Get ready for complex needs of new Medicaid population
Covering childless adults could be more costly than anticipated, because this population had more complex needs than expected, according to some states surveyed in a July 2010 report from the Washington, DC-based Kaiser Commission on Medicaid and the Uninsured, Expanding Medicaid to Low-Income Childless Adults Under Health Reform: Key Lessons from State Experiences.
Robin Rudowitz, MPA, one of the report's authors, says that in talking to states about their experiences, she learned that two-thirds of uninsured adults below 133% FPL are without dependent children.
"Many of them are very low-income under 50% of the poverty level. When you look further, you see many are either at the lower end or the higher end of the age spectrum," says Ms. Rudowitz. "With the 55-to-64 group, you know they are more vulnerable to health risks."
A number of states have already expanded coverage to childless adults or expanded coverage further up the income scale, either through Medicaid or state-funded programs. Currently, 27 states offer no coverage for childless adults, according to a 2009 survey conducted by KCMU with the Center on Budget and Policy Priorities, also based in Washington, DC. Five states offer coverage comparable to Medicaid, 15 provide more limited benefits, and four offer premium assistance to a limited population of adults.
"When we look at the group below 133% FPL, which are all newly eligible for Medicaid, one in six are in fair or poor health. Many have chronic conditions," says Ms. Rudowitz. "If the person is uninsured, he or she has poor access to care."
Uninsured adults at or below 133% FPL are a diverse group, including many sick individuals for whom any coverage is currently unavailable, according to an April 2010 policy brief from KCMU, Expanding Medicaid Under Health Reform: A Look at Adults at or Below 133% of Poverty. Many have problems accessing health care, and about one-third of them have been diagnosed with a chronic condition.
Test new approaches
There is information to be gleaned from states that have expanded coverage, either through state basic health plans or through waivers. "There are quite a few states that have already expanded coverage to optional populations to some extent," says Allison Hamblin, director of complex populations for the Hamilton, NJ-based Center for Health Care Strategies (CHCS).
A significant subset of the expansion population will have a complex range of health needs, including high rates of mental illness and substance abuse, according to a CHCS brief, Covering Low-Income Childless Adults in Medicaid: Experiences from Selected States. The brief's findings are based on 10 states with existing programs for low-income childless adults.
In addition, costs for the expansion population on average are likely to be greater than costs for parents currently enrolled in Medicaid, but less than costs for adults with disabilities.
"Looking at the utilization patterns and demographics, the picture is starting to emerge that the behavioral health and substance abuse needs among the expansion population will be similar to those of the aged, blind, and disabled population," says Ms. Hamblin.
Ms. Hamblin says that in light of this, "there is an incredible opportunity for states to test novel approaches to figure out how to manage care for their costliest populations. The need to have effective systems in place is going to be that much more important when there are 15 million new beneficiaries in the system. Many of them are likely to look like our complex patients that we are now working with."
For this reason, Ms. Hamblin says that state Medicaid programs should be using the time between now and 2014 to build capacity and test new strategies. "By putting some core elements of integrated care management in place today, states will be better positioned to meet the needs of the expansion population in 2014," she says.
Diverse population
"Because we're up to 300% FPL already, a lot of people who are going to be new folks for other states are already in our program," says Philip Poley, chief operating officer for MassHealth.
"When you are talking about childless adults at certain income levels, you are talking about people who might be homeless or struggling with substance abuse problems," says Mr. Poley. "In our experience, it's kind of hard to reach these people and ensure consistent care."
Mr. Poley says that particularly in the upper-income ranges, other childless adults didn't fit this profile at all. Many were working people who just didn't qualify previously for benefits. "Those are folks who just didn't know there was insurance out there for them. We really had to undertake a multifaceted effort to reach them," says Mr. Poley.
The state's Commonwealth Health Insurance Connector Authority, which is similar to the health insurance exchanges that states are required to set up under health care reform, did a major outreach effort. This included partnerships with the Boston Red Sox, health clubs, and organizations that were likely to have individuals who fit this demographic profile.
Make consequences clear
"The other thing that we found out is that somebody may get a piece of information, but they might have to hear it a number of times from lots of different sources before they determine that 'This is real, this applies to me, and I need to take some action,'" says Mr. Poley.
The fact that there was a statewide mandate gave the state the ability to send the message that if individuals didn't obtain coverage, there would be a consequence. "That allowed us to make clear to people that they had to pay attention," says Mr. Poley. "There was also a direct mail campaign, which hit the whole state."
Once the individuals in the expansion populations were enrolled, Mr. Poley says that, "It's the same experience that you have with Medicaid. Some populations are very stable and maintain good connections with the health care system and with the eligibility system, and some don't."
Mr. Poley adds that while some of the expansion population "fits a non-stable life circumstance category, they are not a homogenous group at all. Some are just self-employed individuals who never had coverage before. So, a lot of it was education about health insurance generally and the need to participate in their own care. We had a very good take-up rate."
Before Massachusetts implemented health care reform, there was a high rate of insured and a high rate of individuals with employer-offered insurance. "So, when other states are trying to see if there's anything they can learn from us, perhaps there is, but it's also important to understand the context in which you are starting from," says Mr. Poley. "And those two things were important things in our favor."
There were some state-funded programs that gave benefits to undocumented people through the health safety net, and some immigrants who were legal but weren't covered by Medicaid, because they didn't meet the five-year requirement. "So, before we started health care reform, those were folks who already had an entrée to our system. We were starting from a very good place," says Mr. Poley.
Look at current programs
Mr. Poley says that to meet the needs of the Medicaid expansion population, looking at your existing programs that serve high-cost members is a good place to start. "While you certainly might see this new population bringing some additional high-cost members to the mix, I don't necessarily believe they are completely different in their profile," he says. "Each state is different. Medicaid programs might want to fine-tune their focus on the high-cost groups based on their own demographics."
MaineCare for Childless Adults is a waiver program with a capped enrollment of 20,000 individuals at or below 125% of FPL. This population receives a comprehensive benefit package comparable to the Maine Medicaid program.
Trish Riley, director of the Governor's Office of Health Policy and Finance, says that demographics for childless adults below 100% FPL in Maine are 55% male with an average age of 40, 4% homeless, and 28% are unemployed. Half of the total costs are spent on hospitals and pharmaceuticals, with a per-member, per-month cost of about $430.
"Childless adults are a mixed group and include some very high-cost users," says Ms. Riley. "The group includes people with significant disabilities who are awaiting disability determination and Medicare eligibility."
Contact Ms. Rudowitz at (202) 347-5270 or [email protected], Mr. Poley at (617) 573-1770 or [email protected] and Ms. Riley at (207) 624-7442 or [email protected].
Covering childless adults could be more costly than anticipated, because this population had more complex needs than expected, according to some states surveyed in a July 2010 report from the Washington, DC-based Kaiser Commission on Medicaid and the Uninsured, Expanding Medicaid to Low-Income Childless Adults Under Health Reform: Key Lessons from State Experiences.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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