District of Columbia’s Public
Health Care Programs in a Post
Reform Environment
Presentation for the:
Health Insurance Forum
Department of Health Care Finance
May 26, 2011
Washington DC
Presentation Outline
 Overview of District’s Medicaid Program



Broad Goals of Health Care Reform
Increased Access Through Program Expansion
Service Delivery Reform To Promote Quality
Increased Coverage Through Exchange
Mayor’s Health Care Reform Implementation
Committee
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Key Facts About the Department of Health
Care Finance
 Total Agency FY12 Budget Exceeds $2.1 Billion
 96% of budget spent on Provider Payments



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Hospitals
Managed Care Organizations
Institutional Care (e.g. Nursing Homes)
Physician Payments
 DC Medicaid provides health insurance coverage to
almost 1 in 3 District residents – over 180,000 people
3
Managed Care Is A Growing Component of
Medicaid in the District of Columbia
36%
37%
64%
63%
37%
63%
33%
67%
Notes: D.C. fiscal year is October 1 through September 30; enrollment was averaged from October to September to create
average monthly enrollment. Data were not available for managed care and fee for service enrollment prior to FY2007. Due
to new coverage option state plan amendment and an 1115 waiver for childless adult beneficiaries with incomes between
133 percent and 200 percent of the Federal Poverty Level, over 30,000 individuals were moved from Alliance (not included
in the data above) onto the Medicaid program. The net result is a rapid increase in managed care enrollment in FY2010 and
FY2011, when looking at Medicaid enrollment data only.
4
The Elderly And Disabled Represent 29
Percent Of Medicaid Program Beneficiaries
Demographics Of Beneficiaries In The District of Columbia’s
Medicaid Program
Blind & Disabled
29%
Children
Aged
Adults
Notes: Distributions may not sum to 100% due to rounding effects. Distribution of beneficiaries by category is based on
average Medicaid enrollment in FY10.
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…Yet They Account For 73 Percent Of
Medicaid Program Spending, FY10
Aged
Blind & Disabled
Adults
Aged
29%
73%
Children
Blind & Disabled
Adults
Children
Notes: Distributions may not sum to 100% due to rounding effects.
Source: Spending from ad hoc MMIS report 1/26/2011. FY 2010 date-of-service spending excluding DSH, cost settlements,
Medicare premiums, and drug rebate.
6
The Cost of Serving the Elderly and
Disabled Is Substantially Greater Than The
Cost of Care For Children in Medicaid, FY10
Source: Spending from ad hoc MMIS report 1/26/2011. FY 2010 date-of-service spending excluding DSH, cost settlements,
Medicare premiums, and drug rebate.
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Presentation Outline

Overview of District’s Medicaid Program
 Broad Goals of Health Care Reform

Increased Access Through Program Expansion
Service Delivery Reform To Promote Quality
Increased Coverage Through Exchange

Mayor’s Health Care Reform Implementation
Committee
8
Broad Goals of Health Care Reform Fit
Neatly With District’s History and Focus On
The Uninsured
 New law requires States to expand the Medicaid program to
all persons under age 65 with incomes up to 133% of FPL
 Undocumented immigrants are not eligible
 Federal government will pay:
 100% of this expansion for years (2014-16)
 95% in 2017
 94% in 2018
 93% in 2019
 90% for 2020 and beyond
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DC’s Current Medicaid Eligibility Levels Already
Exceed Targeted Thresholds For Health Reform
DC Medicaid Income Eligibility Thresholds As A Percent of Federal Poverty
$32,670
2014 Heath Reform
Eligibility Threshold
133% of Federal Poverty
(Family of One)
$21,780
$32,670
$24,176
$21,780
$14,483
Medicaid
Eligibility
Groups
Families
Children
w/
Age (0-18)
Children
Pregnant Childless Institution
Adults
and
Women
(Medicaid) Waiver
Note: The District will receive federal support for its eligibility expansion in 2020. Federal
government will pay 90% of the cost of expansion.
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Health Reform Focus On Quality Could
Significantly Impact Programming For
Medicaid In The District
 Significant aspects of the ACA focus on improving the quality of care and
by extension patient outcomes
 Although spending approaches $2 billion questions persist about the
health status of Medicaid and Alliance beneficiaries
 Threshold question is how do we strengthen the link between the
dollars we spend and better patient outcomes
 Progress being made with evidence based approaches to target
problems in prenatal care and we are now beginning to seeing fewer
adverse prenatal outcomes in the District
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Key Questions And Much Work
Remain…..
 How do we get beneficiaries to practice preventive health?
 Regular visits to primary care and follow regimens
 Healthier lifestyle choices – health status has complex
social determinants
 How do we move beneficiaries away from hospitals as a
source of primary care?
 Medicaid is too hospital-based ($300 million on inpatient
care)
 Need more urgent care facilities
 Better management of patient care
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Affordable Care Act Offers Options
Through Medical Homes Concept
 Health Homes – law permits Medicaid enrollees with chronic
physical or mental health conditions to designate a provider
as a health home
 Goal is to address care coordination issues
 Team of health professionals to coordinate and deliver
care
 A mandated list of comprehensive care management and
social support services
 Disease management services
 Prevention services
 Federal government will pay 90 percent of the cost for 2
years
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Affordable Care Act Offers Options Through
Accountable Care Organizations
 Accountable Care Organizations – program that ties provider
reimbursements to quality metrics and reductions in the total cost of care
for an assigned population of patients.
 Four core principles for all ACOs:
1. Provider-led organizations with a strong base of primary care
2. Payments linked to quality improvements that also reduce overall
costs
3. Reliable and progressively more sophisticated performance
measurement to support improvement and provide confidence that
savings are achieved through improvements in care
4. Shared savings model
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Insurance Exchange Is Most Ambitious Goal
of Affordable Care Act
 The Affordable Care Act relies on states to establish health insurance
exchanges
 Goal is to create an insurance marketplaces that provide affordable,
good-quality coverage options to individuals and small businesses
 Forty-eight States and the District of Columbia were awarded their first
Exchange grants in September 2010.
 Those grants were for planning purposes and the next round of grants will
be for the purpose of establishing an Exchange
 DHCF has contracted with Mercer Consulting to provide guidance as to
how the District’s Exchange should be constructed
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Key Questions……….
1. Who will have access to the Exchange and how do
you avoid the problem of adverse selection?
2. How should the Exchange be structured?
3. How much purchasing authority should an
Exchange have?
4. What benefits should be offered in an Exchange?
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Presentation Outline




Overview of District’s Medicaid Program
Broad Goals of Health Care Reform
Increased Access Through Program Expansion
Service Delivery Reform To Promote Quality
Increased Coverage Through Exchange
Mayor’s Health Care Reform Implementation
Committee
17
Mayor Vincent Gray’s Health Reform
Implementation Will Advise Him On Health
Reform Policy
 Mayor Vincent C. Gray announced the creation of the
Mayor’s Health Reform Implementation Committee (HRIC) in
April 2011
 The Committee will advise and make recommendations to
the Mayor’s office on the implementation of the Affordable
Care Act
 The panel will be chaired by Wayne Turnage, Director of the
Department of Health Care Finance and co-chaired by
Department of Health Director Dr. Mohammad Akhter and
Department of Insurance, Securities and Banking
Commissioner William White.
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Mayor Vincent Gray’s Health Reform
Implementation Will Advise Him On Health
Reform Policy
 HRIC will direct the work three subcommittees
 Eligibility and Medicaid Expansion
 Insurance
 Health Delivery System
 Additional committee members will come from related agencies such as
the Department of Human Services, the Department of Mental Health and
the Department of Disability Services
 The committee will submit its recommendations to Deputy Mayor for
Health and Human Services B.B. Otero so that her office can ensure
interagency coordination in implementing the committee’s
recommendations
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