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Medicaid and the Uninsured

Figure 0
Medicaid: The Basics
Diane RowIand, Sc.D.
Executive Director
Kaiser Commission on Medicaid
and the Uninsured
and
Executive Vice President
Kaiser FamiIy Foundation
June 2005
KaiserEDU.org TutoriaI
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Medicaid and the Uninsured
Figure 1
Medicaid's Origin
W Enacted in 1965 as companion IegisIation to
Medicare (TitIe XIX)
W EstabIished an entitIement
W Provided federaI matching grants to states to
finance care
W Focused on the weIfare popuIation:
SingIe parents with dependent chiIdren
Aged, bIind, disabIed
W IncIuded mandatory services and gave states
options for broader coverage
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Medicaid and the Uninsured
Figure 2
Medicaid Today
W Medicaid provides heaIth and Iong-term care
coverage for over 52 miIIion Iow-income peopIe:
Comprehensive, Iow-cost heaIth coverage for 39
miIIion peopIe in Iow-income famiIies
Acute and Iong-term care coverage for over 13
miIIion eIderIy and persons with disabiIities,
incIuding over 6 miIIion Medicare beneficiaries
W Guarantees entitIement to individuaIs and federaI
financing to states
W FederaI and state expenditures of $300 biIIion-with
federaI government funding 57%
W Pays for nearIy 1 in 5 heaIth care doIIars and 1 in 2
nursing home doIIars
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Medicaid and the Uninsured
Figure 3
Medicaid's RoIe for SeIected PopuIations
Note: "Poor is defined as living below the federal poverty level -
$14,680 for a family of three in 2003. SOURCE: KCMU, KFF, and
Urban nstitute estimates; Birth data: NGA, MCH Update.
60%
44%
19%
50%
18%
20%
26%
40%
37%
21%
Percent with Medicaid Coverage:
FamiIies
Aged & DisabIed
Poor
Near Poor
All Children
Low-ncome Children
Low-ncome Adults
Births (Pregnant Women)
Medicare Beneficiaries
People with Severe Disabilities
People Living with HV/ADS
Nursing Home Residents
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Medicaid and the Uninsured
Figure 4
Minimum Medicaid EIigibiIity LeveIs, 2004
133% 133%
100%
42%
74%
0%
0%
100%
200%
Pregnant
Women
Pre-SchooI
ChiIdren
SchooI-
Age
ChiIdren
Parents EIderIy and
IndividuaIs
with
DisabiIities
ChiIdIess
AduIts
Note: The federal poverty level was $9,310 for a single person
and $15,670 for a family of three in 2004.
SOURCE: Cohen Ross and Cox, 2004 and KCMU, Medicaid
Resource Book, 2002.
Income eIigibiIity IeveIs as a percent of the FederaI Poverty LeveI:
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Medicaid and the Uninsured
Figure 5
Medicaid Benefits
W Physician services
W Laboratory and x-ray services
W Inpatient hospitaI services
W Outpatient hospitaI services
W EarIy and periodic screening,
diagnostic, and treatment
(EPSDT) services for
individuaIs under 21
W FamiIy pIanning
W RuraI and federaIIy-quaIified
heaIth center (FQHC) services
W Nurse midwife services
W Nursing faciIity (NF) services
for individuaIs 21 or over
W Prescription drugs
W CIinic services
W DentaI services, dentures
W PhysicaI therapy and rehab services
W Prosthetic devices, eyegIasses
W Primary care case management
W Intermediate care faciIities for the mentaIIy
retarded (ICF/MR) services
W Inpatient psychiatric care for individuaIs
under 21
W Home heaIth care services
W PersonaI care services
W Hospice services
"Mandatory" Items and Services "OptionaI" Items and Services
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Medicaid and the Uninsured
Figure 6
Medicaid Expenditures by Service, 2003
TotaI = $266.1 biIIion
SOURCE: Urban nstitute estimates based on data from CMS (Form 64),
prepared for KCMU.
Inpatient HospitaI
13.6%
Physician/ Lab/
X-ray 3.7%
Outpatient/CIinic
6.7%
Drugs 10.0%
Other Acute 6.3%
Payments to MCOs
15.6%
Nursing
FaciIities 16.8%
ICF/MR 4.4%
MentaI HeaIth 1.8%
Home HeaIth and
PersonaI Care 13.0%
Payments to Medicare
2.3%
DSH Payments
5.4%
Acute
Care
58.2%
Long-
Term
Care
36.0%
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Medicaid and the Uninsured
Figure 7
EnroIIees Expenditures
Medicaid EnroIIees and Expenditures
by EnroIIment Group, 2003
Note: Total expenditures on benefits excludes DSH payments.
SOURCE: KCMU estimates based on CBO and OMB data,
2004.
ChiIdren 19%
EIderIy
26%
DisabIed
43%
AduIts 12%
ChiIdren
48%
EIderIy
9%
DisabIed
16%
AduIts
27%
TotaI = 52.4 miIIion TotaI = $252 biIIion
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Medicaid and the Uninsured
Figure 8
Medicaid Payments Per EnroIIee
by Acute and Long-Term Care, 2003
ChiIdren AduIts DisabIed EIderIy
$1,700
$1,900
$12,300
$12,800
SOURCE: KCMU estimates based on CBO and Urban
nstitute data, 2004.
Long-Term
Care
Acute
Care
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Medicaid and the Uninsured
Figure 9
FederaI MedicaI Assistance
Percentages (FMAP), FY 2005
50 percent (13 states)
61 to <71 percent (15 states & DC)
51 to <61 percent (13 states)
71 + percent (9 states)
SOURCE: Federal Register, December 3, 2003
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Medicaid and the Uninsured
Figure 10
16%
28%
16%
37%
40%
61%
43%
26%
51%
20%
42%
16%
40%
46%
33%
43%
17%
23%
Medicaid/Other PubIic EmpIoyer/Other Private Uninsured
Poor
Near-Poor
(<100% Poverty)
(100-199% Poverty)
Poor
Near-Poor
(<100% Poverty)
(100-199% Poverty)
Poor
Near-Poor
(<100% Poverty)
(100-199% Poverty)
ChiIdren
Parents
AduIts
without
chiIdren
Note: Medicaid/Other Public includes SCHP and other state programs,
Medicare, and military-related coverage. The federal poverty level was
$14,680 for a family of three in 2003. SOURCE: KCMU and Urban
nstitute analysis of March 2004 Current Population Survey.
Medicaid's RoIe for ChiIdren and AduIts, 2003
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Medicaid and the Uninsured
Figure 11
Medicaid's Impact on Access to HeaIth Care
13%
16%
6%
7%
20%
5%
30%
41%
24%
Medicaid Private Uninsured
Percent Reporting
Did Not Receive
Needed Care
No Pap Test in
Past Two Years
No ReguIar Source of
Care
AduIts Women ChiIdren
SOURCES: The 1997 Kaiser/Commonwealth National Survey of
Health nsurance; Kaiser Women's Health Survey, 2004; Dubay and
Kenney, Health Affairs, 2001.
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Medicaid and the Uninsured
Figure 12
Medicaid EnroIIees are Poorer and Sicker Than
The Low-Income PrivateIy Insured PopuIation
61%
48%
69%
16% 15%
27%
0%
25%
50%
75%
100%
Percent of EnroIIed AduIts:
Poor HeaIth Conditions
that Iimit work
Fair or Poor
HeaIth
SOURCE: Coughlin et. al, 2004 based on a 2002 NSAF
analysis for KCMU.
Medicaid
Low-Income and
PrivateIy Insured
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Medicaid and the Uninsured
Figure 13
Average AnnuaI Medicaid Spending
Growth Compared to Growth in Private
HeaIth Spending, 2000-2003
6.9%
9.0%
12.6%
Medicaid Acute Care
Spending Per
EnroIIee
HeaIth Care Spending
Per Person with
Private Coverage
1
MonthIy Premiums
For EmpIoyer-
Sponsored Insurance
2
SOURCES:
1
Strunk and Ginsburg, 2004.
2
Kaiser/HRET Survey, 2003.
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Medicaid and the Uninsured
Figure 14
Other
Medicare
Beneficiaries
32.4 MiIIion
82%
FuII DuaI
EIigibIes
6.1 MiIIion
15%
PartiaI DuaI
EIigibIes
1.1 MiIIion
3%
TotaI Medicare Beneficiaries =
40 miIIion
SOURCE: KCMU estimates based on CMS data and
Urban nstitute analysis of data from MSS.
TotaI DuaIs =
7.2 miIIion
Medicaid Status of Medicare
Beneficiaries, FFY 2002
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Medicaid and the Uninsured
Figure 15
Medicaid EIigibiIity & Benefits for Medicare Beneficiaries, 2005
Pathway Income EIigibiIity
Asset
Limit
IndividuaI
/CoupIe
Medicaid
Benefits
Medicare
Premiums &
Cost-sharing
SS Cash
Assistance
< 74% of poverty
(SS income
eligibility)
$2,000
$3,000
X X
Qualified
Medicare
Beneficiary
(QMB)
< 100% of poverty $4,000
$6,000
X
Specified
Low-ncome
Beneficiary
(SLMB)
100-120% of
poverty
$4,000
$6,000
Premium only
Mandatory Populations
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Medicaid and the Uninsured
Figure 16
Medicaid EIigibiIity & Benefits for Medicare Beneficiaries, 2005
(cont'd)
Pathway Income EIigibiIity
Asset Limit
IndividuaI/
CoupIe
Medicaid
Benefits
Medicare
Premiums &
Cost-sharing
Medically
Needy
ndividuals who spend
income down to a
specified level
$2,000
$3,000
X* X
Poverty Level
< 100% of poverty $2,000
$3,000
X X
Special
ncome Rule
for Nursing
Home
Residents
nstitutionalized
individuals with
income < 300%
of the SS level
$2,000
$3,000
X X
HCBS
Waivers
Must be eligible for institutional care
X X
ptional Populations
Medicaid benefits may be more limited than for SS.
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Medicaid and the Uninsured
Figure 17
14%
24%
28%
22%
52%
11%
24%
13%
2%
9%
17%
71%
Stroke
Diabetes
MentaI
Disorders
Reside in LTC
FaciIity
Income BeIow
$10,000
Fair/Poor HeaIth
Status*

DuaI EnroIIees (Medicare
Beneficiaries with Medicaid - 7.2 m)
Other Medicare Beneficiaries (32.4 m)
DuaI EnroIIees are Poorer and Sicker Than
Other Medicare Beneficiaries
Community-residing individuals only.
SOURCE: KCMU estimates based on analysis of MCBS Cost & Use 2000.
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Medicaid and the Uninsured
Figure 18
Spending on DuaI EIigibIes as a Share of
Medicaid Spending on Benefits, FY2002
TotaI Spending on Benefits = $232.8 BiIIion
SOURCE: Urban nstitute estimates prepared for KCMU based on
an analysis of 2000 MSS data applied to CMS-64 FY2002 data.
Spending on
DuaI EIigibIes
42%
Prescription
Drugs
($13.4 BiIIion)
Non-
Prescription
($82.7 BiIIion)
Spending on
Other Groups
($136.7 BiIIion)
36%
59%
6%
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Medicaid and the Uninsured
Figure 19
NationaI Spending on Nursing Home and
Home HeaIth Care, 2003
TotaI = $110.8 biIIion
SOURCE: CMS, National Health Accounts, 2005.
TotaI = $40 biIIion
Nursing Home Care Home HeaIth Care
Medicaid
46%
Medicare
12%
Out-of-
Pocket
28%
Private
Insurance
8%
Other
6%
Medicaid
25%
Medicare
32%
Out-of-
Pocket
17%
Private
Insurance
21%
Other
5%
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Medicaid and the Uninsured
Figure 20
Growth in Medicaid Long-Term Care
Expenditures, 1991-2003
1991 1996 2001 2002 2003
$34
$52
$75
86%
79%
71%
SOURCE: Burwell et al. 2004, HCFA-64 data.
In BiIIions:
14%
21%
29%
31%
69%
$82
$84
33%
67%
Home & community-
based care
InstitutionaI
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Medicaid and the Uninsured
Figure 21
Average AnnuaI Growth in Medicaid
Expenditures, 1991-2003
27.0%
10.0%
3.6%
7.8%
11.8%
7.1%
1991-1992 '92-'95 '95-'98 '98-2000 '00-'02 '02-'03
SOURCE: Urban nstitute, 2005; data from HCFA Financial
Management Reports, 2004 (HCFA-64/CMS-64).
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Medicaid and the Uninsured
Figure 22
Growing Pressure on Government Spending
Medicaid
17%
PubIic
Assistance
2%
Higher
Education
12%
K-12
Education
35%
AII Other
34%
SOURCE: CBO, aseline :/et O:tlook, January 2005; National
Association of State Budget Officers, 2003 State Expenditure Report, 2004.
State GeneraI Fund Spending
TotaI = $499 BiIIion TotaI = $2.3 TriIIion
FederaI OutIays
Medicaid/
SCHIP
7%
Net Interest
7%
Nondefense
Discretionary
18%
Defense
Discretionary
19%
SociaI
Security
21%
Medicare
12%
Other
16%
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Medicaid and the Uninsured
Figure 23
What's at Stake in Medicaid Reform
HeaIth Insurance
Coverage
25 million children and 14
million adults in low-
income families; 6 million
persons with disabilities
State Capacity for HeaIth
Coverage
43% of federal funds to states
MEDICAID
Support for HeaIth Care
System
17% of national health spending
Assistance to
Medicare
Beneficiaries
7 million aged and
disabled 18% of
Medicare beneficiaries
Long-Term Care
Assistance
1 million nursing home
residents; 43% of long-
term care services