A ARP PUBLIC POLICY INSTITUTE OCTOBER 2018 Fact Sheet Breaking Through the Noise: The Facts about the Medicaid Program Brendan Flinn and Jean Accius AARP Public Policy Institute Medicaid is a lifeline for millions of children, adults with low incomes, individuals with disabilities and older adults who depend on Medicaid for health care services and assistance with long-term services and supports (LTSS) such as eating, bathing, and dressing. This Fact Sheet highlights several key facts that are important to know about Medicaid and the millions of people who depend on this program to address their daily needs. Medicaid Plays a Significant Role in the Health Coverage by Public Payer, F Y 2016 Nation’s Health Care System (in millions) In 2016, total Medicaid spending (federal and state) accounted for 17 percent of all U.S. health care spending.1 Nearly 70 million Americans received health and LTSS coverage through Medicaid. Medicaid is the largest public source of coverage relative to Medicare,2 (45 million) and TRICARE3 (9 million). By comparison, more than 150 million Americans received health coverage through employer-sponsored insurance or other private coverage. Medicaid coverage increased by more than 16 million since the enactment of the Affordable Care Act.4 In the absence of Medicaid, the number of uninsured would be significantly higher. Medicaid is a counter-cyclical program. The number of persons who qualify for Medicaid goes up during times of economic downturn as unemployment rises, individuals and families lose Source: AARP Public Policy Institute analysis of employer-sponsored coverage and incomes decline. Kaiser Family Foundation and Defense Health For example, during the Great Recession Medicaid Agency data. enrollment increased by 8 million people.5 Medicaid Is an Efficient Program Medicaid is an efficient program with lower administrative costs in comparison to private insurance. At the aggregate level, Medicaid spending growth is slower than the growth seen in private health insurance. From 2015 to 2016, total Medicaid spending grew by 3.9 percent whereas private insurance spending grew by 5.1 percent. 1 A ARP PUBLIC POLICY INSTITUTE OCTOBER 2018 Spending at the person level follows a similar trend. because of their high need and high cost for LTSS. From 2010 to 2016, annual per person spending Any structural changes to Medicaid financing growth was also slower in Medicaid (1.3 percent) than would disproportionately impact these populations. in private insurance (3.5 percent) from 2010–2016.6 See the appendix for additional state data on Spending Growth in Medicaid and Private Medicaid enrollment across all ages, among Insurance adults ages 50–64, and adults 65+. Medicaid Provides Extra Help to Low- Income Medicare Beneficiaries Medicaid also provides support to nearly 11 million Medicare beneficiaries (also known as dual eligibles). These individuals are a high need, high cost population and represent some of the poorest and sickest beneficiaries in the Medicare program. Medicaid plays a critical role in their care by covering services for which Medicare does not pay (and low income older adults cannot cover themselves). It provides access to LTSS and, depending on the state, dental and vision services, among others. In addition, Medicaid can cover Source: AARP Public Policy Institute analysis of Centers monthly Medicare Part B premiums (currently for Medicare and Medicaid Services data. $134 for lower income earners) and Medicare’s cost sharing charges for eligible enrollees.8 Medicaid Provides Critical Support for Medicaid Is the Largest Public Payer of Children, People with Disabilities, and Long-Term Services and Supports Older Adults In 2016, Medicaid spent $167 billion on LTSS. Over Children make up the largest group of Medicaid the last five years, the percentage of LTSS spending enrollees (41 percent). Medicaid pays for about going to home and community-based services (HCBS) half of all births in the United States, and covers increased for all populations. However, these figures, more than 3 in 4 children in low-income families. mask substantial spending variations, both by state In addition, the program covers close to half and by demographic group. In FY 2016, more than (48 percent) of children with special health care half (55 percent) of Medicaid LTSS dollars serving needs, including disabilities.7 older adults and people with physical disabilities Older Americans also rely on Medicaid. Close to went towards institutional settings, such as nursing 1 in 4 (23 percent) enrollees are adults aged 50+, homes.9 Nursing home care is about three times the including about 8.7 million adults are between the cost of home and community-based services and ages of 50–64 and 6.7 million adults ages 65+. The often out of line with the strong desire among older program also covers close to half of adults ages adults and individuals with disabilities to receive 18–64 with disabilities (48 percent) and provides services in their homes and communities.10 critical LTSS that individuals and families are not From a state perspective, the percentage of otherwise able to afford. LTSS spending for older people and adults with While the majority of Medicaid enrollees are disabilities going to HCBS ranged from 13 percent children and adults, most of the spending is for in Kentucky to 73 percent in New Mexico. older adults and individuals with disabilities Furthermore, at least 10 states have actually 2 A ARP PUBLIC POLICY INSTITUTE OCTOBER 2018 decreased the share of Medicaid LTSS dollars going This includes work requirements, in which states toward home and community-based care according could eliminate Medicaid coverage for adult enrollees to new analysis from AARP Public Policy Institute.11 who don’t have a job and aren’t completing related activities (e.g., education). One state estimate Medicaid HCBS Expenditures as a Percentage of shows that these policies could reduce coverage by Total Medicaid LTSS Spending, FY2012–FY2016 15 percent,13 and national estimates project that work requirement policies could cause up to four million Americans to lose coverage.14 Adults ages 50–64 are at particular risk in states where they are or may become subject to work requirements, as they often spend longer seeking employment and experience long-term unemployment at rates higher than their younger counterparts.15 Work requirements are often enforced by requiring people to report their work status via a complex, web-based portal. However, a large share of Medicaid enrollees, do not have internet access and therefore would experience significant difficulty reporting their compliance. In Arkansas, for example, some estimate that more than 4,000 people lost coverage due to noncompliance.16 Medicaid Is an Important Support for Low- Wage Workers and Their Families Medicaid Plays a Critical Role in The vast majority of adults enrolled in Medicaid are Addressing the Opioid Crisis either working (60 percent) or in a family with at More than 2 million adults in the U.S. have some least one worker (78 percent). These workers are often type of opioid addiction. By financing treatment and employed in industries (e.g., food service) where recovery, Medicaid is critical in addressing the opioid health coverage is not typically offered. In addition, epidemic. In 2016, Medicaid covered more than close to half (42 percent) work for small businesses half (55 percent) of low-income adults ages 19–64 (fewer than 50 workers) exempt from the employer with an opioid addiction. Of this same group, just mandate. Medicaid helps support low-income 13 percent had private coverage and nearly a quarter working families by ensuring that they have access (24 percent) were uninsured. Medicaid-enrolled to healthcare coverage when their jobs don’t offer people with opioid addictions are more likely to seek this as a benefit. Of Medicaid-enrolled adults who both inpatient and outpatient treatment than those don’t work, more than one-third (36 percent) are ill or with other or no health insurance.17 disabled, another 30 percent are caregiving or raising families, and 15 percent are students.12 Medicaid Is a Popular Program Medicaid enjoys broad, bipartisan support from the Medicaid Work Requirements and Other public. Close to 3 in 4 (74 percent) Americans have Coverage Restrictions Threaten Access to a favorable view of Medicaid, and more than half of Vital Health Care Services Democrats, Republicans and independents say that States have considerable leeway when it comes to Medicaid is working well at both the national and administering their Medicaid program. Over the state levels. About 6 in 10 people say that Medicaid last year, states have submitted proposals to the is important to them and their family, and most federal government to enact policies that could (87 percent) want Medicaid funding to be maintained reduce Medicaid coverage. or increased.18 3 A ARP PUBLIC POLICY INSTITUTE OCTOBER 2018 Appendix. Medicaid Enrollment Across All Ages and Among Older Adults, by State (2016) Total Enrollment among Enrollment among Percent of Enrollees State Enrollment Adults Ages 50–64 Adults Ages 65+ Ages 50+ Alabama 962,100 117,300 116,600 24% Alaska 131,300 14,600 11,800 20% Arizona 1,591,800 214,200 140,600 22% Arkansas 780,500 103,300 68,800 22% California 10,575,800 1,455,700 1,102,600 24% Colorado 1,056,000 134,200 79,000 20% Connecticut 723,700 108,300 75,100 25% Delaware 190,100 27,700 18,800 24% District of Columbia 189,700 33,400 20,400 28% Florida 3,858,400 465,700 574,000 27% Georgia 1,817,900 192,900 197,400 21% Hawaii 244,000 34,800 29,200 26% Idaho 293,000 22,100 31,600 18% Illinois 2,550,400 344,600 201,500 21% Indiana 1,182,800 153,000 91,600 21% Iowa 591,300 75,100 52,100 22% Kansas 401,400 41,000 42,100 21% Kentucky 1,164,500 192,900 84,700 24% Louisiana 1,166,000 143,700 103,600 21% Maine 252,700 41,600 42,300 33% Maryland 1,066,800 148,000 101,000 23% Massachusetts 1,583,300 275,700 182,300 29% Michigan 2,239,800 344,200 189,400 24% Minnesota 989,700 135,200 73,300 21% Mississippi 718,500 83,900 81,100 23% Missouri 881,600 110,400 91,300 23% Montana 203,000 28,000 20,700 24% Nebraska 243,500 20,700 30,300 21% Nevada 569,200 76,700 50,100 22% New Hampshire 181,200 25,900 16,900 24% New Jersey 1,516,000 216,500 164,900 25% New Mexico 664,800 85,400 52,400 21% New York 5,128,300 811,100 574,400 27% North Carolina 1,865,200 199,800 191,900 21% North Dakota 85,900 10,300 9,400 23% Ohio 2,445,000 331,200 176,100 21% Oklahoma 698,300 61,000 64,700 18% Oregon 946,600 140,100 79,800 23% Pennsylvania 2,506,000 360,500 260,200 25% Rhode Island 230,100 41,100 26,000 29% South Carolina 965,900 109,700 105,200 22% South Dakota 125,500 11,700 13,600 20% Tennessee 1,411,100 178,100 134,300 22% Texas 4,791,800 411,400 463,400 18% Utah 341,600 32,200 31,600 19% Vermont 161,900 26,800 16,100 26% Virginia 951,000 99,400 102,700 21% Washington 1,519,000 205,200 128,500 22% West Virginia 520,000 84,900 41,200 24% Wisconsin 1,014,000 140,000 112,600 25% Wyoming 69,600 9,100 8,700 26% United States 66,357,200 8,730,300 6,677,900 23% Source: AARP Public Policy Institute Analysis of the 2016 American Community Survey Data, U.S. Census Bureau 4 A ARP PUBLIC POLICY INSTITUTE OCTOBER 2018 1 Centers for Medicare and Medicaid Services. “National 12 Rachel Garfeld and Robin Rudowitz. “Understanding the Health Expenditures.” Centers for Medicare and Medicaid Intersection of Medicaid and Work.” Washington, DC: Kaiser Services, April 2018. http://www.cms.gov/Research- Family Foundation. https://www.kff.org/medicaid/issue- Statistics-Data-and-Systems/Statistics-Trends-and- brief/understanding-the-intersection-of-medicaid-and-work/ Reports/NationalHealthExpendData/NHE-Fact-Sheet.html 13 Aviva Aron-Dine. Eligibility Restrictions in Recent Medicaid 2 Kaiser Family Foundation. “Health Insurance Coverage of the Waivers Would Cause Many Thousands of People to Become Total Population.” Washington, DC: Kaiser Family Foundation. Uninsured. Washington, DC: Center on Budget and Policy https://www.kff.org/other/state-indicator/total-population/ Priorities. https://www.cbpp.org/research/health/ ?dataView=1&currentTimeframe=0&sortModel=%7B%22colId eligibility-restrictions-in-recent-medicaid-waivers-would- %22:%22Location%22,%22sort%22:%22asc%22%7D cause-many-thousands-of 3 Defense Health Agency. Evaluation of the TRICARE Program: 14 Rachel Garfeld, Robin Rudowitz, and MaryBeth Musumeci. Fiscal Year 2018 Report to Congress. Washington, DC: “Implications of a Medicaid Work Requirement: National Defense Health Agency. https://health.mil/Reference- Estimates of Potential Coverage Losses.” Washington, DC: Center/Reports/2018/05/09/Evaluation-of-the-TRICARE- Kaiser Family Foundation. https://www.kff.org/medicaid/ Program-Fiscal-Year-2018-Report-to-Congress issue-brief/implications-of-a-medicaid-work-requirement- national-estimates-of-potential-coverage-losses/ 4 Kaiser Family Foundation. “Total Monthly Medicaid and CHIP Enrollment.” Washington, DC: Kaiser Family Foundation. 15 Jennifer Schramm. “An Aging Labor Force and the https://www.kff.org/health-reform/state-indicator/total- Challenges of 65+ Jobseekers.” Washington, DC: AARP monthly-medicaid-and-chip-enrollment/ Public Policy Institute, 2018. https://www.aarp.org/ppi/ info-2018/an-aging-labor-force.html 5 Kaiser Family Foundation. “Medicaid Enrollment: June 2011 Data Snapshot.” Washington, DC: Kaiser Family Foundation. 16 Robin Rudowitz and MaryBeth Musumeci. An Early Look at https://www.kff.org/medicaid/issue-brief/medicaid- State Data for Medicaid Work Requirements in Arkansas. enrollment-june-2011-data-snapshot/ Washington, DC: Kaiser Family Foundation, 2018. https://www.kff.org/medicaid/issue-brief/an-early-look-at- 6 Centers for Medicare and Medicaid Services. National Health state-data-for-medicaid-work-requirements-in-arkansas/ Expenditure 2016 Highlights. Baltimore, MD: Centers for Medicare and Medicaid Services, January 2018. 17 Julia Zur and Jennifer Tolbert. “The Opioid Epidemic and https://www.cms.gov/Research-Statistics-Data-and- Medicaid’s Role in Facilitating Access to Treatment.” Systems/Statistics-Trends-and-Reports/NationalHealth Washington, DC: Kaiser Family Foundation, 2018. ExpendData/NationalHealthAccountsHistorical.html https://www.kff.org/medicaid/issue-brief/the-opioid- epidemic-and-medicaids-role-in-facilitating-access-to- 7 Kaiser Family Foundation. “10 Things to Know about treatment/ Medicaid: Setting the Facts Straight.” Washington, DC: Kaiser Family Foundation, 2018. https://www.kff.org/ 18 Kaiser Family Foundation. “Data Note: 10 Charts About medicaid/issue-brief/10-things-to-know-about-medicaid- Public Opinion on Medicaid.” Washington, DC: Kaiser setting-the-facts-straight/ Family Foundation, 2017. https://www.kff.org/medicaid/ poll-fnding/data-note-10-charts-about-public-opinion-on- 8 Jean Accius, Lynda Flowers, and Brendan Flinn. “Low-Income medicaid/ Medicare Beneficiaries Rely on Medicaid for Critical Help.” Washington, DC: AARP Public Policy Institute, 2018. https://www.aarp.org/ppi/info-2017/low-income-medicare- benefciaries-rely-on-medicaid-for-critical-help.html Fact Sheet 645, October 2018 9 Steve Eiken, Kate Sredl, Brian Burwell, and Angie Amos. © AARP PUBLIC POLICY INSTITUTE Medicaid Expenditures for Long-Term Services and 601 E Street, NW Supports in FY 2016. Bethesda, MD: IBM Watson Health. Washington DC 20049 https://www.medicaid.gov/medicaid/ltss/downloads/ Follow us on Twitter @AARPpolicy reports-and-evaluations/ltssexpenditures2016.pdf on facebook.com/AARPpolicy www.aarp.org/ppi 10 Joanne Binette and Kerri Vasold. “2018 Home and Community Preferences: A National Survey of Adults Age 18-Plus.” For more reports from the Public Policy Washington, DC: AARP Research, 2018. https://www.aarp. Institute, visit http://www.aarp.org/ppi/. org/research/topics/community/info-2018/2018-home- community-preference.html 11 Ari Houser, Wendy Fox-Grage, and Kathleen Ujvari. Across the States 2018: Profiles of Long-Term Services and Supports. Washington, DC: AARP Public Policy Institute. http://www.aarp.org/acrossthestates 5