Day 31- Medicaid at 50: State Highlight: West Virginia

wvWest Virginia covers over 530,000 people in its Medicaid and CHIP programs.

West Virginia’s experience with Medicaid expansion has certainly been unique! The state was hot out of the gates when Medicaid expansion first started, enrolling the second highest percent increase. However, in the last year, this has settled to a 50% increase (8th most of expansion states).

The initial increase was largely because the state elected to take advantage of four of the five strategies that CMS offered states to target enrollment and ease the application process. One of the most successful strategies was the SNAP administrative transfer. This strategy uses already existing state SNAP programs to determine eligible individuals. A constant difficulty for advocates and state agency is reaching out to eligible but unenrolled individuals. This strategy assists finding these people by utilizing existing systems, rather than recreating the wheel.

What’s more, West Virginia was the first state to show reports that ER usage hadn’t immediately increased as a result of more people being on Medicaid. I haven’t seen more reports from the state but it would be an interesting thing to follow how ER usage among the newly eligible is different between states. But you didn’t need me to tell you that.

Day 31- Medicaid at 50: Millions and Millions of People

As of the most recent April 2015 Medicaid enrollment report there are currently over 71.1 million people in state Medicaid and CHIP programs. That’s more than the 55 million people in Medicare.

Now I know what you’re thinking– “Emma, Medicaid and CHIP are really 51 programs… isn’t that what you’re also highlighting these 50 days?” Yes yes, well on that measure, Blue Cross Blue Shield does cover 106 million Americans, according to their website, but they are technically 36 different companies. That figure apparently doesn’t include their Medicare or Medicaid contracts.

Can you think of another health insurer that covers more people? The United Kingdom’s National Health Service covers the 64.1 million people in the UK. Can’t think of another?

I can! Indonesia started their new health insurance reforms on January 1, 2014. You were probably too busy paying attention to the United States or something if you hadn’t heard. They already have over 130 million people enrolled (although, I am not sure if there were demands to see enrollment reports or reports of who have paid premiums).

So in conclusion, using back of the envelope math here, Medicaid may be the second largest public health insurance system in world and the second largest health insurer in the US. Well you know what all of the kids say, second the best. Third the nerd, Medicare.

Update: I was recently reminded about China’s Rural Cooperative Medical Scheme which has about 840 million people…. Ok, third largest public insurance program… It’s the age of the nerd I guess.

Day 32 – Medicaid at 50: State Highlight: Washington

Over the coming weeks this blog will highlight a key feature of Medicaid and the individual states that administer Medicaid and CHIP leading up to the program’s 50th anniversary (July 30th). Hopefully, you’ll learn some interesting facts about Medicaid and each of the 51 state programs.

Basics: Washington Apple Health covers 1,696,515 lives

One small but mighty feature of the Affordable Care Act was a two year bump in primary care physician reimbursement within the Medicaid program. A perennial challenge with Medicaid is that lower reimbursements have constrained physician participation. Access to care has been a greater than usual concern with so many people joining Medicaid during the expansion. For two years, the federal government paid to supplement the rates of primary care physicians in Medicaid, raising their payment to parity with Medicare rates. (Speaking of using federal dollars to drive policy change…) At the end of the 2 years, states were free to maintain the higher rates through their own budgets (with standard federal match).

This study in the New England Journal of Medicine found that the reimbursement increases had the intended effect , increasing primary care appointment availability in proportion to the size of the fee increase (see graph). Washington is an expansion state, and Apple Health (what a name!) grappled with the expiration of the fee bump, which they were unable to maintain. In surveying their primary care docs, they found that three-quarters of doctors in small practices would restrict Medicaid patients after the expiration, and one-third would stop taking new Medicaid patients. Now that we are half way through 2015, we should start to see whether or not these concerns have come to pass. The real lesson from this experience is that higher reimbursement for Medicaid primary care providers is a way to increase access, and long-term solutions should be investigated.

Source: NEJM
Source: NEJM

Day 32 – Medicaid at 50: Jobs and the economy

Over the coming weeks this blog will highlight a key feature of Medicaid and the individual states that administer Medicaid and CHIP leading up to the program’s 50th anniversary (July 30th). Hopefully, you’ll learn some interesting facts about Medicaid and each of the 51 state programs.

We’ve mentioned the FMAP and how Medicaid spending can act as an economic stimulus, and now we’ll take a closer look at what that means. This study analyzed the stimulating effects of the ARRA’s FMAP boost. The authors found that marginal increase of $100,000 resulted in 3.8 job-years, of which 3.2 job-years were outside government, health, and education. Another interesting thing about this paper is how they discuss and grapple with the challenges of evaluating extant social programs, where it can be hard to tease apart all the relationships between your different variables.

It wouldn’t be that surprising to find that Medicaid contributes to health care jobs, but it’s quite interesting to see how much of an effect Medicaid seems to have on non-health jobs. This Kaiser Family Foundation report provides a great overview of Medicaid expansion in terms of the economic effects, and summarizes model projections at the state level, so you can look at projected economic impact and jobs state-by-state. The politics of Medicaid can be very contentious, and many argue that the economic benefits of Medicaid are overstated, but a preponderance of evidence points to a positive relationship (of some magnitude) between Medicaid spending and economic growth.

Day 34 – Medicaid at 50: FMAP

[Sorry for the late post – we are back on track!]

One major policy and economic lever of Medicaid is the FMAP, or Federal Medical Assistance Percentage. Unlike Medicare, which is an entirely federal program, Medicaid is a joint state-federal endeavor. This means that the state contributes money for the program, and the federal government matches it at a certain level. The federal matching rate is known as the FMAP. It is based on the state’s per capita income, so low-income states get a higher FMAP than high-income states. The FMAP is calculated every year, and can go up or down based on the economic trends in a given state. The minimum match is 50%, which means the feds match the eligible state Medicaid spending dollar-for-dollar. The current range of FMAPs is 50% to 74.17%. States with FMAPs in the 70s are bringing in almost $3 federal dollars for every state dollar they spend on Medicaid.

The original Medicaid law sets a maximum of 83%, however, there are exceptions to the baseline FMAP calculation. The feds sometimes use the FMAP as an incentive to get states to implement their Medicaid priorities. The most famous example of this is the Medicaid expansion in the Affordable Care Act. In this case, the FMAP is 100% for expansion costs between 2014-2016 (ex. the feds pay all of it), then it starts phasing down to 90%, which it reaches by 2020.

Another way the FMAP can be used is as an economic stimulus. When states are struggling, the federal government can boost the FMAP as a way to get states additional dollars. This helps in two ways: one, it puts direct relief on state budgets since more of the Medicaid budget is carried by the feds. Second, and we’ll talk more about this later, Medicaid dollars are very active in the economy – when Medicaid money comes in, it gets spent right away on goods and services. The American Recovery and Reinvestment Act of 2009 (the stimulus bill) gave a temporary boost to Medicaid FMAPs as a way to help stabilize the economy during a bad recession. The FMAP was also temporarily bumped in response to the 2001 recession, too.

Day 33 – Medicaid at 50: State Highlight: Vermont

Basics: Vermont Medicaid covers 185,478 people

Vermont is famous for things like beautiful nature and Ben & Jerry’s, but for a certain group of people, Vermont’s real claim to fame is health policy. This little state of under 627,000 people has been moving and shaking for decades. In 1989, they created Dr. Dynasaur, which achieved almost universal coverage for kids — nearly 10 years before CHIP. More recently, VT tried to move to a single payer system (they were planning to use a 1332 waiver), but had to scrap this ambitious plan in December 2014 due to cost. Despite this setback, Vermont is still as busy as ever, working on many payment and delivery reforms. For example, they’re using the Health Home option to enhance community-based treatment of opioid addiction. Vermont has been especially hard hit by the opioid epidemic, and has sought to address it by expanding access to medication-assisted treatment (MAT). HHS recommended this approach as a national best practice just this month — once again, Vermont is ahead of the curve.

Oops, I missed some days….

I’m very sorry I was a bit delayed on some days. Michael Anne, my co-blogger has been very diligent to be posting away while I have delayed. I blame the fact that I’ve been ill, but I’m none the less sorry to all the loyal readers (hi dad!).  But here are the posts that I didn’t put up in time!

Day 35: Medicaid at 50– State Highlight: Rhode Island

Rhode Island covers 272,362 people through it’s Medicaid program.

What is better than connecting Medicaid with your first name? Connecting Medicaid, your first name and the great state of Rhode Island. TheEmma Pendleton Bradley Hospital is the oldest pediatric psychiatric hospital in the country. It serves children and adolescents across the state with mental health care.

Medicaid doesn’t pay for inpatient facilities for mental illness with more than 16 beds. This is known as the IMD exclusion. When Medicaid was first enacted (almost 50 years ago, duh), Congress didn’t want the program to replace existing state funded programs that payed for institutions of mental health. However, since the 1960s, states have been deinstitutionalizing their mental health programs, leaving a gap in coverage for many people. In 1972 Congress changed that exemption of inpatient services for children up to 21 years old. This means that children seeing services at the Emma Pendleton Bradley Hospital can have their services paid for by Medicaid. The hospital currently takes Rhode Island’s Medicaid reimbursement. This is great for the children of Rhode Island, but unfortunately, adults are not afforded the same benefit.

Day 34: Medicaid at 50– State Highlight: Utah

Utah covers 303,963 people in it’s Medicaid and CHIP programs.

You might be watching these state Medicaid 1115 waiver demonstrations and be thinking, “Wow! These policies are sooo new. I can’t believe that no one thought of it before!” Well, here is Utah to burst your bubble.

In the early 2000’s Utah’s Republican governor Mike Leavitt initiated and negotiated a waiver demonstration (before Mitt Romney even tried in Massachusetts). This demonstration extended coverage to uninsured parents and other adults up to 150 percent of the poverty line. The demonstration included cost-sharing for these low-income individuals and primary care services. It was not anything close to Medicaid expansion however (or what Massachusetts would later implement). There was a very limited hospital benefit, basically only covering emergency room services. If a person needed surgery or other hospital services, the state would work with hospitals or doctors to provide the individual with charity care.

Utah is currently debating their Medicaid expansion plan. This primary care demonstration is a foundation for building the expanded coverage to low-income adults in Utah. Again, the program is not expansion — the benefits are so limited that it essentially just pays for primary care and ER services. However, the state must remember, before Obamacare, the state was leading the way with extending Medicaid coverage to adults.

(By the way, this information was mainly from the book Medicaid Politics by Frank Thompson. You should buy it!)

Day 43: Medicaid at 50: Safety Net Hospitals

Safety net hospitals serve a large portion of the uninsured and low-income people that would likely be eligible for Medicaid (at least expansion). Either due to state mandates or a mission of providing care to all people, regardless of ability to pay, safety net hospitals disproportionately provide care to people that is often not compensated. In 1981 Congress established the disproportionate share hospital (DSH) payment adjustment in the Omnibus Budget Reconciliation Act of 1981. This law provides additional federal funding to states to disburse to safety net hospitals. While these payments are important to the hospitals, the payments dwarf the cost of treating the uninsured, even with Medicaid’s low reimbursement rates. The DSH allotments to states are set to decrease…eventually.

These DSH allotment decreases and the decrease in uncompensated care in Medicaid expansion are some of the key factors that influence credit rating agencies like Moody’s. Creditors are looking closely at state expansion decisions and congressional decisions on DSH. A better credit rating because of being located in an expansion state could lead to a hospital’s ability to borrow at a lower rate and improve their facilities, that could lead to better care for Medicaid beneficiaries.

Day 42: Medicaid at 50– Medicaid helps state credit ratings

Earlier, I mentioned that Medicaid helps improve a hospital’s credit rating (see above). But Moody’s has also indicated that Medicaid expansion will play a role in their determinations about the overall state’s credit rating. States use these credit ratings to improve their interest rates and borrowing power for infrastructure and other investments. The Medicaid expansion boosts economic stability and keeps people out of poverty. This is good for the state because that can turn into greater revenue and a more productive labor force. The expansion also fills gaps that some states fund for uncompensated care and other services, bringing in additional funds to the state and reducing costs in other programs. This improves the overall budget stability for the state.

Day 41: Medicaid at 50– Many Medicaid beneficiaries are working

One myths of the Medicaid program is that all the people that receive Medicaid aren’t working. This isn’t true! Many people on Medicaid are working, but just not making enough to get subsidies on the Marketplace or not employed by companies that offer health insurance. Additionally, many Medicaid beneficiaries are disabled, elderly, and children– populations that have low employment rates for fairly straightforward reasons.

I can’t really talk about this point better than Drew Altman– and frankly very few people can. So you should just reread his Wall Street Journal explanation and pretend like I was saying it (for my self esteem).