Florida’s Medicaid Program:
Update on Waiver Changes and the
Impact of Health Reform
Joan Alker and Jack Hoadley
Georgetown University Health Policy Institute
Webinar, April 5th, 2011
Per-Person Five Year Growth in Health
Care Costs, 2006-2010
25.00%
19.95%
20.00%
16.54%
15.00%
10.00%
5.00%
-1.03%
0.00%
National Health Expenditures
Employer-Sponsored Insurance
-5.00%
2
Source: Georgetown University Center for Children and Families calculations of
Kaiser Family Foundation & Health Research & Educational Trust, "Employer Health
Benefits 2010 Annual Survey" (September 2010); 2006-2009 and Projected 2010
National Health Expenditure Data; Florida Agency for Health Care Administration,
"Social Services Estimating Conference - Medicaid Services Expenditures" (March 1,
2011); and Florida Agency for Health Care Administration, "Social Services
Estimating Conference - Basic Medicaid Caseloads, Historical and Forecasted"
(January 24, 2011).
Florida Medicaid
Medicaid Essential to Florida’s
Health Care System
o Covers 27% of Florida’s children
o Pays for 51% of Florida deliveries
o Pays for 2/3 of Florida nursing home days
o Leading payer for HIV and mental health
services
o Federal/state matching program
3
Benefits in Florida Per
State Dollar Spent
4
Why Are Costs Going Up?
o Enrollment has grown
because of the recession
o Per person costs have
gone down slightly,
according to state from
$574 to $570
o As table shows costs vary
widely across populations
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Group served
Average cost per
month
Children/Parents
$211
People with
disabilities
$1,482
Dual-eligibles
$1,741
Section 1115 Waiver Update
What is the Process for Approval?
o Waiver expires June 30, 2011; typically 3
year renewal
o Managed care possible for some populations
without a waiver
o Waiver was needed for Low Income Pool for
hospitals, benefit limits, “Opt-out”, enhanced
benefits
o GAO criticized certain aspects of waiver
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Who is Affected by Medicaid Pilots?
Total enrollment as of February 2011: 275,856
County
» Baker
» Broward
» Clay
» Duval
» Nassau
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Enrollment
Percentage
3,028
1.1%
151,607
55%
13,289
4.8%
102,709
37.2%
5,223
1.9%
Source: February 2011 Florida Medicaid Reform Enrollment Report, AHCA
Medicaid Pilots are Small Fraction of
Florida’s Medicaid Program
o Medicaid pilot enrollment is 9.6% of total
Florida Medicaid enrollment
o Lower % of overall spending
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Source: February 2011 Florida Medicaid Reform Enrollment Report, AHCA
Who is Enrolled in Medicaid Pilots?
People receiving
SSI but not
Medicare
12.4%
People receiving
SSI and
Medicare
1.4%
Children and
parents
86.1%
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Source: February 2011 Florida Medicaid Reform Enrollment Report, AHCA
Plan Turnover Very High from 20082011
o Both HMOs and, to lesser degree, Provider
Sponsored Networks have come in and out
of the market
o Duval County: plans representing just under
60% have changed
o Broward County: plans representing 66% of
market share have changed
o Majority of beneficiaries likely had to change
plans raising concerns re access to care
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Duval County Plan Enrollment,
September 2008 and February 2011
PSNs
Sept. 2008= 31.9% PSNs, 68.2% HMOs
HMOs
Feb. 2011= 48.1% PSNs, 51.9% HMOs
Note: PSN and HMO totals for Sept. 2008 do not equal 100% due to rounding error.
12
Source: September 2008 and February 2011 Florida Medicaid Reform Enrollment
Report, AHCA
Broward County Plan Enrollment,
September 2008
PSNs (20.8%)
HMOs (79.1%)
13
Note: PSN and HMO totals do not equal 100% due to rounding error.
Source: September 2008 Florida Medicaid Reform Enrollment Report, AHCA
Broward County Plan Enrollment,
February 2011
PSNs (45.7%)
HMOs (54.2%)
Note: PSN and HMO totals do not equal 100% due to rounding error.
14
Source: February 2011 Florida Medicaid Reform Enrollment Report, AHCA
Share of Enrollment in Provider
Sponsored Networks Increased
15
Source: Georgetown University analysis of February 2008 and February 2011
Florida Medicaid Reform Enrollment Reports, AHCA
http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml
Enrollment in PSNs and HMOs by
Enrollment Group, February 2008
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Source: February 2008 Florida Medicaid Reform Enrollment Report, AHCA
http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml
Enrollment in PSNs and HMOs by
Enrollment Group, February 2011
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Source: February 2011 Florida Medicaid Reform Enrollment Report, AHCA
http://www.fdhc.state.fl.us/MCHQ/Managed_Health_Care/MHMO/med_data.shtml
Other Features of the Waiver
o HMO adult benefit reductions below state plan
level allowed in certain areas (outpatient
therapies, home health, DME chiropractor, adult
dental and hearing, podiatry)
o Most HMOs have not reduced benefits; those
that have done so (Sunshine, United, Medica)
have substantial market share.
o Most plans have added $25 OTC allowance,
some adult dental and vision
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Opt-Out Has Not Been Successful
o Families can choose to apply subsidy to
employer-sponsored insurance but must pay
copays/coinsurance and EPSDT waived
o Very low enrollment – 21 persons most
recently
o Administrative costs likely very very high
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Enhanced Benefits Credits and
Purchases, by Month
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Source: Florida’s Medicaid Reform Enhanced Benefits Program, data from AHCA
presentations at Technical Advisory Panel Meeting presentation, February 2011
What Will Health Reform Mean For
Florida’s Medicaid Program?
Affordable Care Act
o Effective in 2014:
• New coverage through Medicaid
• Availability of state insurance exchanges
• Subsidies to buy insurance through the
exchange
 Incomes up to 400% of poverty ($89,400 for family of
four in today’s dollars)
o Subsidy and Medicaid dollars = $437 per
nonelderly Florida resident
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Medicaid Expansions in the ACA
o New eligibility for people with low incomes
• Childless adults
• Parents
• Adults with disabilities
o Most costs met with federal funds
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Medicaid/CHIP Eligibility Levels in Florida (% of
Poverty), Today and After Health Reform
200%
185%
133%
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133%
133%
133%
Many Adults in Florida Will Gain
Insurance
o Today Florida has 3rd
highest uninsured rate
o 54% of nonelderly
adults up to 133% of
poverty lack insurance
o Between half and 3/4
of them would gain
coverage
o Most children are
already covered
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1.4 million
1.1 million
680,000
Currently
Uninsured
Lower Rate Higher Rate
Number Gaining
Insurance
Most Funding Will Come from Federal
Dollars
o Over 10 years, US will
pay average 94% of
cost of new coverage
o With this leverage, new
state funds will be an
increase of only 2-4
percent over current
levels
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AHCA Estimates of State Costs for
Medicaid Expansions
o AHCA published estimate of $4.1 billion for
new Medicaid coverage and $2 billion for
increased primary care payment
• Over six years, 2014 to 2019
o Unrealistic assumptions:
• 100% enrollment of those newly eligible
• 100% enrollment of eligible but not enrolled
• No offsetting savings
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Children’s Medicaid/CHIP
Participation Rates - 2008
28
Source: Who And Where Are The Children Yet To Enroll In Medicaid And The Children's
Health Insurance Program?, Health Affairs, October 2010,
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0747.
A Different Way to Estimate Costs
o New enrollment
•
Assume enrollment rates of 57% to 75% (Urban Institute)
o Per-person costs
•
Assume lower rate than today: sickest, most costly people
are already enrolled
o Consider sources of offsetting savings
•
•
Less need to support safety-net providers
Some people receiving state- or county-funded services
become eligible for Medicaid or insurance exchanges
 Medically needy
 People requiring mental health or substance services
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Comparing Estimates on the Impact of
Medicaid Expansions in Florida
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Source
AHCA Estimate
Our Estimate
Cost of expanded
Medicaid enrollment
Assumes unrealistic
100% enrollment rate
Assumes optimistic 75%
enrollment rate
Cost of raising primary
care payment rates
Assumes state costs
after 2014
Same assumption
Savings from reduced
need for safety net
None
Assumes at least 25%
to 50% reduction in
associated costs
Savings from transfer of
medically needy to
exchanges
None
Assumes at least 25%
to 50% reduction in
associated costs
Magnitude of Estimated Costs and Savings: An
Alternative to AHCA Numbers
Costs
(billions)
$8
Expanded
Enrollment
Primary Care
Payments
$6
$4
$2
$0
-$2
-$4
-$6
-$8
-$10
Savings
(billions)
-$12
-$14
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AHCA
Alternative
Offsetting
Savings
Total Cost
Or Savings
The Bottom Line on the Impact of
ACA Medicaid Expansion
o AHCA estimates $6 billion in increased costs
o Georgetown estimates a range from $1
billion in increased costs to possibly $3
billion in savings
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For More Information
o Visit the Jessie Ball duPont Fund website
• www.dupontfund.org
o Or the Georgetown University project website
• http://hpi.georgetown.edu/floridamedicaid
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