medicaid and the 4 a’s: use of 1115 waivers and state plan amendments american cancer society...
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Medicaid and the 4 A’s: Use of 1115 Waivers and State Plan
Amendments
American Cancer SocietyWashington, Dc
June 5, 2008Erin Reidy
Why a Medicaid Evaluative Tool?
• ACS 4A’s campaign
• Recent 1115 and SPA activity
• Uncertainty about Medicaid reform among ACS state advocates
3
We cannot reach our goals without addressing Access to Care
8090
100110120130140150160170180190200210220
'75 '78 '81 '84 '87 '90 '93 '96 '99 '02 '05 '08 '10 '13
Year
Ra
te
2015 Goals – Reduce Mortality by 50 Percent
2003 Rate 190.1
1991 Baseline 215.1
2015 Goal 107.6
2015 Rate 160.5
Why the Cancer Lens
• The cancer community can play a greater role in influencing what public policy approaches are followed than they do today
• It is difficult to understand all the complexities of health care reform proposals, but people do understand cancer
• If it works for cancer patients, then it can work for almost any condition
Why do we care about Medicaid?
• Increases access to care
• Cancer screening
• Cancer treatment
40%
83%
56%48%
88%
75%
19%
68%
38%
Medicaid Private UninsuredPercent
Received recommended colorectal cancer screening in
past 10 years, 2005
Pap Test in Past Three Years, 2005
Mammogram in Past Two Years, 2005
Adults, 50-64Women, 18-64 Women, 40-64
SOURCES: Ward, Elizabeth, et al. "Association of Insurance with Cancer Care Utilization and Outcomes." CA: A Cancer Journal for Clinicians 58.1 (2008): 9-31.
Why do we care about Medicaid?
Why do we care about Medicaid?
• Increases access to care
• Cancer screening
• Cancer treatment
• Health disparities
• Low-income
• Racial/ethnic minorities
• Smoking
• Higher rate of smoking in the Medicaid population
Odds of More Advanced Stage at Diagnosis Breast Cancer, NCDB, 1998-2004
*Odds ratio is significant at the 95% confidence level.Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of diagnosis, and facility type.Source: Halpern et al, 2007 (manuscript in preparation)
Insurance Stage II vs. IStage III or IV
vs. I Private 1.0 (Ref.) 1.0 (Ref.) Uninsured 1.5* 2.4* Medicaid 1.5* 2.5* Medicare Age 65+ 0.9* 1.0
Race Non-Hispanic White 1.0 (Ref.) 1.0 (Ref.) Non-Hispanic Black 1.5* 1.9* Hispanic 1.3* 1.4*
What’s behind poor Medicaid outcomes?
• Retroactive enrollment
• Social Determinants of Health
• High rates of co-morbidities
• Continuities in care
The 4 A’s
• Available
• Affordable
• Adequate
• Administratively Simple
Illustration of the 4 A’s and Medicaid
•Available
• Must meet specific eligibility criteria
• Affordable
• Premiums and co-pays may be high
• Adequate
• Benefits, providers may not meet needs of cancer patients
• Administratively Simple
• Awareness and transparency may be lacking
• Appeals may be burdensome
Medicaid- Availability
• Eligibility
• “optional” groups
• Spend-down/pay-in programs
• Application
• Face to face interviews
• Self-declaration of income
• Enrollment
• Presumptive eligibility
• Enrollment caps
• Waiting periods
Medicaid- Affordability
• Premiums
• Premiums charged to beneficiaries greater than 150% FPL
• Multiple payment options
• Cost-sharing
• Under the DRA, co-payments to 20% of cost of services, or 10% of cost for lower-income beneficiaries.
• Total cost sharing can exceed 2-3% of a family’s income
• Can be denied at point of service
Medicaid- Adequacy
• Covered benefits
• “Benchmark” benefits
• Tiered benefits
• “Optional” services
• Benefit limits
• Annual/lifetime benefit limit
• Limited number of prescriptions
• Limits on number of treatments, visits, etc.
Medicaid- Administrative Simplicity
• Awareness
• Widely advertised
• Use of community organizations for enrollment
• Transparency
• Written in clear, simple language
• Materials in multiple languages
• Access to a live person for benefit explanations
• Plan Assignment
• Simple, publicized methods for switching
• Reassign enrollees to same plan after break in coverage
Conclusion
• Evaluative Tool can help advocates better questions about Medicaid reform proposals
• Provides the basis for developing practical and more specific evaluative criteria in the four main areas: adequacy, availability, affordability, and administrative simplicity
• The Society is not currently offering its own plan, but rather will evaluate proposals put forth by others and decide whether to support them
Thank you!