Alina Salganicoff, Ph.D. Vice President and Director, Women’s Health Policy

1. Medicaid’s Role for Women across the Lifespan: Current Issues and the Impact of the Affordable Care Act for Women in Michigan Alina Salganicoff, Ph.D. Vice President and Director, Women’s Health Policy The Henry J. Kaiser Family Foundation Michigan Consumers For Health Care Webinar February 15, 2012

2. Why Medicaid Matters to Women

3. Health Insurance Coverage for Women in Michigan, 2010 Source of health care insurance for women ages 18-64: Insurance coverage in the U.S. Insurance coverage in Michigan “Other” includes programs such as Medicare and military-related coverage. The federal poverty level for a family of four in 2010 was $22,050. Source: KFF/Urban Institute (UI) tabulations of 2010 and 2011 ASEC Supplement to the CPS revised data. UI analysis of 2011 ASEC Supplement to the CPS, U.S. Census Bureau.

4. Projected Expansion and Assistance For Uninsured Women in Michigan Source of Insurance Type of Assistance No Subsidies >400% FPL Tax Credits 139-399% FPL Medicaid ≤138% FPL 3.1Million Women Ages 19-64 497,000 Women Ages 19-64 “Other” includes programs such as Medicare and military-related coverage. The federal poverty level for a family of four in 2010 was $22,050. Source: KFF/Urban Institute (UI) tabulations of 2010 and 2011 ASEC Supplement to the CPS revised data. UI analysis of 2011 ASEC Supplement to the CPS, U.S. Census Bureau.

5. Median Medicaid/CHIP Income Eligibility Thresholds for Adults in Michigan, 2011 2014: Minimum Medicaid Eligibility Under ACA = 138% FPL Note: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI). The federal poverty level (FPL) is $18,350 for a family of three in 2011. Source: KCMU, Performing Under Pressure: Annual Findings of a 50-state Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2011-2012, January 2012.

6. Women Comprise Majority of Adults on Medicaid and the Majority are in their Reproductive Years Distribution of Adult Medicaid Enrollees in Michigan, by Sex Distribution of Adult Women Enrollees in Michigan, by Age Group Total= 960,300 adults Total= 642,000 women The federal poverty level for a family of four in 2010 was $22,050. Source: KCMU analysis of 2008 MSIS data.

7. Profile of Non-Elderly Women on Medicaid in Michigan, 2010 Other*, 2% College degree and higher Asian, 1% ≥200% FPL 9% 5% Some college or associates degree African-American 100-199% FPL Excellent- Good High school graduate 50 to 99% FPL White Fair/Poor <50% FPL Less than high school Note: Includes women on Medicaid ages 19 to 64. The federal poverty level was $18,310 for a family of three in 2010. *Other consists of American Indian/Aleutian Eskimo, Pacific Islander, two or more races. Source: KFF/Urban Institute (UI) tabulations of 2010 and 2011 ASEC Supplement to the CPS revised data. UI analysis of 2011 ASEC Supplement to the CPS, U.S. Census Bureau.

8. Women on Medicaid Have Significant Health Needs Percentage of Non-elderly Women Reporting They Have Been Diagnosed With Condition in Past Five Years: Note: Among women ages 18 to 64. Source: Kaiser Family Foundation, Kaiser Women’s Health Survey, 2008.

9. Women Are the Majority of Long-Term Care Population in the U.S. Total = 1.4 million Total = 2.3 million Note: Nursing home residents refer to those ages 65 and older. Data from 2008. Source: Kaiser Family Foundation analysis of Medicare Current Beneficiary Survey.

10. Figure 9 What Does Medicaid Cover? Optional Benefits Mandatory Benefits • Prescription drugs • Clinic services • Dental services, dentures • Physical therapy and rehab services • Prosthetic devices, eyeglasses • Primary care case management • Intermediate care facilities for the mentally retarded (ICF/MR) services • Inpatient psychiatric care for individuals <age 21 • Home health care and other services provided under home and community-based waivers • Personal care services • Hospice services • ‘Health home’ services for individuals with chronic conditions * • Home and community-based attendant services and supports* • Physician services • Laboratory and x-ray services • Inpatient hospital services • Outpatient hospital services • Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals <age 21 • Family planning services • Rural and federally-qualified health center (FQHC) services • Nurse midwife services • Nursing facility services for individuals >age 21 • Home health care services for individuals entitled to nursing facility care • Smoking cessation services for pregnant women* • Free-standing birth center services * *Benefit classification established by the Patient Protection and Affordable Care Act (ACA) on March 23, 2010. NOTE: As of August 2011.

11. Preventive care Screenings- breast and cervical cancer, STI screening, and chronic condition prevention and screening Family Planning- This is a mandatory benefit and the federal government covers 90% of costs. No cost sharing is allowed, and specific services provided vary among states. Pregnancy Related Care Maternity- Medicaid finances 40-50% of births nationally. Typically covers prenatal care, screenings, delivery, and post-partum care up to 60 days. Abortion- Federal financing of abortion is limited to cases of rape, incest, and life endangerment through the Hyde Amendment Mental Health- covers a range of services including behavioral health and substance abuse rehabilitation and treatment Long-term care Home and Community Based Care- Includes home health workers, transportation, and support services to help beneficiaries remain in their homes Nursing home care- Institutional LTC accounts for approximately 24% of Medicaid spending, but only 2.3% of enrollees Medicaid Services of Importance to Women Source: KCMU, Medicaid’s Long-Term Care Users: Spending Patterns Across Institutional and Community-Based Settings, 2011.

12. IL Medicaid Family Planning Expansions, 2011 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI State plan amendment (6 states) Federal waiver (22 states) No expansion program (22 states, DC) Source: Guttmacher Institute, Medicaid Family Planning Eligibility Expansions, State Policies in Brief, November 2011.

13. IL Share of Births Covered by Medicaid, 2006 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI 20 to 29% FPL (4 states) 30 to 39% FPL (13 states) 40 to 49% FPL (13 states) 50 to 59% FPL (14 states) ≥ 60% FPL (6 states + DC) Source: Sonfield, A., Kost, K., Benson Gold, R., & Finer, L.B. (2011). The public cost of births resulting from unintended pregnancies: National and state-level estimates. Perspectives on Sexual and Reproductive Health 43(2): 94-102.

14. State Medicaid Coverage of Prenatal Services, 2009 Number of state Medicaid programs that cover: Note: Out of 44 states that responded to the survey. Source: Kaiser Family Foundation, State Medicaid Coverage of Perinatal Services: Summary of State Survey Findings, 2009.

15. IL Abortion Financing Under Medicaid, 2011 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI Uses state funds to pay for abortions in other circumstances (17 states) Hyde states – cover abortions only in case of rape, incest, life endangerment (33 states and DC) Source: Guttmacher Institute, State Funding of Abortion Under Medicaid, State Policies in Brief, September 2011.

16. Medicaid Helps Alleviate Some Barriers to Care Percentage of non-elderly women reporting: No Pap test in past two years * * No breast exam in past two years * No usual source of care * No MD visit in past year * Note: Includes women 18 to 64. *Significantly different from Private Insurance, p<.05. Source: Kaiser Family Foundation, 2008Kaiser Women’s Health Survey.

17. But, Not All Barriers Note: Includes women 18 to 64. *Significantly different from Private, p<.05. Source: Kaiser Family Foundation, 2008Kaiser Women’s Health Survey, 2011.

18. Figure 17 Michigan Medicaid Enrollees and Expenditures, FY 2008 23% 63% Total = 1.97 million Total = $9.2 billion NOTE: Percentages may not add up to 100 due to rounding. SOURCE:KFF, Statehealthfacts.org, 2011.

19. Figure 18 Percent Change in Total Medicaid Spending and Enrollment, FY 1998 – FY 2012 NOTE: Enrollment percentage changes from June to June of each year. Spending growth percentages in state fiscal year. SOURCE: Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends. KCMU, http://www.kff.org/medicaid/8248.cfm

20. Figure 19 Medicaid: State Spending per Beneficiary Source: The Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from Medicaid Statistical Information System (MSIS) and CMS-64 reports from the Centers for Medicare and Medicaid Services (CMS), 2011.

21. Figure 20 Medicaid Today and Tomorrow Minimum Floor for Health Insurance Coverage to 138% FPL Health Insurance Coverage for Certain Categories Additional Federal Financing for Coverage MEDICAID Shared Financing States and Federal Govt. Additional Options Long-Term Care / Medicare and Medicaid Coordination for Dual Eligibles Support for Health Care System Assistance for Medicaid and Medicare duals / Long-Term Care

22. Figure 21 Summary and Outlook • Critical lifeline to care for 21 million low-income women • Foundation for new coverage for low-income individuals under health reform • Challenges • Disproportionately sick population • Ensuring access to services • States still struggling from the effects of the Great Recession, so pressure to control Medicaid spending persists • States face tight timelines and have limited staff to prepare for the implementation of health reform • Opportunities • Health reform presents opportunities to significantly reduce the number of uninsured • Greater focus on developing quality metrics for Medicaid- how to we keep the focus on women?