main brochure - Health Policy Institute of Ohio
Transcription
main brochure - Health Policy Institute of Ohio
Ohio Medicaid Basics February 2003 Ohio Medicaid provides a broad range of health services to 1.6 million low-income working families, children, and aged, blind, and disabled Ohioans. Introduction a Ohio Medicaid Basics Enacted in 1965 at the same time as Medicare through Title XIX of the federal Social Security Act, the Medicaid program is the largest of the federal-state partnerships for low-income Americans. Medicaid provides federal matching funds to states for certain health care services for eligible individuals. Each state administers its own Medicaid program. The federal Centers for Medicare and Medicaid Services (CMS) monitor staterun programs and establish new requirements for service delivery and quality, funding, and eligibility standards. State participation is voluntary and all states have participated since 1982. Ohio Medicaid began in 1968. Ohio Medicaid: • covers 1 out of every 3 births • covers 1 out of every 4 children • covers 1 out of every 4 seniors over age 85 • spends a smaller portion on administrative costs than 47 states • pays for 70% of all nursing home care in the state • covers children in families up to 200% of the Federal Poverty Level (FPL) • covers working parents in families earning up to 100% FPL • covers Medicare premiums for eligible seniors and people with disabilities Overview of Ohio Medicaid Ohio Medicaid is administered by the Office of Ohio Health Plans of the Ohio Department of Job and Family Services (DJFS). Each of Ohio’s 88 county-level DJFSs also plays an important role in Ohio Medicaid. Medicaid represents a significant portion of Ohio’s overall state budget. Ohio spends approximately 24% of state funds on Medicaid, making it the second-largest budget item after education. As a result, an increase in program costs can have a serious impact on the overall fiscal condition of the state. Contents Eligibility ........................................................ 2 Key Programs ................................................ 3 Mandatory Medicaid Services .................... 5 Delivery Systems .......................................... 6 Financing and Expenditures ....................... 9 Controlling Medicaid Expenditures ........ 12 Why Changing Medicaid Isn’t Easy ........ 13 An Ohio Parent’s View of Medicaid ........ 15 Online Resources ........................................ 16 Endnotes ...................................................... 16 Although the majority of people enrolled in Ohio Medicaid are families and children, the majority of expenditures pay for services to aged, blind, and disabled Ohioans. Eligibility Ohio Medicaid E ligibility C o v er ed Populat ions Incom e Guidelines* <200% Federal Poverty Level (FPL) Children (up to age 19) Parents <100% F P L Pregnant Women <150% F P L Disabled Individuals <64% FPL** Ohioans age 65 & over <64% FPL** Qualified Medicare Beneficiaries <100% F P L Institutional Level of Care Income less than cost of care * A sset t est s and ot her f act ors af f ect el i gi bi l i t y, whi ch i s det erm i ned by t he count y DJFSs. ** Deduct i ons and except i ons appl y. Peopl e m ay have m edi cal expenses deduct ed f rom i ncom e cal cul at i ons t o "spend down" t o t hi s l evel . 2003 Federal Poverty Levels (FPL)* Annual Income Family S ize 100% FP L 150% FP L 200% FP L 1 $8,980 $13,470 $17,960 2 $12,120 $18,180 $24,240 3 $15,260 $22,890 $30,520 4 $18,400 $27,600 $36,800 In general, Medicaid covers low-income children, their parents, and aged, blind, or disabled people. However, certain income and resource criteria must be met as well. Income criteria are largely based on poverty guidelines established by the federal government. Resource criteria—which largely apply only to aged, blind, and disabled people applying for Medicaid—are based on savings, home ownership, and other assets. Parents and Children The Ohio Medicaid program covers over 870,000 low-income children and 400,000 low-income adults in families with children. The majority of eligible adults in families with children are women. Children represent the largest demographic group served by Ohio Medicaid, with nearly half of all eligible Ohioans being age 14 or younger. Pregnant women who meet certain income criteria are also eligible for coverage during their pregnancy. Aged Approximately 33% of all Ohioans age 65 and over are currently covered by Ohio Medicaid. Some are eligible because they receive cash assistance through the Social Security Administration’s Supplemental Security Income (SSI) program. Others have too much income to qualify for SSI but have large medical or long-term care expenses that reduce or “spend down” their incomes to qualify. Blind and Disabled An estimated 16% of Ohioans covered by Medicaid qualify for services due to a “physical or mental impairment that inhibits work and that has lasted or will last at least 12 months or result in death.” This excludes disabled individuals who are first eligible by virtue of age or income. Most individuals with a major disability are eligible for cash assistance through SSI and therefore qualify for Medicaid. Others qualify by “spending down” their incomes on medical expenses. Some people with a disability also receive Medicaid assistance to help pay their Medicare premiums. * These appl y t o t he 48 cont i guous st at es and D.C. 2 Ohio Medicaid Basics • February 2003 Key Programs Ohio Medicaid consists of many programs. Four of the largest programs are: 1. Healthy Families and Related 2. Healthy Start 3. Aged, Blind, or Disabled 4. Medicare Premium Assistance Program 1. Healthy Families and Related The Healthy Families and Related program covers low-income families and children. The majority of families covered in this category are single-parent families. There are three divisions within Healthy Families and Related: Healthy Families, Transitional Medicaid, and Other Related Groups. Healthy Families, previously known as Low-Income Families, provides health care coverage primarily to low-income working families. A small number of covered families also receive Ohio Works First (OWF) cash assistance. Although Healthy Families is a freestanding program, it was not always so. Historically, Medicaid was not available to a family unless they also received cash assistance. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, sometimes called welfare reform legislation, enabled Medicaid to become a stand-alone program. Families who qualify can now receive Medicaid coverage without receiving cash assistance. On July 1, 2000, Healthy Families coverage was expanded to families earning up to 100% of the Federal Poverty Level (FPL). In addition, procedural changes made at that time allow families who need only Healthy Families coverage and not cash assistance to apply by mail. Also, new verification requirements allow families to only have to provide proof of income, of other health care coverage, and of pregnancy. These simplifications help working families obtain medical coverage through Healthy Families. Transitional Medicaid provides temporary Medicaid coverage for working families who had received Healthy Families coverage but who now have earned incomes above the eligibility criteria. Under this program, Medicaid eligibility is guaranteed for six months, and can be extended for an additional six months if monthly income is less than or equal to 185% FPL. Other Related Groups includes “Ribicoff children,” certain 19 and 20 year olds who meet particular income and asset limits. Ohio Medicaid Basics • February 2003 3 2. Healthy Start Healthy Start provides health care coverage for children from birth through age 18 in families with incomes up to 200% FPL. Children in families with incomes at 151–200% FPL are eligible only if they do not have other health coverage. Children in families with incomes at or below 150% FPL are eligible regardless of other health coverage. Newborns are automatically eligible for 12 months of Healthy Start coverage if the mother was eligible for Medicaid when the baby was born. This 12-month period exists regardless of subsequent changes in the mother’s income. Pregnant women with family incomes up to 150% FPL also qualify for Healthy Start. Coverage for the woman begins at confirmation of pregnancy and ends two months after the end of the pregnancy. In determining financial eligibility, the pregnant woman’s family size includes the number of babies expected as a result of the State Children’s Health pregnancy. Insurance Program The federal Balanced Budget Act (BBA) of 1997 amended the Social Security Act to create Title XXI, the State Children’s Health Insurance Program (SCHIP). In each state, SCHIP provides health insurance for children in families with income too high to qualify for Medicaid but too low to afford private coverage. The federal government matches the state’s SCHIP spending at a higher rate than that for Medicaid. In Ohio for FY 2002, the federal match for Medicaid is 58.8%, but the match for Healthy Start, Ohio’s SCHIP, is 71.2%. Just before the BBA was passed, the Ohio legislature passed its 1998–1999 state budget, which included a Healthy Start expansion. Ohio’s SCHIP was implemented as part of this expansion in 1998. Currently, uninsured children in families up to 200% FPL are covered by SCHIP, and Ohio receives the federal SCHIP match rate for services. Children in families up to 150% FPL who have inadequate health insurance—i.e., underinsured—are also covered by Ohio Medicaid, and Ohio receives the federal Medicaid match rate for services. 4 3. Aged, Blind, or Disabled Ohioans who are age 65 and older, who are blind, or who have a major disabling condition are covered under the Aged, Blind, or Disabled (ABD) program. These Ohioans account for 29% of all Ohio Medicaid consumers. Approximately 41% of individuals covered by the ABD program are eligible by virtue of age. Many people age 65 and older who qualify for Medicaid also have a disability, but they first became eligible for Medicaid due to age, not disability. People with disabilities account for about 59% of people in the ABD program. People of all ages with a wide variety of disabilities, such as blindness, mental retardation, or severe mental illness, can qualify if their disability, income, and resources meet certain criteria. The Healthy Families and Related programs also include some people with disabilities. Certain low-income people with disabilities receive Healthy Families or Healthy Start Ohio Medicaid Basics • February 2003 because their condition does not meet the criteria for the ABD program. Or, individuals may choose to enroll in Healthy Families or Healthy Start rather than the ABD program because the enrollment process is easier. Others may select the ABD program because they need long-term care services not available through Healthy Families or Healthy Start. 4. Medicare Premium Assistance Program The federal government requires that state Medicaid programs pay Medicare premiums, deductibles, or coinsurance for qualified people enrolled in Medicare Parts A or B. Many would argue that Medicaid substantively underwrites the Medicare program. Ohio Medicaid uses several categories of Medicare Premium Assistance Programs to meet this requirement. Mandatory Medicaid Services States are required to cover a minimum set of services under Medicaid, including: • inpatient hospital services; • outpatient services, including those delivered in Rural Health Clinics and Federally Qualified Health Centers (FQHCs); • physician services; • nursing facility services and home health services for people age 21 and older; • skilled home health services for adults, including durable medical equipment (optional for others who need durable medical equipment); • family planning services and supplies; • lab and X-ray services; • nurse-midwife, certified family nurse practitioner, and certified pediatric nurse practitioner services; Ohio Medicaid Basics • February 2003 Optional Services Covered by Ohio Medicaid States may opt to cover additional services, which also qualify for federal matching funds. Ohio covers the following optional services under Medicaid with a focus on preventive care for Ohio’s most vulnerable residents: • ambulance and ambulette services; • additional durable medical equipment and supplies; • self-administered prescription drugs; • speech and hearing services, including hearing aids; • services of licensed practitioners, including podiatrists, chiropractors, physical therapists, mechanotherapists, psychologists, and private duty nurses; • intermediate care facility services, including those for people with mental retardation; • hospice care; • dental services, including dentures; • vision services, including eyeglasses; • certain prosthetic and orthotic devices; • home health services for consumers who require less than a skilled nursing facility; • community alcohol and other drug addiction treatment services; • freestanding ambulatory clinics and outpatient health facilities; • community mental health services; and • waiver services. While some of these services are considered “optional,” most are central to effective health care (i.e., prescription drugs and dental care and mental health services). In many cases, eliminating “optional” services would increase utilization and costs of some mandatory services, particularly emergency room care and hospitalizations. In addition, certain segments of the population, like families with mentally retarded children, depend upon these optional services for care, making these services difficult to discontinue. 5 • medical and surgical services of a dentist; • transportation; and • screening and treatment services to all eligibles under the age of 21 under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program (called “HEALTHCHEK” in Ohio). Delivery Systems Services covered by Medicaid are bundled into two benefit packages: Primary and Acute Health Care and Long-Term Care. In addition, the Ohio DJFS operates the Hospital Care Assurance Program under Ohio Medicaid. Primary and Acute Health Care Medicaid’s Primary and Acute (P&A) Health Care package provides physician, hospital, laboratory, medications, preventive care, family planning, and other services. People have access to P&A services through either the Fee-for-Service system or the Managed Care system, depending upon the type of Medicaid for which they are eligible. The P&A Health Care package also covers prescription medications for all Ohio Medicaid consumers. In the Fee-for-Service system, Medicaid beneficiaries present a Medicaid card when they access health care. The Ohio DJFS pays for services based on an established fee schedule, though a few providers are paid on a cost-based schedule. The Managed Care system started in 1978, when the Ohio DJFS first contracted with managed care plans (MCPs) in an effort to ensure access to services and quality of care as well as to better predict Medicaid costs. As of October 2002, approximately 400,000 Ohioans were enrolled in one of six licensed Medicaid MCPs. About 40% of Healthy Family and Healthy Start consumers are enrolled in MCPs operating in 15 counties. Managed care helps assure access to a primary care provider, emphasizes preventive care, and encourages the appropriate utilization of services in the most cost-effective settings. MCPs provide services beyond those required in the Fee-for-Service system, including grievance processes and call centers for member services. 6 Ohio Medicaid Basics • February 2003 Prescription Medications are increasingly becoming a core feature of health care for all Americans. Ohio Medicaid’s pharmacy expenditures have more than doubled in the past five years, including an 18.8% increase in prescription drug spending in 2000. Other states are also seeing increases, and, nationally, these recent increases are believed to be due to: • price inflation (22%), • a shift to higher-priced medications (36%), and • an increase in the number of prescriptions filled (42%).1 Although the rising cost of prescription medications is a critical issue, Ohio Medicaid’s prescription program compares favorably to other states. A recent study shows that, when compared to Ohio: • 42 states experienced higher rates of growth in their drug programs in 1999 to 2000, • 45 states had higher average costs per prescription, Ohio Access for People with • 39 states paid higher dispensing fees, Disabilities and Changes in the aging and disabled • 42 states paid higher product costs than populations are affecting the way services are Ohio.2 organized and delivered in Ohio. Many of the traditional, institutional-based services offered to these populations are now being offered in Long-Term Care The Long-Term Care (LTC) benefit package community-based settings, such as the provides additional services to people who person’s own home or an assisted living have chronic or disabling conditions and facility. meet certain “level of care” criteria. LTC In 2001 the Governor announced Ohio Access, a services fall into two categories based on the statewide blueprint for long-term care setting in which services are delivered. developed in conjunction with consumers, Because LTC services are rarely covered by providers, and community representatives. private insurance or Medicare, Medicaid is The Office of Budget and Management the primary source of coverage for many coordinated this initiative with the who need these services. participation of the Departments of Job and Facility-Based Care covers services provided Family Services, Mental Health, Mental in certain residential settings and accounts Retardation and Developmental Disabilities, for the largest portion of Ohio Medicaid Health, Aging, and Alcohol and Drug costs. In fact, Ohio Medicaid is the leading Addiction Services. payer of nursing facilities in the state, as it Goals for Ohio Access include that Ohio’s covers 70% of all days of care for nursing seniors and people with disabilities: facility residents. • live with dignity in the settings they prefer; Medicaid also covers care in residential • have access to safe, high-quality, long-term facilities for developmental disabilities, care services wherever they live; and including mental retardation. All 6,000 • control funds available for their care and are Ohioans living in intermediate care involved in choosing services and residential facilities for the mentally caregivers. retarded are Medicaid consumers. Ohio Medicaid Basics • February 2003 7 Community-Based Care incorporates a number of programs into a framework that increasingly emphasizes the delivery of services in settings other than institutional or nursing facilities, settings such as the home or community. The Ohio Home Care Program provides home care services to all eligible Medicaid consumers depending on their medical needs. Ohio also uses Home- and Community-Based Service (HCBS) Waivers to allow certain Medicaid consumers to remain in the community—including remaining in their own homes—with supportive services rather than move into an institution to receive the care they need. Waiver services are available on a limited basis and eligibility is based on income, resources, and level of care required. What’s a Waiver? Federal law requires that Medicaid consumers have freedom of choice of providers, that the program is available statewide, and that services are available in amount, duration, and scope sufficient to achieve their purpose. States can also choose to cover optional services and eligible groups. Some options are specifically described in the Social Security Act, while other options are available through “waivers.” The term “waiver” is used whenever an exception to federal law has been granted to the state by the Centers for Medicaid and Medicare (CMS). For example, Home- and Community-Based Care waivers, provided under Section 1915(c), allow people to receive Medicaid-covered care in the community or at home rather than in a nursing facility. In 1989, Ohio implemented a 1915(b) waiver, which waives the freedom of choice requirement so a state can implement a managed care program. In 1996, Ohio implemented a Section 1115 demonstration waiver, which allows for research and demonstration of comprehensive health program reforms, to implement a managed care program, OhioCare. When this waiver expired in 2001, Ohio Medicaid assessed the OhioCare program objectives and decided to change the 1115 authority to a 1915(b) authority. 8 Ohio currently has four HCBS waiver programs, all of which are funded by Medicaid: PASSPORT, the Ohio Home Care Waiver, the Individual Options Waiver, and the Residential Facility Waiver. In response to the growing demand for more waiver slots, Ohio increased the number of residents served through HCBS waiver slots from roughly 10,000 in 1992 to nearly 50,000 in 2002. For any given individual, home care is less expensive than institutional care. Also, the evidence suggests that those who enter institutional care settings generally do not return home. Therefore, prevention of institutional care is important both for quality of life and for cost containment. The HCBS waivers help prevent institutional care. A difficult tension is created as expansion of coverage for community-based services broadens the potential pool of individuals who might choose waiver services. As program eligibility expands, higher utilization of community-based services can quickly deplete the per-person savings. Hospital Care Assurance Program The Hospital Care Assurance Program (HCAP) assures that care is available for a wide range of medically underserved Ohio Medicaid Basics • February 2003 populations. Through HCAP, Ohio meets the federal requirement to provide additional payments to hospitals providing a disproportionate share of uncompensated services to indigent people. In exchange for receiving HCAP funds, hospitals must provide basic, medically necessary hospital services free of charge to people whose incomes are at or below 100% FPL. In 2001, participating Ohio hospitals had more than 325,000 HCAPeligible outpatient visits and nearly 30,000 HCAP-eligible inpatient discharges. HCAP assesses and collects fees from each hospital, which are pooled and used to draw down federal matching funds. These funds are then distributed back to hospitals relative to each hospital’s share of the total statewide indigent care services delivered. Financing and Expenditures Between 1987 and 2000, federal Medicaid matching funding to states increased from 26% of the federal budget ($108 billion) to 43% ($246 billion).3 Much of the complexity in the Ohio Medicaid budget is the result of trying to maximize these federal matching dollars through interdepartmental fund transfers and other strategies. Medicaid Financing Ohio Medicaid is funded through Ohio General Revenue Funds (GRF) and federal matching funds based on the Federal Medicaid Assistance Percentage (FMAP). Ohio’s FMAP match for FY 2002 is 50% for Medicaid administrative activities, 58.8% for Medicaid services, and 71.2% for SCHIP. Medicaid accounts for 16% of Ohio’s GRF but 31% of the GRF if the federal match is included. Of total state spending, including GRF and non-GRF funds, Medicaid accounts for 24% of the state budget. The Ohio Medicaid Budget for State Fiscal Year (SFY) 2003 is $8.5 billion, an 8.0% increase over SFY 02. However, nearly 10% of the 2002 Ohio Medicaid budget is funded with non-GRF sources, including $150 million from the state’s Budget Stabilization Fund, which is a one-time source not available for future years. Ohio Medicaid Basics • February 2003 Medicaid as a portion of all Ohio state spending (SFY 2001) 9 Medicaid Expenditures In 2001, Ohio Medicaid spent $5.26 billion, or almost 70% of its budget, on: • nursing facilities ($2.46 billion), • hospitals ($1.6 billion), and • prescription medications ($1.2 billion). Families and children constitute the largest segment of the Ohio Medicaid population (71% of covered Ohioans) but account for less than 25% of all Ohio Medicaid costs. In fact, state data suggest Ohio Medicaid Spending by Provider Category that a significant portion of overall Medicaid costs are associated with a relatively small number of consumers. The prediction and control of Medicaid spending is far more difficult than for other state programs. Medicaid expenditures are heavily influenced by economic conditions and other factors beyond the control of administrators and legislators. For example, as incomes decrease, more people are eligible for Medicaid. At the same time, state tax revenues are also decreasing. The result is that Medicaid costs increase while states are experiencing their greatest economic challenges. Identifying Causes of Spending Increases In general, the chief causes of Medicaid’s spending growth are the same factors increasing private health insurance costs. A recent survey of Medicaid officials in all 50 states and the District of Columbia identified the leading reasons for Medicaid expenditure growth as: • prescription medications, • enrollment growth, • medical inflation and utilization, and • long term care costs.4 The projected average annual growth rate for Medicaid through 2005 falls between the growth rates projected for Medicare and for private insurance.5 10 Ohio Medicaid Basics • February 2003 Ohio Medicaid Caseloads SFY 95–01 Medicaid spending is a function of changes in the number and types of consumers enrolled. A recent 3-year increase in enrollment is likely the result of: • expanded eligibility criteria, • a growing aging population, • simplification of the application process, • increased outreach activities, • a weakened economy, and • a natural correction after decreases in enrollment when Medicaid was delinked from welfare in 1996. Of federal Medicaid spending growth between 2001 and 2002, 57% was due to people in the ABD program, 28% was due to children and families, and 15% was due to factors not related to a specific population.6 The Ohio DJFS estimates that 75% of present spending increases are due to costs of services, while 25% are due to increased caseload.7 In general, elderly and disabled people use Ohio Medicaid per member, per month costs medical care and medications more often than the general population. Therefore, cost increases for these services have an even greater impact on the Medicaid budget. A recent study estimated Ohio’s long-term care and other Medicaid costs through the year 2025. Based on historical levels of state revenue, medical cost increases, and demographic trends, the Medicaid program as currently structured would consume the entire state budget in 25 years, in part due to the rising elderly population.8 Ohio Medicaid Basics • February 2003 11 Controlling Medicaid Expenditures In FY 2002, 45 states implemented cost containment measures aimed at controlling spending growth. Most states expect FY 2003 to be an even more difficult budget year. Strategies states are using to reduce expenditures are outlined below.9 Provider Rate Cuts or Freezes. A large number of states plan to cut or freeze provider payments, especially automatic cost increases tied to an economic price index for hospitals or nursing homes. How does Ohio compare? Ohio’s per member per month (PMPM) expenditures for three of the four Medicaideligible populations are at or below national averages. Nat ional Aver age Ohio Aver age Ohio's Rank* Adult s $2,000 $1,530 29th Childr en $1,451 $1,241 45th Disabled $8,784 $8,719 25th $10,308 $12,316 14th Populat ion Aged Pharmacy-Related Actions. The most common pharmacy cost-containment actions were requiring prior authorization of selected brand name products and reducing costs of drug products by increasing discounts or creating a Maximum Allowable Cost (MAC) list for generic medications. Benefit Reductions. Several states reduced benefits, including dental, home health, podiatry, chiropractic, vision, psychological counseling, and medical translator services. * Rank i s based on t he st at e wi t h t he hi ghest PMPM expendi t ures. Theref ore, a rank of 29t h m eans Ohi o has t he 29t h hi ghest expendi t ures of al l 50 st at es. Long-Term Care. Several states proposed long-term care cuts, including instituting new payment procedures, closing nursing homes, and requiring that long-term care facilities have both Medicare and Medicaid certification. Copayments for Non-Pharmacy Services. Copayments are now required in some states for services such as transportation, doctor visits, non-emergency room visits, waiver services, and certain feefor-service ambulatory services. Managed Care Expansions. Some states proposed managed care expansions such as moving people from fee-for-service programs into managed care, expanding primary care case management (PCCM) statewide, requiring mandatory enrollment into PCCM, and expanding risk-based managed care. Disease Management Programs. Increasingly, states are using a disease management approach to lower costs and provide more timely, appropriate, and higher quality care. Specific disease management programs target chronic conditions like asthma, 12 Ohio Medicaid Basics • February 2003 diabetes, congestive heart failure, hypertension, and chronic obstructive pulmonary disease. Eligibility Cuts. In FY 2003, 18 states planned eligibility cuts or restrictions compared to 8 states in FY 2002. Of the 18 states, 3 enacted cuts that will eliminate coverage for a large number of people on Medicaid. Cost-containment strategies like these can be very complex. Often, a policy change that appears reasonable can produce an unintended consequence that undermines the intent of the Medicaid Medicaid’s Role in the program or that causes increased spending Economy on other Medicaid services. For example, Representing 12% of the U.S. gross domestic reducing or freezing provider rates can have product, health care is a large and growing a serious impact on access to services and part of state and local economies. Medicaid could cause increases in emergency room makes up a significant portion of the total utilization or hospitalizations. national spending on major health concerns.10 Case in point: Although Medicaid covers Tot al nat ional Por t ion spending in paid by dental services for children, low payment 2000 (billions) Medicaid rates have reduced the number of dentists willing to care for these children. Many kids Tot al per sonal healt h $1,130 16.7% car e live with untreated dental problems because they can not afford routine care. These Pr ofessional ser vices $422 11.1% children end up needing more expensive Hospit al car e $412 17.0% emergency room services for severe pain, abscesses, and other dental problems— Pr escr ipt ion dr ugs $122 17.2% services for which Medicaid pays the bill. Nur sing hom e car e $92 48.2% Ohio policymakers have these and other difficult issues to consider as they work to sustain Ohio Medicaid, a program important for the health of the state. Ultimately, many believe that significant federal changes are also necessary for the long-term health of the Medicaid program. Why Changing Medicaid Isn’t Easy Ohio Medicaid is not a single program but rather a collection of programs, services, and funding mechanisms that is part of the increasingly complex health and human services system. In many cases, an adjustment to one element of this system will have unintended effects or consequences on other elements. Ohio Medicaid Basics • February 2003 13 Therefore, policymakers, state administrators, and others use a systems approach when considering changes to Medicaid. Economic effects are especially considered, as Medicaid brings new funding to the state through federal matches that fluctuate relative to state spending. Ohio Medicaid has an obvious impact on the lives of the lowincome individuals, children, and families it serves. Connections between Ohio Medicaid and other important issues, however, are not always as clear. For example, Ohio Medicaid: • helps maintain a healthy work force; • helps reduce personal bankruptcies, the number one reason for which is unpaid medical debt; • helps kids stay healthy and succeed in school; • supports welfare-to-work efforts; and • supports nearly all state-funded health and human servicerelated agencies—including university medical schools, mental health agencies, and health departments. Medicaid also supports the state’s entire health care infrastructure by helping to: • reduce uncompensated care, • promote earlier treatment in appropriate settings and reduce preventable hospitalizations, • decrease unnecessary emergency room use, and • support education and training in academic medical centers. Without the Medicaid program, these infrastructure costs would be passed on to employers and their employees through higher insurance premiums. In addition, individuals, families, and society as a whole would For More Information about Medicaid bear the human costs of Ohio Medicaid Basics provides a brief overview of the Ohio untreated illnesses. Medicaid program. For more information about the federal Medicaid program, including federal eligibility requirements, benefits, financing, and administration, please refer to The Medicaid Resource Book, a publication of The Kaiser Commission on Medicaid and the Uninsured, published by The Henry J. Kaiser Family Foundation. The Medicaid Resource Book is available at www.kff.org or by calling 800.656.4533. For more information about Ohio Medicaid, please visit the Ohio Health Plans program of the Ohio Department of Job and Family Services at www.state.oh.us/odjfs/ohp/. 14 Ohio Medicaid is an important and complex system that touches the lives of individuals and families across the state. Understanding the basics of this system is an important step toward improving the health of millions of Ohioans. Ohio Medicaid Basics • February 2003 An Ohio Parent’s View of Medicaid The security of knowing that the kids can get what they need is so valuable to us. I’m not afraid that the next trip to the doctor or a kid falling off a bike will wipe us out financially. And if one of the kids is running a fever, we don’t have to “play Russian roulette” wondering if it’s bad enough to call the doctor and spend $100, or should we wait, hoping it will get better on its own. We really struggle with that, and hope we don’t make the wrong decision. I’m grateful for this program, and we don’t take advantage of it by making unnecessary trips to the doctor. —Statement of John Reed, of Salem, Ohio; taken from the Kaiser Commission on Medicaid and the Uninsured and Alliance for Health Reform briefing “Medicaid Coverage for All Children Living in Poverty,” September 30, 2002. Online Resources • Agency for Healthcare Research and Quality—www.ahrq.gov • Center for Health Care Strategies—www.chcs.org • Center on Budget and Policy Priorities—www.cbpp.org • Centers for Medicare and Medicaid Services (CMS)—www.cms.gov • Children’s Defense Fund—Ohio—www.cdfohio.org • Families USA—www.familiesusa.org • Health Affairs—www.healthaffairs.org • Heritage Foundation—www.heritage.org/Research/HealthCare • The Kaiser Commission on Medicaid and the Uninsured—www.kff.org/kcmu • National Association of State Medicaid Directors—www.nasmd.org • National Center for Health Statistics—www.cdc.gov/nchs • Ohio Department of Jobs and Family Services—www.state.oh.us/odjfs • The Urban Institute—www.urban.org Endnotes 1 Kaiser Commission on Medicaid and the Uninsured (2002). Medicaid Spending Growth: Results from a 2002 Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 2 National Pharmaceutical Council (2001). Pharmaceutical Benefits under State Medical Assistance Programs. Washington, DC: Author. 3 National Association of State Budget Officers (2001). 2000 State Expenditure Report. Washington, DC: Author. 4 Kaiser Commission on Medicaid and the Uninsured (2002). Medicaid Spending Growth: Results from a 2002 Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 5 Health Care Financing Administration (2001). National Health Expenditure Projections. Washington, DC: Author. 6 Kaiser Commission on Medicaid and the Uninsured (2002). Analysis of CBO Medicaid Baseline. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 7 Bill Hayes, Ph.D., Assistant Deputy Director, Ohio Department of Job and Family Services (personal communication, October 2002). 8 Begala, J.A., Ellis, D.A., Weiner, G.D. (October 2002). Future Ohio Medicaid Services and Spending for Older Adults and People with Disabilities. Presented at Ohio Medicaid Basics is a project of The a meeting of the House Select Health Foundation of Greater Cincinnati and Committee on Medicaid Reform, the George Gund Foundation. Statistics were Columbus, OH. provided by the Ohio Department of Job and 9 Kaiser Commission on Medicaid and the Family Services (DJFS) unless otherwise Uninsured (2002). Medicaid Spending indicated. Growth: Results from a 2002 Survey. Menlo Park, CA: The Henry J. Kaiser Additional copies of Ohio Medicaid Basics are Family Foundation. available by calling The Health Foundation of 10 Tobler, L. (August 2002). Medicaid: Greater Cincinnati toll-free at 888.310.4904 or Challenges and Opportunities. Presented by visiting our website at at a meeting of the Ohio Select www.healthfoundation.org. Committee on Medicaid Reform and Select Committee on Quality Health Care, Columbus, OH. 16 Ohio Medicaid Basics • February 2003