Robin Rudowitz, Associate Director, Kaiser Commission on Medicaid and the Uninsured, discusses the financial implications of Medicaid expansion and the Affordable Care Act.

1. Economics of the Medicaid Expansion
Robin Rudowitz
Associate Director, Kaiser Commission on Medicaid and the Uninsured
Bob Graham Center for Public Service
Gainesville, Florida
April 9, 2014

2. Figure 1
Compared to the US, Florida has a higher uninsured rate.
42%
5%14%
17%
2%
20%
Florida
Employer
Individual
Medicaid
Medicare
Other Public
Uninsured
49%
5%
16%
13%
1%
16%
United States
NOTES: Data may not total to 100% due to rounding. Medicaid includes the Children’s Health Insurance Program (CHIP) and Other Public
includes non-elderly Medicare and military-related insurance.
SOURCE: KCMU/Urban Institute analysis of the 2011 and 2012 ASEC Supplement to the CPS.

3. Figure 2
27%
25%
22%
22%
21%
20% 20% 19%
18% 18%
17% 17%
16% 16%
15% 15%
12%
9%
TX FL LA GA AR OK NC SC US MS WV KY AL TN VA MD DE DC
SOURCE: KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS.
Florida has the second highest rate of nonelderly
uninsured in the South.
Uninsured Rates among Nonelderly Southerners by State, 2011-2012
United States: 18%
The South: 21%

4. Figure 3
SOURCE: KCMU/Urban Institute analysis of 2011 American Community Survey
Florida accounts for 8% of the country’s uninsured at or
below 138% FPL.
51%
Total: 25.4 Million
Nonelderly Uninsured ≤138% FPL by Location
FLTXCA GA, IL,
NY, NC
Other
States

5. Figure 4
The ACA seeks to increase access to affordable health
coverage options, especially for adults.
Medicaid Coverage For
Low-Income
Individuals
Employer-Sponsored Coverage
Marketplaces With Subsidies
For Moderate Income
Individuals
Individual
Mandate
Health Insurance
Market Reforms
Universal Coverage

6. Figure 5
The ACA Medicaid expansion fills current gaps in coverage.
*138% FPL = $16,105 for an individual and $27,310 for a family of three in 2014.
Adults
Elderly &
Persons with
Disabilities
Parents
Pregnant
Women
Children
Extends to Adults
≤138% FPL*
Medicaid Eligibility Today
Medicaid Eligibility
in 2014Limited to Specific Low-Income Groups
Extends to Adults ≤138% FPL*

7. Figure 6
The ACA modernizes the Medicaid application and
enrollment experience in all states.
ACA VisionPAST
Real-time
determination
Data
Hub
$
#
Dear __,
You are
eligible for…
Apply in person Multiple options
to apply
Provide paper
documentation
Electronic
verification
Wait for eligibility
determination
Medicaid
CHIP
Marketplace
No Wrong Door
to Coverage

8. Figure 7
100% 100% 100%
95% 94% 93% 90%
60% 60% 60% 60% 60% 60% 60%
2014 2015 2016 2017 2018 2019 2020 and
Beyond
Federal Share for Newly Eligible Traditional FMAP in FL
The federal government will pay for the vast majority of
costs to cover those newly eligible.

9. Figure 8
The Medicaid expansion has coverage and fiscal
implications for states.
Increased State
Economic Activity
Increased Provider
Revenue
Reduction in the Number
of Uninsured
↓ Uncompensated Care Costs
↓ State-funded health
programs (e.g. Mental health)
Increased State Savings
Federal + State
Funds
+
↑ Jobs and Revenues

10. Figure 9
Implementing the ACA Medicaid expansion will bring increased
payments to hospitals that could offset reductions in DSH.
0.0%
10.0%
20.0%
30.0%
40.0%
MA
VT
NY
DC
DE
MN
IA
ME
WA
AK
IL
NM
RI
MD
CT
MI
CA
NE
NJ
HI
KS
WI
OK
NH
PA
ID
TN
UT
MT
MO
VA
WY
TX
SD
IN
LA
CO
KY
NC
WV
SC
NV
AL
OR
OH
AR
GA
MS
ND
FL
For FL – 31% Increase or
$33.6 billion
NOTE: AZ is not included because analysis includes only FFS payments (and AZ has no FFS). Includes federal
and state spending.
Source: Urban Institute estimates prepared for the Kaiser Commission on Medicaid and the Uninsured,
October 2012.

11. Figure 10
NOTES: Data as of March 26, 2014. *AR, IA and MI have approved waivers for Medicaid expansion (MI
plans to implement Apr. 2014). IN and PA have pending waivers for alternative Medicaid expansions.
WI amended its Medicaid program to cover adults up to 100% FPL, but did not adopt the expansion. NH
has passed legislation approving the Medicaid expansion to begin in July 2014.
SOURCES: Based on data from CMS here, and KCMU analysis of more recent state legislation, public
statements mad by Governors, or issuance of waiver proposal.
Due to the Supreme Court ruling, states effectively have the
option to implement the Medicaid expansion.
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV
NE
MT
MO
MS
MN
MI*
MA
MD
ME
LA
KYKS
IA*
IN*IL
ID
HI
GA
FL
DC
DE
CT
CO
CA
AR*AZ
AK
AL
Implementing Expansion in 2014 (27 States including DC)
Open Debate (5 States)
Not Moving Forward at this Time (19 States)

12. Figure 11
Nearly 764,000 poor nonelderly uninsured adults in Florida
will fall into the ACA coverage gap in 2014.
NOTE: Excludes undocumented immigrants and legal immigrants who have been in the US for <5 years.
SOURCE: KFF analysis of March 2012 and 2013 CPS and 2014 Medicaid MAGI eligibility levels.
763,890 UNINSURED ADULTS
35% FPL
Parents
($6,836 for a family of 3)
Medicaid Eligibility
Limits in Florida
0% FPL
Childless Adults
100% FPL
($11,490 for an
individual)
400% FPL
($45,960 for an
individual)

13. Figure 12
Other
Southern
States
33%
Georgia, 8%
Florida
16%
Texas
22%
Midwest
11%
Northeast
6%
West
4%
NOTE: Based on state Medicaid expansion decisions as of March 2014. Excludes undocumented
immigrants. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and
2012-2013 Current Population Survey.
8 in 10 poor uninsured adults in the coverage gap live in
the South with 16% in Florida.
Total: 4.8 Million Adults in the Coverage Gap
South
79%
(3.8 M)

14. Figure 13
White,
42%
Black
28%
Hispanic
26%
Other
4%
Notes: Excludes legal immigrants who have been in the country for five years or less and immigrants
who are undocumented.
The poverty level for a family of three in 2013 is $19,530. Totals may not sum to 100% due to rounding.
Source: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and 2012-2013
Current Population Survey. See technical appendices available at http://www.kff.org/health-
reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ for
more detail.
19-24
years,
24%
25-34
years
24%
35-54
years
36%
55-64
years
16%
In Florida, demographic characteristics of adults in the coverage
gap largely mirror those of poor uninsured adults.
Total = 763,890 in the Coverage Gap
Distribution By
Age:
Distribution By
Race/Ethnicity:
Parents,
23%
Childless
Adults
77%
Parent Status:

15. Figure 14
• Gains in access and increased use of health care
– More likely to have usual place of care, better perceived access
– Increased use of preventive care, physician services, Rx drugs,
hospital admissions
– Increased emergency department use
Recent findings from an Oregon study point to benefits of
Medicaid coverage.
• Reduced depression, mixed results on physical health
– Reduced rates of depression, but no change in blood pressure, cholesterol, or
blood sugar
– Self-reported improvements in physical and mental health, overall well-being
• Increased financial security
– Near elimination of catastrophic medical spending
– Reductions in other measures of financial strain
• Questions
– Longer-run impact of improved access and delivery system reforms on
outcomes
Figure 17

16. Figure 15
• Most states implementing the Medicaid expansion through State
Plan Amendment (SPA) using flexibility provided in the law
• Limited number of states are seeking waivers for alternative
approaches to implement the ACA
• 1115 Waiver authority is for demonstrations that promote the
objectives of the Medicaid program
– Authorizes the HHS Secretary to waive certain federal Medicaid requirements and
provide federal matching funds for costs that would not otherwise be matched
– Section 1115 waivers are required to be budget neutral to the federal government
– Waiver approval involves negotiations between a state and HHS
– The ACA requires transparency and meaningful opportunities for public input in the
1115 waiver process
Some states are exploring alternative approaches to
implementing the Medicaid expansion.

17. Figure 16
Premium
Assistance
Premiums
Healthy
Behavior
Incentives
Benefit
Changes
Work
Requirements
Arkansas
(approved)
x
Iowa (approved) x x x x
Michigan
(approved)
x x
Pennsylvania
(proposed)
x x x x x
Key themes have emerged in alternative approaches to the
Medicaid expansion.
Key Themes in Recent ACA Expansion Waivers

18. Figure 17
• Will there be movement in the legislature on the Medicaid expansion in
Florida?
• How well will new enrollment systems work and how well will systems be
coordinated across health programs?
• What will happen to individuals in the coverage gap if Florida does not
implement the expansion?
• What can Florida learn from other states that are moving forward?
– How are alternative models to implement the expansion working?
– What is the effect on state revenues?
– Implications for providers?
– Implications for broader state economy?
What to look for going forward….