CHA RT PACK
Medicaid and its Role in
State/Federal Budgets &
Health Reform
April 2013
Figure 1
#1: What is Medicaid and What Does it Do?
Figure 2
Medicaid has many vital roles in our health care system.
Health Insurance
Coverage
Assistance to Medicare
Beneficiaries
Long-Term Care
Assistance
31 million children & 16
million adults in low-income
families; 16 million elderly
and persons with disabilities
9.4 million aged and
disabled — 20% of Medicare
beneficiaries
1.6 million institutional
residents; 2.8 million
community-based residents
MEDICAID
Support for Health Care System
and Safety-net
State Capacity for Health
Coverage
16% of national health spending;
40% of long-term care spending
For FY 2013, FMAPs range
from 50 – 73.4%
1
Figure 3
Medicaid is a major source of health coverage and spending.
Health Spending
Health Coverage
Consumer
Out-ofPocket
13%
Uninsured
16%
Medicaid
16%
EmployerSponsored
Insurance
49%
Private
Health
Insurance
35%
Medicare
13%
Medicaid
16%
Medicare
24%
Other
Private
Funds
8%
Other
Public
1%
Private
Non-Group
5%
Total = 307.9 million
Other
Government
Programs
4%
Total = $2.3 trillion
NOTE: Health spending total does not include administrative spending.
SOURCE: Health insurance coverage: KCMU/Urban Institute analysis of 2011 data from 2012 ASEC Supplement to the CPS.
Health expenditures: KFF calculations using 2011 NHE data from CMS, Office of the Actuary
Figure 4
Medicaid helps to fill gaps in private insurance coverage.
Employer/Other Private
32%
Medicaid/Other Public
15%
29%
Uninsured
5%
4%
12%
32%
90%
48%
73%
39%
20%
<100% FPL
100-199% FPL
200-399% FPL
NOTE: FPL-- Federal Poverty Level. The FPL was $22,350 for a family of four in 2011.
Data may not total 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS
2
400%+ FPL
Figure 5
Medicaid eligibility levels are more limited for adults than
for children.
235%
185%
Minimum Medicaid Eligibility under Health Reform - 138% FPL
($24,344 for a family of 3 in 2012)
61%
37%
0%
Children
Pregnant Women
Working
Parents
Jobless
Parents
Childless
Adults
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured
and the Georgetown University Center for Children and Families, 2013.
Figure 6
All but 4 states set Medicaid/CHIP eligibility for children at
200% FPL or higher.
VT
WA
MT
MN
OR
ID
NV
WY
SD
UT
CO
CA
(CHIP closed)
CT RI
NJ
DE
MD
PA
IN
MO
OK
MA
NY
MI
IL
KS
NM
NH
WI
IA
NE
AZ
ME
ND
OH
WV
KY
TN
AR
MS
AL
VA
DC
NC
SC
GA
LA
TX
FL
AK
HI
< 200% FPL (4 states)
200-249% FPL (22 states)
250% or higher FPL (25 states, including DC)
NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. OK has a premium assistance program for select
children up to 200% of the FPL. AZ’s CHIP program is currently closed to new enrollment.
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the
Georgetown University Center for Children and Families, 2013.
3
Medicaid coverage for working parents is more limited.
VT
WA
MT
ID
NH
WY
UT
CO
CA
AZ
WI
SD
OH
IN
MO
OK
NM
PA
IL
KS
NY
MI
IA
NE
NV
ME
ND
MN
OR
Figure 7
WV
KY
NC
TN
AR
MS
VA
MA
CT RI
NJ
DE
MD
DC
SC
GA
AL
LA
TX
FL
AK
HI
< 50% FPL (16 states)
50% - 99% FPL (17 states)
100% FPL or Greater (18 states, including DC)
NOTE: The federal poverty line (FPL) for a family of three in 2012 is $19,090 per year. Several states also offer coverage with a benefit
package that is more limited than Medicaid to parents at higher income levels through waiver or state-funded coverage.
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the
Georgetown University Center for Children and Families, 2013.
Only 9 states provide full Medicaid to childless adults.
WA
(closed)
VT*
MT
ND
(closed)
ID
WY
NV
CA
UT*
(closed)
AZ
(closed)
CO
(Closed)
WI
SD
(closed)
MI
IL
KS
WV
KY
MS
AL
VA
CT
NJNJ
DE
MD
RI
DC
NC
TN
AR
(closed)
PA
OH
(closed)
MO*
OK
NM
IN
MA
NY
(closed)
IA
NE
ME
(closed)
NH
MN
OR*
Figure 8
SC
GA
LA
TX
FL
AK
HI
No Coverage (26 states)
More Limited than Medicaid (16 states)
Medicaid Benefits (9 states, including DC)
“Closed” denotes enrollment closed to new applicants
NOTE: Map identifies the broadest scope of coverage in the state. MN and VT also offer waiver coverage that is more limited
than Medicaid. OR and UT also offer “premium assistance” with open enrollment. IL, LA, and MO offer coverage limited to
adults residing in a single county or area.
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured
and the Georgetown University Center for Children and Families, 2013.
4
Medicaid is the largest source of funding for safety-net
providers.
Health Center Revenues by Payer,
2011
Safety-Net Hospital Net Revenues
by Payer, 2010
Federal /
State / Local
Payments
11%
Medicare
6%
Commercial
27%
Private
7%
Federal 330
Grants
17%
Medicaid
35%
Medicaid
38%
Other
Grants &
Contracts
24%
Medicare
21%
Other
4%
Figure 9
Other
Public
2%
Uninsured
2%
Uninsured/
Self Pay
6%
Total = $12.7 Billion
Total = $47 Billion
SOURCES: Data for hospitals from America’s Safety Net Hospitals and Health Systems, 2010, National Association of Public
Hospitals and Health Systems, May 2012. Health center data from 2011 Uniform Data System (UDS), BPHC/HRSA/HHS.
Figure 10
9 Million dual eligible beneficiaries are covered by both
Medicare and Medicaid.
Medicare
37 Million
Dual
Eligibles
9 Million
Total Medicare Beneficiaries, 2008:
46 million
Medicaid
51 Million
Total Medicaid Beneficiaries, 2008:
60 million
SOURCE: Kaiser Family Foundation analysis of Medicare Current Beneficiary Survey, 2008, and KCMU and Urban Institute
estimates based on data from the FY2008 MSIS.
5
Medicaid provides benefits to reflect the needs of the
population it serves.
Low-Income
Families
Individuals
with
Disabilities
Elderly
Individuals
Figure 11
• Pregnant Women: Pre-natal care and delivery costs
• Children: Routine and specialized care for childhood development
(immunizations, dental, vision, speech therapy)
• Families: Affordable coverage to prepare for the unexpected
(emergency dental, hospitalizations, antibiotics)
• Autistic Child: In-home therapy, speech/occupational therapy
• Cerebral Palsy: Assistance to gain independence (personal care,
case management and assistive technology)
• HIV/AIDS: Physician services, prescription drugs
• Mental Illness: Prescription drugs, physicians services
• Medicare beneficiary: help paying for Medicare premiums and cost
sharing
• Community Waiver Participant: community based care and
personal care
• Nursing Home Resident: care paid by Medicaid since Medicare
does not cover institutional care
Six in ten dollars of Medicaid spending is for state
expansion enrollees and optional services.
Figure 12
Mandatory
Services for
State Expansion
Enrollees
27%
Mandatory
Services for
Federal Core
Enrollees
40%
Optional
Services for
Federal Core
Enrollees
19%
Optional
Services for
State Expansion
Enrollees
14%
Total = $311 billion
NOTE: Total expenditures do not include disproportionate share hospital (DSH) payments, drug rebates, administrative costs, or
accounting adjustments. Shares may not sum to 100% due to rounding.
SOURCE: Urban Institute estimates based on FFY data from the 2007 MSIS and CMS 64.
6
Figure 13
Medicaid provides access to care that is comparable to
private insurance and better than access for the uninsured.
Employer/Other Private
Medicaid/Other Public
Uninsured
53%
30%
28%
26%
20%
11%
2% 3%
2% 2%
12%
7%
10% 10%
10%
4%
1% 1%
No Usual
Postponed
Source of Care Seeking Care
Due to Cost
Went Without
Needed Care
Due to Cost
No Usual
Postponed
Source of Care Seeking Care
Due to Cost
Children
Went Without
Needed Care
Due to Cost
Nonelderly Adults
NOTES: In past 12 months. Respondents who said usual source of care was the emergency room were included among
those not having a usual source of care. All differences between the uninsured and the two insurance groups are
statistically significant (p<0.05).
SOURCE: KCMU analysis of 2011 NHIS data.
Figure 14
Most Medicaid enrollees receive care through private
managed care.
VT
WA
MT
MN
OR
ID
NV
WY
SD
CA
AZ
CO
OK
NY
MI
PA
IL
KS
NM
NH
WI
IA
NE
UT
ME
ND
IN
MO
OH
WV
KY
MS
AL
DC
NC
TN
AR
VA
MA
CT RI
NJ
DE
MD
SC
GA
LA
TX
AK
FL
HI
0% - 50% (9 states)
51% - 65% (15 states)
66% - 80% (17 states and DC)
80%+ (9 states)
U.S. Overall = 65.9%
NOTE: Includes enrollment in MCOs and PCCMs. Most data as of October 2010.
SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011.
7
#1: What is Medicaid and What Does it Do?
Answers
Figure 15
• Medicaid is the nation’s primary health insurance program for Americans with low
incomes and significant health care needs.
• Medicaid increases access to care and limits out-of-pocket burdens for low-income
people.
• Medicaid is the largest source of funding for safety-net providers and the dominant
payer for long-term care. Medicaid also helps to make Medicare work for low-income
elderly and disabled beneficiaries.
• Medicaid provides an entitlement to coverage for individuals eligible for the program.
Medicaid also guarantees federal matching payments to states with no cap in order
to meet program needs.
• States administer Medicaid within broad federal rules.
• Although Medicaid is publicly financed, the program purchases health services
primarily in the private sector.
Figure 16
#2: What does Medicaid cost and why?
8
Figure 17
Medicaid provides support for providers and services in the
health care system.
31%
Medicaid as a share of national
health care spending:
18%
16%
8%
Total
National
Spending
(billions)
Total Health
Services and
Supplies
Hospital Care
$851
$2,279
Professional
Services
7%
Nursing Home
Care
$723
$149
Prescription
Drugs
$263
NOTE: Includes neither spending on CHIP nor administrative spending. Definition of nursing facility care was revised from
previous years and no longer includes residential care facilities for mental retardation, mental health or substance abuse.
The nursing facility category includes continuing care retirement communities.
SOURCE: CMS, Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2013. Data for
2011.
Figure 18
The majority of Medicaid expenditures are for acute care.
DSH
4.2%
Mental Health
0.9%
Long-Term
Care
30.2%
ICF/MR
3.3%
Physician, Lab & Xray
3.6%
Inpatient
14.6%
Home Health and
Personal Care
13.5%
Outpatient/Clinic
6.8%
Nursing Facilities
12.5%
Other Acute
9.3%
Payments to Medicare
3.6%
Drugs
3.5%
Payments to MCOs
24.1%
Total = $413.9 billion
NOTE: Excludes administrative spending, adjustments and payments to the territories.
SOURCE: Urban Institute estimates based on FY 2011 data from CMS (Form 64), prepared for the Kaiser Commission on
Medicaid and the Uninsured.
9
Acute
Care
65.6%
Medicaid spending growth per capita was slower than
private health care spending from 2007 to 2011.
Figure 19
Spending Growth FFY 2007-2011
5.3%
3.5%
3.3%
2.3%
0.1%
Medicaid LTC Per Medicaid Services Medicaid Acute
Enrollee
Per Enrollee
Care Per Enrollee
NHE Per Capita
Private Health
Insurance Per
Enrollee
NOTE: Acute Care includes payments to managed care plans.
SOURCE: Medicaid estimates from Urban Institute analysis of data from the Medicaid Statistical Information System (MSIS),
Medicaid Financial Management Reports (CMS Form 64), and Kaiser Commission and Health Management Associates data.
NHE and private health insurance data from Centers for Medicare & Medicaid Services Office of the Actuary, National Health
Statistics Group.
Figure 20
Medicaid enrollment and spending growth is accelerated
during economic downturns.
Spending Growth
Enrollment Growth
12.7%
10.4%
8.7%
6.8%
9.3%
7.5%
4.7%
9.7%
8.5%
7.7%
7.8%
6.4%
5.8%
3.8%
5.6%
3.2%
4.3%
1.3%
0.4%
-1.9%
7.6%
6.6%
3.1%
3.2%
0.2%
7.2%
4.4%
3.8%
3.2%
2.0%
2.7%
-0.5%
Adopted
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
NOTE: Enrollment percentage changes from June to June of each year. Spending growth percentages in state fiscal year.
SOURCE: Medicaid Enrollment June 2011 Data Snapshot, KCMU, June 2012. Spending Data from KCMU Analysis of CMS Form 64 Data
for Historic Medicaid Growth Rates. FY 2012 and FY 2013 data based on KCMU survey of Medicaid officials in 50 states and DC
conducted by Health Management Associates, October 2012.
10
The elderly and disabled account for the majority of
Medicaid spending.
Figure 21
Disabled 15%
Elderly 10%
Disabled 42%
Adults 26%
Elderly 23%
Adults 14%
Children 49%
Children 20%
Enrollees
Total = 62.7 Milion
Expenditures
Total = $346.5 Billion
NOTE: Percentages may not add up to 100 due to rounding.
SOURCE: KCMU/Urban Institute estimates based on data from FFY 2009 MSIS and CMS-64, 2012. MSIS FFY 2008 data were
used for PA, UT, and WI, but adjusted to 2009 CMS-64.
Disability and long-term care drive higher per-enrollee
spending.
Acute Care
Figure 22
Long-Term Care
$15,840
$13,149
$6,275
$9,748
$2,305 $65
$9,565
$2,900 $13
$2,240
$2,887
Children
Adults
$3,401
Disabled
Elderly
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on FFY 2009 MSIS and
CMS-64 data. MSIS FFY 2008 data was used for PA, UT, and WI, but adjusted to 2009 CMS-64.
11
Figure 23
Duals account for 38% of Medicaid spending.
Medicaid Spending
Medicaid Enrollment
Premiums
Medicare
3%
Acute
Other
7%
Acute
2%
Other
Aged &
Disabled
10%
Adults
26%
Dual
Eligibles
15%
Non-Dual
Spending
62%
Dual
Spending
38%
Long-Term
Care
25%
Children
49%
Prescribed
Drugs
0.4%
Total = 62.7 Million
Total = $358.5 Billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FFY 2009
MSIS and CMS-64 reports, 2012. 2008 MSIS data was used for PA, UT, and WI, because 2009 data were unavailable.
Top 5% of enrollees accounted for more than half of
Medicaid spending in FFY 2009.
Bottom 95%
of Spenders
Bottom 95%
of Spenders
Figure 24
Top 5%
Children 3.7%
Adults 1.9%
Top 5%
Children 0.3%
Adults 0.2%
5% Disabled 2.5%
Elderly 2.0%
Disabled 30.4% 54%
Elderly 18.6%
Enrollees
Expenditures
Total = 62.7 million
Total = $346.5 billion
SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.
MSIS FY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS-64.
12
#2: What does Medicaid cost and why?
Answers
Figure 25
• Medicaid accounts for about one sixth of total health care spending in the country.
• On a per enrollee basis, Medicaid spending is growing more slowly than premiums
for employer-sponsored insurance or national health care spending. However it is
subject to same market pressures as other payers.
• Enrollment is the dominant driver in Medicaid spending, especially during periods of
economic downturn.
• The elderly and disabled account for the majority of Medicaid spending.
• Medicaid spending is concentrated among a small number of beneficiaries with
complex health care needs.
• States have a strong incentive to manage Medicaid cost growth.
Figure 26
#3: What is Medicaid’s role in state budgets?
13
Figure 27
Medicaid Costs are Shared by the States and the Federal
Government
VT
WA
ND
MT
MN
OR
SD
ID
WY
UT
CA
AZ
CO
MO
OK
NM
LA
TX
AK
KY
WV VA
MS
AL
NH
MA
RI
DC
NC
TN
AR
CT
NJ
DE
MD
PA
OH
IN
IL
KS
NY
MI
IA
NE
NV
WI
ME
SC
GA
FL
HI
FFY 2013 FMAP
50 percent
50.1-59.9 percent
60.0-66.9 percent
67.0-74.0 percent
(14 states)
(14 states)
(12 states)
(11 states, including DC)
NOTE: FMAP percentages are rounded to the nearest tenth of a percentage point. These rates will be in effect Oct. 1, 2012 –
Sept. 30, 2013.
SOURCE: Federal Register, November 30, 2011 (Vol 76, No. 230), pp 74061-74063, at http://www.gpo.gov/fdsys/pkg/FR2011-11-30/pdf/2011-30860.pdf.
Figure 28
State Tax Revenue, 1989 – 2012
20%
15.9%
15%
11.3%
10%
5.4%
3.3%
5%
4.9%
0%
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
-5%
-10%
-9.4%
-15%
-16.3%
-20%
SOURCE: Percent change in quarterly state tax revenue, US Census Bureau. Updated October 2012.
14
Since the start of the recession about 10 million more
enrolled in Medicaid.
Total Monthly
Enrollment
(in Millions)
June
42.3
43.6
2007
2008
47.0
2009
50.4
2010
Figure 29
52.6
2011
NOTE: The orange bars denote the period since the most recession started, though it technically started in December 2007.
SOURCE: Compiled by Health Management Associates from State Medicaid enrollment reports for the Kaiser Commission
on Medicaid and the Uninsured.
Figure 30
Drops in revenues had a larger impact on state budgets than
increases in Medicaid spending during the recession.
Decline in
Medicaid
Spending
-$22 Billion
Decline in State
Revenues
-$80 Billion
NOTES: Measures the change in state own source revenues (taxes, miscellaneous revenues, and charges) between state
fiscal years 2008 and 2010 compared the change in state spending on Medicaid between state fiscal years 2008 and 2010.
Medicaid spending does not include administrative costs, accounting adjustments, or the U.S. Territories.
SOURCES: 2008, 2009, and 2010 Annual Survey of State Government Finances. U.S. Census Bureau, 2012.
KCMU and Urban Institute estimates based on data from HCFA/CMS (Form 64), 2010.
15
Figure 31
Medicaid is a budget Item and a revenue item in state
budgets.
Medicaid
Elementary & Secondary Education
43.8%
48.2%
56.1%
Other
12.5%
35.1%
20.2%
43.7%
23.7%
Total State Spending
$1.66 Trillion
16.7%
General Funds
$635.5 Billion
Federal Funds
$565.9 Billion
SOURCE: Actual FY 2011 data reported in: State Expenditure Report. NASBO, December 2012.
Figure 32
Shares of state general fund spending for Medicaid and
education have remained fairly stable over time.
Elementary and Secondary Education
33.4%
Medicaid
Higher Education
35.7% 35.7% 35.2% 35.1% 35.8% 35.8% 35.4%
35.5% 35.1% 34.7%
34.4% 34.5% 35.2%
34.4% 34.1% 35.0% 35.2%
Economic Downturn, Slow
Recovery, ARRA-Enhanced
Matching Funds
19.6%
15.8%
14.4% 14.7% 14.6% 14.8% 14.4% 14.4% 15.2%
17.2% 16.9% 17.1% 17.4% 16.6%
16.0% 16.3%
14.8%
16.7%
12.9% 12.9% 13.0% 13.1% 12.4% 12.8% 12.7% 12.4% 12.5%
11.7% 11.6% 11.3% 11.0% 11.7% 11.5% 11.5% 11.3%
10.0%
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Estimated
SOURCE: State Expenditure Report. NASBO, December 2012.
16
Figure 33
Medicaid helps to generate jobs in state economies.
Federal Medicaid Matching Dollars
—Injection of New Money—
State Medicaid Dollars
Direct
Effects
Health Care Services
Vendors
JOBS
Indirect
Effects
(ex. Medical Supply Firm)
Employee Income
Induced
Effects
Consumer Goods and
Services
Taxes
State budget pressures have resulted in Medicaid cost
containment efforts, but eligibility is protected.
2012
48
47
45
Figure 34
Adopted for 2013
42
18
8
10
7
2
Any Cost
Containment
Action
Provider Payments
Benefits
Long-Term Care
Eligibility
NOTE: Past survey results indicate not all adopted actions are implemented. Provider payment restrictions include rate cuts for any
provider or freezes for nursing facilities or hospitals. Survey was conducted in July and August 2012.
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2012.
17
6
Figure 35
States are also moving ahead with initiatives to better
coordinate care, especially for more complex populations.
FY 2012
Adopted FY 2013
45
35
34
30
20
Any Managed Care
Expansions or Initiatives
Any Care Coordination
Initiatives
Any Dual Eligible Initiatives
SOURCE: KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October
2012.
#3: What is Medicaid’s role in state budgets?
Answers
Figure 36
• The Medicaid program is jointly funded by states and the federal government.
• Medicaid is a counter-cyclical program; during economic downturns, individuals lose
jobs, incomes drop, state revenues decline, and more individuals qualify and enroll
in Medicaid which increases spending.
• Medicaid is the largest source of federal revenue for states. Medicaid funds support
health care providers, jobs and state economies overall.
• Due to budget pressures over the last decade, states have adopted an array of cost
containment measures.
18
Figure 37
#4: What is Medicaid’s role in the federal budget?
Figure 38
Medicaid is the third largest domestic program in the federal
budget.
Social Security
23%
Medicare1
17%
Defense and
Nondefense
Discretionary
34%
Other2
13%
Medicaid
7%
Net Interest
6%
Projected FY 2013 Total Federal Outlays = $3.6 trillion
NOTE: FY is fiscal year. 1Amount for Medicare is mandatory spending and excludes offsetting premium receipts (premiums paid by
beneficiaries and state contribution (clawback) payments to Medicare Part D). 2”Other” category includes other mandatory outlays and
offsetting receipts.
SOURCE: Kaiser Family Foundation based on Congressional Budget Office, Budget and Economic Outlook Fiscal Years 2013-2023,
February 2013.
19
Figure 39
CBO’s most recent projections of federal Medicaid spending are
lower than previous projections as current spending has slowed.
700
March 2012 Baseline
August 2012
February 2013 Baseline
622
600
500
425
383
400
300
200
451
337
416
382
399
341 372
474
446
422
540
506
479
449
577
514
476
592
549
505
536
572
276
275
305 331
258
275
267 297
253
265
251
100
0
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
SOURCE: Medicaid Spending and Enrollment Detail for CBO’s March 2013 Baseline and the February 2013 Baseline
Figure 40
The House Budget Plan is estimated to result in a 38% reduction
in federal Medicaid spending over the 2013-2022 period.
-$4,591
-$932
Cut due to
ACA repeal
-$810
Cut due to
Block Grant
38% Reduction
in Spending
-$2,849
Spending Under Current Law, Including
ACA
Spending Under the House Budget Plan
Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured, October 2012
20
Figure 41
Medicaid enrollment in 2022 would decline significantly
under the House Budget Plan.
Enrollment Cut: 37.5 Million
17.0
20.5
Enrollment Cut: 31.3 Million
ACA Repeal
Block Grant
17.0
14.3
75.0
43.7
37.5
Current Law, Including ACA
% Enrollment Cut from
Repeal and Block Grant
%Enrollment Cut from
Block Grant
Scenario 1: Assuming Current Per
Enrollee Spending Growth
50%
Scenario 2: Assuming Reduction in
Per Enrollee Spending Growth
35%
42%
25%
Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured, October 2012.
#4: What is Medicaid’s role in the federal budget?
Answers
Figure 42
• Medicaid is the third-largest domestic program in the federal budget.
• Medicaid is exempt from automatic budget reductions; however Medicaid continues
to be discussed as part of federal deficit reduction efforts.
• Leading budget proposals for FFY 2014 released by the Administration and House
Republicans take fundamentally different approaches to Medicaid spending.
• The FMAP formula that determines the federal share of Medicaid spending has
remained steady since the start of the program; Congress has only amended the
formula to provide more federal funding, not less.
21
Figure 43
#5: What is Medicaid’s role in health reform?
Expanding Medicaid is a key element in health reform.
Figure 44
Universal Coverage
Medicaid Coverage
For Low-Income
Individuals
Individual
Mandate
Exchanges With Subsidies
for Moderate Income
Individuals
Health Insurance
Market Reforms
Employer-Sponsored Coverage
22
Figure 45
Under the ACA, there will be fewer uninsured as individuals
gain coverage through Medicaid and new exchanges.
Total Nonelderly Population = 288 million
10%
Uninsured
17%
Medicaid/CHIP
10%
9%
8%
Exchange
Private Non-Group /
Other
58%
56%
Employersponsored
Insurance
Without Health Reform
(56 Million Uninsured)
With Health Reform
(29 Million Uninsured)
Uninsured
19%
Medicaid/CHIP
13%
Private
Non-Group/Other
Employersponsored
Insurance
NOTE: This assumes that all states choose to expand Medicaid eligibility up to 138% FPL January 2014.
SOURCE: Congressional Budget Office, February 2013. Total may not equal 100% due to rounding
Figure 46
More than half of the uninsured have incomes at or below 138%
of poverty, the Medicaid eligibility floor under the ACA.
Income
EmployerSponsored
Insurance,
56%
Family Type
10%
400% +
16%
Children
39%
139-399% FPL
(Subsidies)
25%
Parents
59%
Adults
without
Dependent
Children
Uninsured
18%
51%
Medicaid*
21%
Private Non-Group,
6%
≤ 138%
(Medicaid)
47.9 M Uninsured
266.4 M Nonelderly
NOTES: * Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related
coverage. The federal poverty level for a family of four in 2011 was $22,350.
Numbers may not add to 100 due to rounding.
SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
23
Figure 47
There is significant variation in the share of the uninsured
that is below the Medicaid expansion limit across states.
VT
WA
ND
MT
OR
CA
CA
AZ
CO
IL
KS
OK
NM
MI
IA
NE
UT
NY
WI
WY
NV
NH
MN
SD
ID
TX
IN
MO
PA
OH
WV
KY
AL
VA
CT
NJ
DE
MD
MA
RI
DC
NC
TN
AR
MS
AK
ME
SC
GA
LA
FL
HI
United States:
51% Uninsured
<138% FPL
26% – 47% (17 states, including DC)
48% – 52% (18 states)
53% - 61% (16 states)
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's
March 2011 and 2012 Current Population Survey (CPS: Annual Social and Economic Supplements).
Figure 48
The ACA streamlines enrollment processes, making it easier
to obtain coverage.
Multiple Ways
to Enroll
HEALTH
INSURANCE
$
Medicaid
CHIP
Exchange
Data
Hub
Single Application
for Multiple Programs
#
Use of Electronic
Data to Verify Eligibility
24
Dear ______,
You are
eligible for…
Real-Time Eligibility
Determinations
The federal government will fund the vast majority of
Medicaid expansion costs.
State
Savings
$952 Billion
$76
Billion
Federal
↑ 26%
Figure 49
State
21.3 Million
New Enrollees by 2022
Provider
Revenue
Increased
Economic Activity
↑ 3%
Cost
Impact
NOTE: Assumes all states expand Medicaid.
#5: What is Medicaid’s role in health reform?
Answers
Figure 50
• Health reform builds on Medicaid as a base of coverage for low-income Americans.
• As they plan their FY 2014 budgets, states are debating whether to adopt the
Medicaid expansion.
• The Federal Government will finance over 90% of the cost of the Medicaid expansion
in new states; overall, many states are likely to see net savings from the Medicaid
expansion.
• The Medicaid expansion would significantly reduce the uninsured and increase
access to care.
• The ACA provides new options to expand community-based long-term care and to
coordinate care for high cost populations.
25
the henry j. kaiser family foundation
Headquarters
2400 Sand Hill Road
Menlo Park, CA 94025
Phone 650-854-9400 Fax 650-854-4800
Washington Offices and
Barbara Jordan Conference Center
1330 G Street, NW
Washington, DC 20005
Phone 202-347-5270 Fax 202-347-5274
www.kff.org
This publication (#8162-03) is available on the Kaiser Family Foundation’s website at www.kff.org.
The Kaiser Family Foundation, a leader in health policy analysis, health journalism and
communication, is dedicated to filling the need for trusted, independent information on the major
health issues facing our nation and its people. The Foundation is a non-profit private operating
foundation, based in Menlo Park, California.