Section 1115 Medicaid Expansion Waivers: Implementation Experiences

This report summarizes SHADAC's analysis of how four states implemented Section 1115 Medicaid expansion wiavers. These states--Arkansas, Indiana, Iowa, and Michigan--are among eight that have expanded their Medicaid programs through Section 1115 of the Social Security Act rather than through the expansion option available under the Affordable Care Act (ACA).

SHADAC's analysis was commissioned by the Medicaid and CHIP Payment and Access Commission (MACPAC) and sought to understan how Arkansas, Indiana, Iowa, and Michigan approached the implementation of key provisions of their Section 1115 Medicaid expansion waivers:

• Exchange plan premium assistance (Arkansas & Iowa)
• Enrollee contribution requirements (Iowa & Michigan)
• Health savings accounts (Arkansas & Indiana)
• Healthy behavior incentives (Indiana, Iowa, & Michigan)
• Graduated copayments for emergency department use (Indiana)

SHADAC researchers conducted interviews with 33 individuals representing current and former state agency staff and health insurance carriers in the four study states to identify the steps that states took to operationalize their programs. The report provides background information on the waiver program elements implemented in each of the four study states, summarizes the key pieces of administrative capacity that states put into place to implement their waivers, and details the specific program challenges they faced.

Access the report.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

New SHADAC Brief Explores the Impact of Federal Health Care Reform in Minnesota

A new brief from SHADAC deputy director Elizabeth Lukanen considers Minnesota’s health insurance market before and after passage of the Affordable Care Act (ACA) as well as the outlook for the state’s market given the current policy environment.

Minnesota’s Market before and after the ACA

The brief, “The Impact of Health Care Reform in Minnesota,” explores insurance coverage, public program generosity, insurance market regulations, and care quality and costs in Minnesota. Except in the area of costs, Minnesota had relatively high marks in these areas predating the ACA. Since the ACA went into effect, the state’s uninsured rate has declined further, although the cost of health care and coverage in Minnesota continues to rise, with a substantial number of Minnesotans (an estimated 50,000 to 70,000) foregoing coverage on the individual market between 2016 and 2017 due to costs.

Health Reform Today: Minnesota

The current health reform focus in Minnesota is the state’s individual insurance market, which state lawmakers have been working to stabilize following the exit of several major insurers. Lawmakers passed a premium relief bill in 2017 to assist consumers in the individual market with the cost of coverage. To further reduce premiums, the state established a state-funded reinsurance program that will reimburse insurers for 80% of insurance claims between $50,000 and $250,000.

Health Reform Today: The National Picture

There have been numerous attempts to repeal and replace the ACA since President Trump took office, but none has so far been successful. In the meantime, the Trump administration can significantly reform health care through other legislative vehicles and has taken steps to do so. Most recently, President Trump signed legislation overhauling the nation’s tax code that included a provision repealing the ACA’s individual mandate tax penalty. The impact of this particular change on the health insurance market as a whole—and the individual market in particular—is not yet known, but experts are concerned about the likelihood of healthier individuals choosing to opt-out of purchasing health insurance, leaving the market to support less healthy individuals.

Looking Ahead

Federal direction on health reform remains unclear, and this uncertainty may be taking a toll on coverage gains made under the ACA, with recent Gallup data showing an increase in the national uninsured rate since the end of 2016. In the face of federal uncertainty and the potential for coverage losses, many states, including Minnesota, are likely to continue to move forward with state-specific legislation to stabilize their individual markets and provide coverage for their residents.

Read the full brief.

Related

Learn about states' efforts to stabilize their individual insurance markets through 1332 waiver reinsurance programs.

Health Care Reform: The Impact of Federal Health Care Reform in Minnesota

Prior to the passage of the Affordable Care Act (ACA) in 2010, Minnesota's health insurance market was, for the most part, relatively high-functioning across indicators of health insurnace access and quality of care, although the state faced common challenges in the area of health care costs. This brief, by SHADAC deputy director Elizabeth Lukanen, considers Minnesota's health insurance market before and after the passage of the ACA as well as the outlook for the state's market given the current policy environment.

Download a PDF of the brief.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

Now Available: Final Evaluation Report on the SIM Initiative in Minnesota

SHADAC’s final evaluation report on the SIM Initiative in Minnesota is now publicly available.

This report presents the final results of the state-level evaluation of Minnesota’s SIM initiative. SHADAC conducted this evaluation between January 2015 and September 2017 under a contract with the Minnesota Department of Human Services (DHS) and in collaboration with both DHS and the Minnesota Department of Health (MDH).

This report draws on the first evaluation report (submitted in 2016) and details final results for the last two years of Minnesota’s initiative, with a focus on the following:

• Minnesota’s SIM investments both within and outside of state government
• Key outcomes of the SIM initiative in Minnesota
• Outcomes and sustainability findings specific to the areas of:
  1. E-health
  2. Integrated Health Partnership (IHP) data analytics
  3. Team-based, integrated/coordinated care
  4. Accountable Communities for Health (ACHs)
  5. ACO alignment
• The continuation of Minnesota’s SIM model beyond SIM funding and future considerations for the state

Access SHADAC’s final evaluation report on the SIM initiative in Minnesota.

Access the executive summary of SHADAC’s final evaluation report.

Read a blog summarizing key findings from the evaluation of SIM in Minnesota.

SHADAC Staff

p 612.624.4802
e shadac@umn.edu

SHARE Results from Fred Blavin in Health Affairs: Among Near-Poor Adults, Access to Medicaid Reduced Out-of-Pocket Spending and Uninsurance

According to an article released today in Health Affairs, adults with incomes between 100 and 138 percent of the federal poverty level (FPL)—i.e., “near-poor” adults—saw lower out-of-pocket (OOP) costs and a reduced likelihood of being uninsured in states that expanded Medicaid than in non-expansion states.

Overview: Access to Medicaid among Near-Poor Adults

The analysis, which is based on a SHARE-funded study led by Dr. Fred Blavin (Urban Institute), used 2010 to 2015 data from the Current Population Survey (CPS) and the American Community Survey (ACS) along with state Medicaid expansion decisions as a natural experiment to estimate the impact of access to Medicaid on OOP health expenses and health insurance coverage, compared with access to subsidized Marketplace coverage. In states that chose not to expand Medicaid, near-poor adults may qualify for tax credits to purchase Marketplace plans that involve OOP premiums and cost-sharing; in expansion states, this population would generally face no premiums and minimal cost-sharing if they enrolled in Medicaid instead.

Key Findings: Out-of-Pocket Spending

Using OOP spending information from the CPS, Dr. Blavin and his co-authors found that Medicaid expansion, relative to Marketplace access, was associated with a $344 (33.9%) reduction in average total OOP spending, a $125 (23.0%) reduction in average OOP premium spending, and a $218 (46.4%) reduction in average OOP cost-sharing spending from 2010-2013 (before Medicaid expansion) to 2014-2015 (after Medicaid expansion). These decreases in average OOP spending were primarily driven by declines in the probability of having any OOP spending.

The $344 reduction in average total OOP spending from Medicaid expansion corresponds to 2 percent of annual income for adults in the 100 to 138 percent FPL range, and this is consistent with the amount that near-poor individuals would have to pay out-of-pocket for a Marketplace plan in a states that chose not to expand Medicaid. The authors note, however, that the impact of expansion for those who newly enrolled in Medicaid is likely to be higher, especially for those who had high OOP expenses prior to the ACA—e.g., high-cost uninsured adults and those with expensive employer plans.

Key Findings: Coverage

Using coverage information from the ACS, the authors found that Medicaid expansion reduced the probability of being uninsured among near-poor adults by 4.5 percentage points between 2010-2013 and 2014-2015, compared to non-expansion states. This impact was driven by significant increases in Medicaid coverage that were partially offset by declines in ESI and direct purchase coverage.

According to the authors, these findings imply that more restrictive eligibility and enrollment policies, combined with higher premiums for Marketplace coverage relative to Medicaid, were associated with lower take-up rates among near-poor adults. 

Read the full Health Affairs article.