family Foundation.
Sufficient number of work credits to qualify for
Social Security payments
Figure 27
Qualifying for Medicare
Individuals under age 65 can qualify for Medicare on the basis
of disability if they have a sufficient work history and after a
waiting period
1.
SSA determines that an individual has a disability;
2. To ensure that disability is permanent or long-lasting,
individuals must then wait 5 months before they start
receiving SSDI;
3. Starting when they first receive SSDI, individuals must wait
an additional 24 months to start receiving Medicare
Individuals with disabilities since childhood can receive
Medicare based on the work history of a parent. These
individuals are called disabled adult children (DACs), and
are subject to the 24 month waiting period when they turn 18
(or develop a disability before age 22)
Figure 28
Medicare Covers a Population with
Diverse Needs and Significant Vulnerabilities
Percent of Total Medicare Population:
Low-Income <150% FPL
($14,700 in 2006)
39%
35%
3+ Chronic Conditions
Fair/Poor Health
Cognitive/Mental Impairment
Enrolled in Medicaid
(“Dual Eligibles”)
Under-65 Disabled
Age 85+
Nursing Home Resident
SOURCE: Medicare Current Beneficiary Surveys 2003 and 2002.
31%
27%
Figure 29
MMA Out-of-Pocket Drug Spending in
2008
Out-of-Pocket
Spending
Individual Pays 5%
Catastrophic
Coverage
Medicare Part D
Benefit
Plan Pays 15%
Medicare Pays 80%
No
Coverage
$3,216 Gap
$5,726
(equivalent to $4,050 in
out-of-pocket spending)
$2,510
Partial
Coverage
up to Limit
Deductible
25%
Plan Pays 75%
$275
Ne w Medicare Legislation
+ ~$304 in annual premiums
SOURCE: Kaiser Family Foundation.
Figure 30
Limitations of Medicare
In addition to prescription drug affordability issues, gaps in
Medicare coverage that shift costs and responsibilities onto
Medicaid and Ryan White include:
– Long-term services and supports
– Dental care and dentures
– Hearing aids
– Routine eye care and eyeglasses
– Routine foot care
– Limited mental health services
Figure 31
Thoughts on Expanding Health
Insurance Coverage
• Efforts to expand access to health coverage—and achieve
universal coverage—are important
• Recent state efforts to achieve universal coverage are
encouraging—but likely insufficient
– Federal leadership and new resources are needed
– Close attention to low-income populations is needed
– Focus has been on working people, with little to no
attention on needs of people with chronic conditions
• Access to coverage alone, however, is not a solution
– Coverage also must be adequate and affordable
– Many current state efforts appear to fudge the
affordability issue and do not fully address the
adequacy issue
Figure 32
In Any Reformed Health System, the
Ryan White Programs Are Still Needed
• The Ryan White programs fill in gaps left by private coverage,
Medicaid, and Medicare
• If a major universal coverage initiative were enacted, the gaps
to be filled by Ryan White programs may change, but these
programs would still be necessary
• Nearly all universal coverage initiatives are predicated on
building on existing financing and delivery systems—i.e. they
assume the Ryan White programs are here to stay
• Nearly all so-called universal coverage proposals leave gaps
related to HIV/AIDS care: consider access, adequacy,
and affordability
Figure 33
Will we be on offense or defense
in the coming year?
—Reform and expansion or retrenchment?
• Many believe that universal coverage will be built on three
legs: bolstering existing employer-sponsored insurance,
asking individuals to fairly contribute to the cost of their
care, and targeting expansions of public programs for lowincome and costly/complex populations
• Severe economic downturn will likely lead to temporary
increase in Medicaid FMAP (Many policy makers would
prefer to build this into law to deal with counter-cyclical
nature of program)
• As states face budget pressures and cut back, we will
likely hear Medicaid scapegoated
Figure 34
Medicaid Issues to Consider
Medicaid’s Role in the Broader Health System
• Remove categorical distinctions and cover all poor people or all
poor seniors and people with disabilities?
• Re-think medically needy coverage to better permit people with
catastrophic needs to spenddown into Medicaid?
Flexibility versus Uniformity
• Is the current variation across states acceptable?
• How do we improve the delivery system across 50+ programs?
Long-Term Services Policy and Medicare
• Medicaid is our de facto national long-term care program, not
intended to play this role—how do we expand other sources of
financing for long-term care?
• How do we rebalance LTC to expand community services?
• What is the proper responsibility of Medicaid for Medicare
beneficiaries (huge burden from waiting period and LTC)
Figure 35
Medicare Issues to Consider
Does the program match the populations it serves
• Is the benefits package appropriate for a population of seniors and
people with disabilities?
• Can modest changes be made to meet LTC needs?
Financing
• How do we deal with cost pressures and demographic change?
• Do we believe the program is too generous or do we need to
broaden financing?
• Leveling the playing field between traditional Medicare and
Medicare Advantage
Delivery system improvements
• How do we adopt evidence-based practices and new technology?
• What are model approaches for integrating care for duals?
Figure 36
Opportunities in Health Reform
• Major role for the HIV/AIDS community: There are
significant efforts underway to enact major health reform
legislation. Many people want to assume people with
disabilities are protected. HIV/AIDS advocates need to fight
for a role in the debate.
• Potential to expand Medicaid eligibility: Policy makers
are considering options ranging from moving all people into
private coverage and eliminating Medicaid to expanding
Medicaid to all low-income people without categorical
distinctions.
• Need to tell policy makers why Medicaid often works
better than private insurance: Policy makers do not
understand Medicaid’s unique roles. We must tell the good
news story about how Medicaid can be improved, but
that it works.