WHAT’S THE MATTER WITH THE
MEDICAID GAP IN KANSAS?
Objectives
By the end of this session, participants will be able to:
• discuss the main provisions of the Affordable Care Act
• recognize the implications of Medicaid expansion for the
uninsured poor
• understand the Medicaid gap and its effects on Kansas
citizens
U.S. HEALTH CARE SYSTEM
• High costs/low quality
• Services restricted/rationed
• Inexplicable range of costs
• Innovation/diffusion of best
practices very slow
• “Competition . . . currently
exists at the wrong level.”
http://ucatlas.ucsc.edu/spend.php
HEALTH CARE COVERAGE
PRIOR TO ACA
• Employer-subsidized
plans – 59%
• Uninsured – 19%
• Individual – 6%
• Government – 23%
(2009)
http://www.mypremiermd.com/Rates%20&%20I
nsurance.html
WHO ARE THE UNINSURED?
• 41.3 million non-elderly
• 86% were adults
• 27% below poverty
• 80% are US citizens
• 85% low- or moderate-income
families
• 71% in families with one or
more FT workers
• 14% with PT workers
• Rates affected by occupation,
race, state of residence
UNINSURED EMPLOYEES
• Employee-sponsored
coverage offered by 57% of
companies
• 80% of eligible employees
participated
• Two-thirds of adult
uninsured were workers
• Didn’t work enough hours
• Employer didn’t offer
• Employers cited cost as the
main barrier
Majerol, M. Newkirk, V. & Garfield, R. (December 2014).
FINANCIAL IMPLICATIONS
OF UNINSURANCE -- INDIVIDUAL
• Most uninsured do not receive free or cheaper care
• Charged 2-4 times what 3rd party payers pay
• Often must pay “up front”
• Total expenditures less, but out-of-pocket much
higher
• Tend to avoid getting care unless necessary
• Increased risk of amassing unaffordable medical bills
• Few savings and assets to use for health care costs
• Risk difficulty paying off debt
BURDEN OF
UNCOMPENSATED CARE
• By provider:
• 60% hospitals
• 26% community-based
• 14% physicians
• $84.9 billion in 2013
• $53.3 billion to offset costs
• Burden to insured
consumers
• Increased premiums
Increased out-of-pocket
costs
NON-EMPLOYER
HEALTH INSURANCE COVERAGE
• Private insurance
purchased on individual
market
• Very few covered prior to
ACA (5%)
• Obtaining coverage difficult
• Pre-existing conditions
• Older adults
• High rates
Patient Protection and Affordable Care Act
• “ACA” or “Obamacare”
THE AFFORDABLE CARE ACT
• Individual mandate
• Employer mandate
• Medicaid expansion
• Premium & cost-sharing
subsidies
• Health insurance exchanges
THE AFFORDABLE CARE ACT
• Changes to private insurance
• Dependent coverage up to age 26
• 80% of premiums spent on direct
care
• No pre-existing conditions
• No life-time caps
• Must cover preventive care such
as immunizations
THE AFFORDABLE CARE ACT
• New regulations on
payers/employers
• Some incentives to change
at provider level – new
health care delivery models
• Incentives/requirements for
some innovations (EMR)
What is Medicaid Expansion?
MEDICAID EXPANSION
• Expansion of Medicaid up to
138% of FPL
• Goal – extend coverage to 32
million people by 2019
• CBO projected 16 million
covered through Medicaid
expansion
• Supreme court ruling reduced
this trajectory to 12 million
IMPACT OF INSURANCE EXPANSION
ON UNCOMPENSATED CARE COSTS
• Volumes of uninsured
less in Medicaidexpansion states
• Inpatient admissions
• ED visits
• Volumes of Medicaid
patients increased
• UCC $5.7 billion less
DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in 2014.
Department of Health and Human Services, September 24, 2014. Retrieved on January 6, 2015 from:
http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf
WHAT IS THE MEDICAID GAP?
• In states without
Medicaid expansion,
most childless adults
below 100% of FPL will
not have access to
coverage
• 4 million people
nationally are in the
coverage gap with
income:
• greater than Medicaid eligibility
• below lower limit for Marketplace
premium tax credits
/
http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-instates-that-do-not-expand-medicaid-an-update
The ACA in Kansas
• Kansas has one of the lowest standards for Medicaid
eligibility
• Non-pregnant, non-elderly adults, must be less than 38%
of the FPL
• Must be between 100% and 400% of FPL to qualify for
subsidies for exchanges
• 182,000 Kansans are in the ‘Medicaid Gap’ –
• too poor for tax credits
• too ‘well-off’ for Medicaid
Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act?
Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015
from: http://kff.org/health-reform/fact-sheet/state-profiles-uninsured-under-aca-kansas/
KanCare 2.0 in 2015
• Medicaid expansion is
voluntary for states
after 2012 SCOTUS
decision
• Federal share is 100%
for newly eligible until
2016, then drops to
90%
• Regardless of state’s
decision, Medicare
cuts will occur
KanCare Expansion
• KHA lobbying for a “Kansas-based” solution
• KanCare 2.0 – a statewide demonstration program to provide
coverage for all individuals < 138% of FPL
• Utilize 100% federal match – provision to opt out if this drops
below 90%
• Helps keep Kansas taxpayer dollars in Kansas
• Preservation of Kansas health care system
• Focus on health delivery reform initiatives
• Improving health status/quality of care
• Promoting patient-centered medical homes
• Reducing ED utilization
• Increase use of prenatal care
• Reduce infant mortality rates
KHA. (2015) Guiding principles for KanCare 2.0, Kansas Hospital Association. Retrieved on
January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/
KanCare Expansion
• Can cover 160,000
• Improved access to
• right care
• right place
• right time
• Reduced ED visits
• Creation of 4000 jobs
• Health care (>50%)
• Construction, retail,
wholesale, professional,
etc
• Prevent closure of rural
hospitals
KanCare Expansion 2015
• Bill introduced
• Supported by KHA
• Moved from one
committee to another
• Did not to to floor for a
vote
• Dropped at end of
session with budget
crisis taking priority
• http://www.kha-net.org/CriticalIssues/KanCareExpansion/
Estimated costs to hospitals in Kansas
without KanCare expansion
• SVRHC -- $7,626,712.00
• St. Francis -- $3,587,120.00
• All hospitals -- $106,075,220.00
Medicaid Expansion in 2016????
• KHA drafted plan similar to
Indiana’s plan
• Beneficiaries pay up to 2% of
monthly income
• Those above FPL make
monthly payments into
personal health care accounts
• $25 co-pay for ED if nonemergent care
• Locked out of coverage if they
fall behind
Medicaid Expansion in 2016????
• House Speaker Ray Merrick
expected to prevent vote in
House
• Representative Susan
Concannon (R) – supports bill
but was removed from HHS
committee prior to session
• Governor Brownback “may
discuss” but plan must be
“budget neutral”
Medicaid Expansion in 2016????
• Special funds to pay for
expansion
• Premiums from beneficiaries
• Drug rebate program
• Privilege taxes from KanCare
managed care organizations
• Reduced need for KanCare
services, which currently cost
the state
The Bridge to a Healthy Kansas
• 150,000 eligible Kansans
• Unique Kansas solution
• Budget-neutral
• Provides a path to health and
personal responsibility
• Good business (healthy
workforce)
• Keeps Kansas dollars in Kansas
• Helps community hospitals;
keeps health care accessible in
rural Kansas
• http://www.khi.org/as
sets/uploads/news/1
4108/the_bridge_to_
a_healthy_kansas_fi
nancial_infographic_
1-13-16.pdf
RESOURCES – EDUCATE
YOURSELVES!
• http://www.nursingworld.org/healthcarereform
• American Nurses Association
• http://kff.org/health-reform/
• Henry J. Kaiser Family Foundation
• http://kff.org/health-reform/fact-sheet/summary-of-the-
affordable-care-act/
• Henry J. Kaiser Family Foundation
• http://www.kha-net.org/
• Kansas Hospital Association
• https://www.healthcare.gov/
• HealthCare.Gov
• http://www.aha.org/
• American Hospital Association
• http://www.khi.org/
• Kansas Health Institute
References
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AMA News Room. (2013). AMA analysis lists states where one private health insurer rules. Retrieved from http://www.amaassn.org/ama/pub/news/news/2013/2013-11-07-study-anticompetitive-market-conditions.page
Cauchi, R & Landess, S. (2012). Out-of-state health insurance: allowing the purchase, Retrieved from http://www.ncsl.org/research/health/out-of-state-healthinsurance-purchases.aspx
DeLeire, T., Joynt, K., and McDonald, R. (2014). Impact of insurance expansion on hospital uncompensated care costs in 2014. Department of Health and Human
Services, September 24, 2014. Retrieved on January 6, 2015 from: http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf
Henry J. Kaiser Family Foundation (April 25, 2013). Summary of the Affordable Care Act. Henry J. Kaiser Family Foundation. Retrieved on January 28, 2015
from: http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/
Henry J. Kaiser Family Foundation. (January, 2014). How will the uninsured in Kansas fare under the Affordable Care Act? Henry J. Kaiser Family Foundation:
The Kaiser Commission on Medicaid and the Uninsured. Retrieved on February 3, 2015 from: http://kff.org/health-reform/fact-sheet/state-profiles-uninsuredunder-aca-kansas/
Henry J. Kaiser Family Foundation (January 12, 2016, sugust 28, 2014). Current status of state Medicaid expansion decisions. Retrieved from:
https://kaiserfamilyfoundation.files.wordpress.com/2016/01/current-status-of-the-medicaid-expansion-decisions-healthreform.png
http://www.acep.org/News-Media-top-banner/The-Uninsured--Access-To-Medical-Care/
Huang, C.C & Smith, S. (2014). Number of uninsured Kansans in 2013 unchanged from 2012: Trend shows more people receiving public coverage. Kansas
Health Institute. December 17, 2014. Retrieved on February 7, 2015 from: http://www.khi.org/policy/article/rate-uninsured-kansans-unchanged-2012-trend-showsInstitute of Medicine. (2013). Consequences of uninsurance, IOM Retrieved on January 31, 2014 from:
http://www.iom.edu/Activities/HealthServices/InsuranceStatus.aspx
Keckley, PH, Coughlin, S, Korenda, L, & Rice, E. (2011) The impact of health reform on the individual insurance market: a strategic assessment. Deloitte Issue
Brief. Retrieved from http://www.deloitte.com/assets/DcomUnitedStates/Local%20Assets/Documents/Health%20Reform%20Issues%20Briefs/us_chs_HealthReformAndTheIndividualInsuranceMarket_IssueBrief_101011.p
df
KHA (2015). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/
KHA (2016). KanCare expansion, Kansas Hospital Association. Retrieved on January 29, 2015 from: http://www.kha-net.org/CriticalIssues/KanCareExpansion/
Kansas Health Institute (KHI) (2016). The Bridge to a Healthy Kansas infographic. Retrieved from:
http://www.khi.org/assets/uploads/news/14108/the_bridge_to_a_healthy_kansas_financial_infographic_1-13-16.pdf
Majerol, M. Newkirk, V. & Garfield, R. (December 2014). The uninsured: A primer. Key facts about health insurance and the uninsured in America. Henry J.
Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured. Retrieved on January 29, 2015 from: http://kff.org/uninsured/report/theuninsured-a-primer/
McLean, J. (2015) Kansas Medicaid expansion said to be off the table. KCUR. Retrieved from: http://kcur.org/post/kansas-medicaid-expansion-said-betable#stream/0
Porter, ME & Teisberg, EO. (2013). Redefining competition in healthcare, Harvard Business Review. Retrieved from http://hbr.org/web/extras/insight-center/healthcare/redefining-competition-in-health-care
Rockefeller Institute of Government. (2014). Kansas: Baseline report. State-leve field network study of the implementation of the Affordable Care Act, State
University of New York, December 1, 2014, Retrieved on February 7, 2015 from:
http://www.issuelab.org/resource/kansas_baseline_report__state_level_field_network_study_of_the_implementation_of_the_affordable_care_act
Schartz, K. S. (2015). What’s the matter with the Medicaid gap in Kansas? The Kansas Nurse, 90(5), pp. 13-16.
Stoll, K. and Bailey, K. (2009) Hidden health tax: Americans pay a premium, Families USA, May, 2009. Retrieved on January 31, 2015 from:
http://familiesusa.org/product/hidden-health-tax-americans-pay-premium
UC Atlas (2011) Health care spending, US Atlas of Global Inequality. Retrieved on January 31, 2015 from: http://ucatlas.ucsc.edu/spend.php