# Presentation: 719241

## Health Coverage and Access to Care:  Key Issues for Native Women 

- Usha Ranji, M.S.
- Senior Policy Analyst
- Kaiser Family Foundation
- August 15, 2007

- Figure 1

**Notes:**
Good morning.  Thank you for the invitation to join all of you today.  I am excited to be here today.  I don’t know how many of you are familiar with the Kaiser Family Foundation, so I’ll take just a minute to tell you that the KFF is is an operating foundation that conducts policy analysis and research on major issues confronting the health care system.  This includes financing and access to care, and throughout our work, we have a focus on low-income populations and how the health care system works for these groups.  We have a particular interest in how national, state, and local health policies affect women’s access to health services.  I should also mention that despite our name, KFF is 
totally separate and not associated with Kaiser Permanente, the health care provider.  

## Coverage Matters

- Note:  Includes women 18 to 64.
- Source: Kaiser Family Foundation, *2004* *Kaiser Women’s Health Survey*.

- Women’s use of health care services, by type of insurance, 2004:

- Figure 2

**Notes:**
So, we’ve heard this morning about some very important components of the delivery of health services, including some models of care and practice and effective communication.   I’m going to switch gears a little and focus on another important aspect of health care, and that is the impact of health insurance coverage.

Now, I probably don’t need to convince anyone in this room of this, but coverage matters.

These are data from the kaiser Women’s health Survey, a nationally representative survey of adult women that we conducted in 2004 about coverage, access, and experiences with the health care system.

## Demographic Characteristics of American Indian and Alaska Native Women

- Source: Kaiser Family Foundation analysis of the March 2006 Current Population Survey, US Census Bureau.

- 2 parents with kids: 24%

- 1 parent with kids: 21%

- Multigenerational/ other with kids: 9%

- Married couple, no kids: 19%

- Other adults together, no kids: 17%

- Other adults alone, no kids: 10%

- 2 full time 19%

- 1 full time: 49%

- Part time only: 9%

- Non-workers: 23%

- 0 - 99%: 35%

- 100 - 199%: 24%

- 200 - 299%: 13%

- 300 - 399%: 11%

- 400% and above: 17%

- Figure 3

**Notes:**
I want to begin with some background on the populations that you all work with.  These are some basic demographic data on Native women, drawn from the Census Bureau.
Of course, we’re talking about a very diverse population of women on  a number of measures, in terms of family and work situations,  income, educational level and generally resources that they have available. That affect access to coverage and health care costs. 

Drop education from this slide.

Over half are raising children.  Nearly seven in ten live in a household with at least one full-time worker, which affects access to health insurance.  Over one-third live below the poverty line, that’s about $X for a family of three, and another quarter are under 200%. About half of women have either a high school education or lower, that’s something that I think that we don’t think about very often but that also is very important in terms not only the resources that they have in terms of coverage but also in terms of navigating an increasingly complex health care system. 

## Insurance Coverage

- Figure 4

**Notes:**
So, today, I am going to review the major sources of health insurance coverage for women, their major features, and then discuss  

## Health Insurance Coverage of Adults Ages 18 to 64, by Sex, 2005	

**Health Insurance Coverage of Adults ****Ages 18 to 64, by Sex, 2005****	**

- Note:  Other includes Medicare, CHAMPUS, and other sources of coverage.
- Source:  Kaiser Family Foundation analysis of the March 2006 Current Population Survey, US Census Bureau.

- Figure 5

**Notes:**
Most nonelderly women and men get their coverage through their employers.  However, differences in work status and  Medicaid policy translates into  in slightly difference coverage profiles for men and women.   

Although men and women are equally likely – about two thirds -- to be covered by employer sponsored coverage, women are less likely to be covered in their own name and more likely to be covered as dependants. This is because they are more likely to work part-time or part-year or work in low-wage jobs that don’t offer benefits.  

Having dependant coverage make women more vulnerable to losing coverage should they  become widowed or divorced.  With rapid growth  in insurance costs, women are also increasingly becoming vulnerable to losing coverage if employee costs become too expensive for workers and their families to shoulder.  

Women are less likely to be unininsured than men, but this is largely attributable to Medicaid because women are more likely to qualify than men.  I’ll talk more about Medicaid eligibility policy a few minutes.   

## Differences in Health Coverage Rates of Women by Race/Ethnicity are Significant 

- Note:  Includes women ages 18 to 64. Other includes Medicare, CHAMPUS, and other sources of coverage.
- Source:  Kaiser Family Foundation analysis of the March 2006 Current Population Survey, US Census Bureau.

- Figure 6

**Am. Indian/ Alaska Native**

**Notes:**
And among women, there are significant differences in health coverage rates between different racial and ethnic groups.  On average, women of color are more likely to be uninsured and have lower rates of employer-sponsored insurance.  Latina women are most likely to be uninsured, with nearly four in ten without insurance and just half having ESI, compared to 14% uninsured and nearly eight in ten in the private market  among White women.

Native women are also at very high risk for being uninsured.  Nearly one in five do not have any source of coverage at all and another 15% rely on IHS alone.   Just half have private coverage and 16% receive Medicaid.

## Affordability and Scope of Coverage: Limits of Private Insurance

- Affordability of care is still a  problem for many women with private coverage:
- Premiums, Copays, Deductibles, Rx out-of-pocket costs
- Large variation in what and how much is covered: Contraception, Clinical trials, Mental Health, State Mandates
- Many can be excluded from the individual market

**Note:**  Other includes Medicare, CHAMPUS, and other sources of coverage.
**Source:**  Kaiser Family Foundation analysis of March 2005 Current Population Survey, US Census Bureau.

- Figure 7

**Notes:**
The two major  policy concerns with private coverage relate to the affordability of care and scope of coverage. 

We have also seen substantial and consistent increases in copayments for doctors visits and for prescription drugs.  Given that half of nonelderly women rely on rx on a regular basis  these cost increases have a disproportionate effect on women.

We also see that there is considerable variation in from state to state in what plans are required to cover.  

We’ve seen dramatic growth in the past few years of polices such contraceptive coverage mandates for women.  As of August 2004, 21 states require that plans that cover prescription drugs also must cover contraceptives.  There is,however, no federal law that mandates that plans and employers offer contraceptive coverage, although several federal rulings have determined that employers must offer contraceptives if they also cover rx. 

States also have many policies in place that require that plans covers certain preventive services such as pap smears or mammograms, and also allow women in managed care to see an ob/gyn with a referral from her PCP.  

Coverage of screening services for STDs and parity mandates for mental health services are much less common.

Although states have many benefit mandate policies in effect, self-funded plans are exempt from these requirements through ERISA.  This is significant because currently over half of workers are covered by self funded plans. To affect these types of plans, legislative change is required at the federal level, state action is not enough.  

## Medicaid and Women

- Figure 8

**Notes:**
Medicaid, the nation’s health coverage program for low-income people is the backbone of the health care safety net and is critical for low-income women, including Native women.

## Medicaid Basics

- Largest single health insurance program in the country - provides health and long-term care coverage to over 50 million people
- Jointly run by federal government and individual states
- Eligibility determined by income as well as categorical criteria
- States establish eligibility and benefit levels under broad federal guidelines
- Children account for 50% of Medicaid beneficiaries;  69% of beneficiaries 18+ are women
- 16% of AI/AN women receive Medicaid

- Figure 9

**Notes:**
Medicaid is the largest single health insurance program in the country - provides health and long-term care coverage to over 50 million people 

It is jointly operated by federal government and individual states.  That is each state operates its own program under broad federal guidelines and financing is shared by the two, based on a complicated matching formula that determines what share the feds pick up and what share each state pays.  
To qualify for Medicaid, an individual must meet both income and categorical criteria.  Medicaid is only available to categories of individuals – children, pregnant women, parents of dependent children, some seniors with very low incomes, and people with disabilities.  Within each of these categories, there is an income threshold that an individual must be below.  And what this means is that there are many low-income individuals who do not qualify for Medicaid.
The income criteria for each category are set by each state as well as the particular package of benefits that are covered.

Here, there is some more detail on the scope of services covered by Medicaid.  On the left are “mandatory” services that states must cover. all states were required to cover mandatory services such as physician and hospital services, EPSDT, and family planning. 
On the right, are “optional” services that states may cover and can receive federal matching funds for, including drugs, dental care, home health, and personal care. 

Overall, children comprise half of the Medicaid population and women account for approximately 70% of adult beneficiaries.

And, medicaid plays an important role for Native women, covering approximately 16% of American Indian/Alaska native women.  

## Medicaid Plays a Critical Role for Low-Income Women 

**Covers 20 million low-income women  **
- Eligibility limited to pregnant women, mothers, seniors, or disabled** **
- 63% are women on program are of reproductive age (ages 18 to 44)
- Women on Medicaid have considerable health needs (they tend to have higher rates of arthritis, diabetes, asthma and anxiety/depression than their privately insured or uninsured counterparts)
**Provides coverage for a wide range of services  **
- Physician and hospital care, mental health, prescription drugs, and long-term care
**Improves access to physicians and preventive care**
- Women on Medicaid more likely to get regular care, mammograms, pap tests than uninsured women and as likely as privately insured low-income women

- Figure 10

**Notes:**
As you probably know Medicaid is an incredibly important program for low-income women. 

However, for women, Medicaid eligibility is limited to those who are low-income and pregnant, very poor with children, over 65 or those with disabilities and eligible for SSI.  

For those women, Medicaid covers a broad  range of services from physician care to long-term care and has been shown to improve access and provide levels of care that are on a par with private coverage for low-income women.

Here in New Mexico, nearly 600,000 women are on Medicaid.  Approximately 42% of  low-income women.

What I don’t want to lose sight of, however, is who these women are.  Women on Medicaid contend with a host of challenges and are among some of the most vulnerable among us.  The vast majority are low-income – that’s family incomes below $30,000 for a family of three.  Most have children to care for.  A sizable share are working, and nearly four in ten women on Medicaid are in fair or poor health.  In sum, women on Medicaid include some of the most vulnerable among us.  

## Medicaid Coverage of Reproductive Health Services

**Preventive services**:  family planning, oral contraceptives, gynecological exams, STD testing, treatment and counseling
**Family Planning Services:  **mandatory Medicaid benefit
*Enhanced Match***:  **federal govt. pays 90% of cost of family planning services and supplies (regular Medicaid match ranges from 50 to 77%)
*Freedom of Choice in Medicaid Managed Care***:  **Beneficiaries may obtain services from any Medicaid-participating provider, plans may invoke religious/moral exemptions from providing services
*Exempt from Cost-Sharing*
*State Waiver Programs***:  **Expansions to provide family planning services to low-income women who do not otherwise qualify for Medicaid
**Maternity care:**  mandatory eligibility for all pregnant women up to 133% FPL, pays for 40% all US births, range of prenatal services, 60 days postpartum coverage
**Abortion coverage:** very limited, Federal Hyde Amendment prohibits use of federal funds on abortion, 17 states use state-only funds to cover “medically necessary” abortions

- Figure 11

**Notes:**
Now, ~2/3 of women on Medicaid are in their reproductive years, so family planning, perinatal services, and abortion are all important services for this group of women.

Family planning has long had special status under Medicaid.  It is a mandatory benefit that states must cover.  And, states have incentive to do so, because the federal government pays 90% of the cost of family planning services, so it has an enhanced match rate that exceeds the normal rate for all other services.  Today, Medicaid is the largest public payer of fp services.
FP services are also exempt from cost-sharing, so women should not have to pay any out-of-pocket costs for these services,  and for women in Medicaid managed care,  by law, they are allowed to obtain fp services from any Medicaid-participating provider.

Medicaid is also a major financier of maternity care services, paying for at least 40% of all births in the U.S.  This varies among the states, and is actually highest here in NM,  paying for 2/3 of births in 2002.

Abortion, however, is a reproductive service that has very limited coverage under medicaid.  Federal law prohibits the use of federal funds on abortion.  States can use their own dollars to finance “medically necessary” abortions, but obviously this medical necessity criteria poses a limit in scope as well.

## Half of States Extend Family Planning Services to Women Who Do Not Qualify for Full Medicaid

** **

**AZ**

**AR**

**MS**

**LA**

**WA**

**MN**

**ND**

**WY**

**ID**

**UT**

**CO**

**OR**

**NV**

**CA**

**MT**

**IA**

**WI**

**MI**

**NE**

**SD**

**ME**

**MO**

**KS**

**OH**

**IN**

**NY**

- IL

**KY**

**TN**

**NC**

**NH**

**MA**

**VT**

**PA**

**VA**

**WV**

**CT**

**NJ**

**DE**

**MD**

**RI**

**HI**

**DC**

**AK**

**SC**

**NM**

**OK**

**GA**

- Note: *The federal poverty level for a family of three in 2007 is $17,170.
- Source:  Alan Guttmacher Institute, *State Policies in Brief*, June 2007.

**TX**

**FL**

**AL**

**Losing coverage postpartum (6 states)**

**Based on income (19 states)**

**Losing coverage for any reason (1 state)**

- Figure 12

**Notes:**
Extends Medicaid coverage for family planning to low-income women ineligible for full Medicaid assistance - Since 1993, some states have used Medicaid as a vehicle to provide family planning benefits to low-income, uninsured women

1115 waiver used to make this expansion

States have extended eligiblity for a family planning and related services through the use of special Medicaid programs called waivers. These benefits have been extended to women who either have lost their Medicaid coverage, recently had a baby, or who are low-income

Family planning covered at a 90% federal match - Because the federal government matches 90 cents for every dime a state spends on family planning, the Medicaid expansion is a relatively inexpensive way for states to improve access to these services. 

States have extended coverage to women who: 
lose Medicaid coverage at the end of the postpartum period
lose Medicaid for any reason or
are low-income

## Medicare and Women

- Figure 13

**Notes:**
Another critically important public program is Medicare, which covers virtually all people over age of 65 and some younger people with permanent disabilities.  

## Medicare Beneficiaries, by Age and Sex, 2004

- Source: KFF analysis  of 2004 Medicare Current Beneficiary Survey.

**Number of **
**Beneficiaries**

**43 million**

**6.5 million**

**18 million**

**13 million**

**5 million**

**Age**

- Figure 14

**Notes:**

And, Medicare really is a women’s issue..  In fact, women account for more than half (56%) of the total Medicare population.  While men comprise the majority of the under-65 disabled population on Medicare, across the board, women make up a larger and increasing share of the older age groups.  Among beneficiaries ages 85 and older, seven out of ten are women.   This is due in part to women’s longer lifespans.

##   Federal health insurance program designed for the elderly 
   and people with disabilities

  Covers 43 million people – Most are seniors (65 and older);   
   about 15% are younger and have disability

  Financed by combination of payroll tax on employers and 
   employees as well as premiums paid by beneficiaries

  Broad coverage of many basic benefits – inpatient hospital,
   physician charges, outpatient care, annual mammography, variety of
   ancillary services/procedures, and most recently prescription drugs 

  To fill gaps, many individuals purchase supplemental coverage and
   low—income can qualify for Medicaid 

  Long-term care NOT covered by Medicare

-    and people with disabilities
-   Covers 43 million people – Most are seniors (65 and older);
-    about 15% are younger and have disability
-   Financed by combination of payroll tax on employers and
-    employees as well as premiums paid by beneficiaries
-   Broad coverage of many basic benefits – inpatient hospital,
-    physician charges, outpatient care, annual mammography, variety of
-    ancillary services/procedures, and most recently prescription drugs
-   To fill gaps, many individuals purchase supplemental coverage and
-    low—income can qualify for Medicaid
-   Long-term care NOT covered by Medicare

**Medicare Basics**

- Figure 15

**Notes:**
Unlike Medicaid, Medicare is operated by the federal government alone.  It is the nation’s second largest insurance program, covering 43 million people, most of whom are seniors, but about 15% are younger and qualify due to a disability.
PARTSA_D
Premiums
Financing comes primarily from taxes on workers and employers that are paid throughout the course of an individual’s working life, but also from premiums that beneficiaries must pay.  This is important because out-of-pocket costs can be significant for Medicare beneficiaries, most of whom are older and live on fixed incomes.

Medicare covers a broad range of preventive, treatment, and hospital care.  Of course, one of the major changes in recent years was the adoption of the new prescription drug benefit.  

However, long-term care services such as a nursing home stay are not covered under Medicare.

## Distribution of Out-of-Pocket Health Spending by Medicare Beneficiaries Age 65+, 2002

- Note: Estimates reflect mean out-of-pocket spending for Medicare and private insurance premiums and health care services. Source: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2002 Cost and Use File.

**Women 65+**

**Men 65+**

**$3,991**

**$3,269**

**Distribution of Out-of-Pocket Health Spending by Medicare Beneficiaries Age 65+, 2002**

**$1,450**

**$1,407**

**$557**

**$671**

**$428**

**$206**

**$1,210**

**$634**

**$546**

**$152**

- Figure 16

**Notes:**
And, older women face a number of challenges that can affect their access to care.  They  have fewer financial resources than men due to  a lifetime of working for lower wages at jobs that offer fewer benefits such as retirement or because their  lower incomes limit the amount of money they can put towards their retirement. 

While nearly all women over 65 have Medicare, as I said Medicare can pose significant out-of-pocket expenses, and many have difficulty affording the premiums, copayments and deductibles.  
As we’ve been hearing, Medicare premiums have been rising.  This past year they  rose 17%.  So, many seniors, particularly those of modest means, may be forced to make some very difficult trade offs to meet these payments. 

And while we have a relatively new drug benefit under Medicare, there is increasing evidence that many seniors will have still difficulty affording prescription drugs.

And finally long-term care is a poorly understood but critically important women’s health issue, given women’s longer lifespans, higher rates of disability, and lower incomes to pay for the costs.

And as we look to the future, we will see that long-term care will account for an increasing share of health expenses as the population ages.  Long-term care Coverage is quite limited in most private health insurance plans and private long-term care insurance can be prohibitably expensive for many adults, especially seniors.  Although Medicare is the primary payer of health care services for seniors, it only covers nursing home and home health care for  patient who have just been discharged from the hospital.  It does not  provide ongoing  long-term care coverage that many people with chronic health problems need.  Medicaid is the nation’s single largest source of financing for nursing home care, but only those who are very poor or who have impoverished themselves with their health and long-term care expenditures are eligible.  Nearly one-third of all long-term care expenditures are paid for directly by families and the costs of that care can be quite burdensome.  A year of care in a nursing home can cost $50,000 or more.  Hiring a home health aide at $12 an hour for four hours a day, five days a week would cost over $12,000 for a year.  Unfortunately there are few public policy solutions on the table at this time to address these devastating costs.  This is a critical issue for women and as the population of women ages, this will become even more of a priority.

## Out-of-Pocket Spending by Women on Medicare Age 65+, by Income, 2002

- Note: Estimates include out-of-pocket spending for Medicare and private insurance premiums and health care services.
- Source: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2002 Cost and Use file.

- Median Out-of-Pocket Spending As Percent of Income

- Median Out-of-Pocket Spending

- Figure 17

## Uninsured Women

- Figure 18

**Notes:**
And one of the most vexing challenges for providers is treating the uninsured.  The number continues to climb, currently around 46 million people do not have coverage.  Men are slightly more likely lack insurance, but that 46 million does include about 9 million children and 17 million women.

And the uninsured are diverse as well.  Most live in a household where at least one person is working, so for some reason, they do not have access to employer-sponsored insurance.

And from a clinical standpoint, research has also documented poorer health outcomes for the uninsured.

As I mentioned earlier, one in five Native women are uninsured, and another 16% have IHS coverage only.  This coverage is critical for many women, but as I’m sure all of you know too well, IHS faces a number of challenges as well.

## Insurance Affects Access to Preventive Services 

- Note:  Mammogram among women 40-64; Colon cancer screening among women 50 - 64; osteoporosis screening among women 45-64.                                                                                                                                              Source:  Kaiser Family Foundation, *2004* *Kaiser Women’s Health Survey*.

- Percent of women 18 to 64 reporting they have
- NOT received screening test in past two years:

- Figure 19

**Notes:**
And, we see tangible outcomes on the impact of insurance.  Preventive services are very important to women yet in many cases we still fall short. This is percentage of women reporting they have NOT had a particular test recently.
Most women have had a blood pressure check and about three–quarters have had either a breast exam, a pap smear, or a mammogram for women that are 40 and older. Two-thirds of women said that they have had a blood cholesterol screening in the past two years, but not quite in four in ten have had colon cancer screenings or an osteoporosis check in the past two years. 

Clearly, a lot of different players can help improve these rates, including providers, out public health system on greater  education and awareness about the importance of these screening services, but we do see a significant difference between the insured and uninsured. 

## As Well as Treatment Services 

**As Well as Treatment Services **

- Note: *Significantly different from Private, p<.05.
- Source: Kaiser Family Foundation, *2004* *Kaiser Women’s Health Survey*.

- Percent of women 18 and over reporting that in the past year they:

- *

- *

- *

- *

- *

- Figure 20

**Notes:**

You can also see here the important impact of having coverage on gaining prescription drugs. Across the board you see that uninsured women are significantly more likely to report that they either didn’t fill a prescription because of cost, or they skipped or took smaller doses of prescription drugs, or that they spent less on basic family needs to pay for their prescription medication. 

## Policy Challenges

- Figure 21

## Health Care Costs on the Rise

- *Estimate is statistically different from the previous year shown at p<0.05.
- Note:  Data on premium increases reflect the cost of health insurance premiums for a family of four.Source:  Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999–2006; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988, 1989, 1990; Bureau of Labor Statistics, Consumer Price Index  (U.S. City Average of Annual Inflation (April to April), 1988–2006; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988–2006 (April to April).

**    ****3.8%**

**    ****3.5%**

**Slide 13**

**Health Care Costs on the Rise**

- Change in cost of health insurance premiums:

- Figure 22

**Notes:**
Context,  HC costs rising. Employer-sponsored health insurance premiums increased an average of 7.7% in 2006,  according to the Kaiser/HRET Annual Employer Health Benefits Survey.
While the pace has slowed in just the past couple of years, you can see that hc costs still outpace inflation and worker earnings three-fold, making the costs very acute.

## Cost Increasingly a Barrier to Care...  Even for Women with Insurance Coverage

**Cost Increasingly a Barrier to Care...  ****Even for Women with Insurance Coverage**

- Percent of women ages 18 to 64 reporting they delayed or went without care they thought was needed in past year due to costs:

- Note:  * Significantly different from 2001, p< .05.                                                                                                          Source:  Kaiser Family Foundation, *Kaiser Women’s Health Surveys*,* *2001, 2004.

- Figure 23

**Notes:**
You can see here the difference here that having coverage makes in terms of allowing people to afford care. While overall one in four women delayed care they thought they needed because of cost, two-thirds of uninsured women reported this problem. It should be noted while it makes a difference, having coverage doesn’t address all of the issues in terms of access and I’m going to talk about those in a little bit. We found that 17% of women with private insurance and 13% of women with Medicare also delayed or went without care because they couldn’t afford it as did one one-third of women with Medicaid. While Medicaid only permits nominal cost sharing, even small costs may be prohibitively expensive for women and really serve as a barrier to their care.

And we conducted this survey in 2001, so we were also able to look at some trends. While much remained unchanged in the three years, we did find some differences, and here’s a statistically significant increase in the share of women who report that they delayed or went without care because of cost. That rose overall from 24% of women in 2001 to 27%. The rise in the uninsured I think is particularly striking, that’s an eight point increase but we also saw a four point increase in the women with private insurance who are reporting that they delayed or went without care they thought they needed because of cost.

## Federal Budget Pressures and Responses 

- Rising federal deficit
- Pressure to cut deficit and extend tax cuts
- Interest in reducing federal spending on Medicaidand Medicare
- Federal Action:
- Deficit Reduction Act
- President’s FY 2008 proposals
- Secretary’s Medicaid Commission
- Congressional impasse on Medicare Advantage plans and SCHIP

**Federal Deficit Projections, 2006–2016**

- Note: Adjusted baseline accounts for the impact of the Deficit Reduction Act, extension of tax cuts, AMT reform and war costs
- Source: CBO, *Baseline Budget Outlook*, January 2006.

**Billions of Dollars**

- Figure 24

**Notes:**
And, in the public sector, there has been pressure to reduce the deficit while extending tax cuts at the same time. In response to these pressures, Medicaid has been a target area for reduced federal spending and made up a significant share of the savings in the recently passed Deficit Reduction Act.

## Deficit Reduction Act: Key Medicaid Changes

**Citizenship documentation**
- New requirement for current and new beneficiaries to document citizenship
- Previously: states established citizenship or satisfactory immigration status (47 states allowed applicants to self-declare citizenship status)
**Benefits**
- Allows “benchmark” or “Secretary-approved” coverage for some groups
- Previously: states provided “mandatory” benefits and could choose to provide “optional” benefits (e.g., prescription drugs)
**Premiums & Cost Sharing** (family planning/pregnancy services exempt)
- Allows higher or new cost sharing/premiums; states can make co-pays enforceable
- Previously: nominal cost sharing allowed; premiums generally prohibited
**Comparability and State-wideness**
- Allows variation in benefits and cost sharing across groups and geographic areas
- Previously states generally were required to have uniform benefits and cost sharing across groups and areas of the state

- Figure 25

**Notes:**
The Deficit Reduction Act was signed into law over a year agoon February 8, 2006 is
Citizenship documentation:  One of the major changes imposed by the DRA is the requirement for beneficiaries to prove their citizenship status with documentation, where previously most states allowed individuals to self-declare.

Benefits:  The DRA also allows states to make some significant changes to their benefit structure.  States can now have latitude to add or eliminate coverage for certain benefits if the Health Secretary approves the changes.  As opposed to the mandatory/optional benefits that I listed earlier.  This has potential to scale back benefits.

Premiums and Cost-sharing:  Historically, Medicaid has not charge premiums and allowed only nominal cost-sharing, but now states have more flexibility to charge some beneficiaries premiums, increase cost-sharing, and deny services if a beneficiary cannot pay them.

Uniformity:  And in that same spirit of state flexibility, states can now provide different benefits packages and cost-sharing requirements to different groups within a state.

We haven’t seen a lot of states take up these options yet, just a few, but these are important openings that those who work with low-income populations need to watch.

## Some New Directions in Medicaid

**Emphasis on personal actions and responsibility**
- Behavior modification through incentives
- “Consumer choice” of managed care plans
- Long-Term Care Consumer Direction
- Increased premiums and/or cost sharing
**“****Tailored” benefits**
- Variation in benefit packages across groups or geographic areas
**Increased role of private marketplace**
- Increased control to plans to determine benefit packages
- Emphasis on premium assistance
- Public/private long-term care partnerships
**Restricting spending/increasing spending predictability**
- Defined contribution approaches
- Aggregate cap on federal funding

- Figure 26

**Notes:**
Through changes in the DRA and waivers, there appear to be some new directions that state Medicaid programs are taking:  
First, there is a new emphasis on personal responsibility.  New plans include penalties and rewards as incentives to change behaviors, greater choice among managed care plans, and increased use of premiums and cost-sharing.
State plans are also beginning to develop “Tailored” benefits in which different eligibility groups qualify for a different set of benefits.  
They are also increasingly adopting more strategies to increase the role of private marketplace that give plans more control over benefits and utilization and provide assistance with premiums so beneficiaries who work can buy in to private insurance if it is offered 
And finally, states are placing greater emphasis on restricting spending and increasing spending predictability.  

## Medicare Challenges

- Dealing with Medicare’s cost pressures and ensuring program’s finances can keep up with aging of population
- Setting fair payment for providers and plans, without putting program in financial jeopardy
- Monitoring and improving implementation of the drug benefit
- Balancing the role of traditional Medicare vs. Medicare Advantage
- Improving coverage and care for the chronically ill, those with limited incomes, and for beneficiaries with long-term needs

- Figure 27

**Notes:**
As the population ages, many will turn to the Medicare program as their primary source of health insurance, and as a pillar of their retirement security. 

While Medicare has been a successful and popular program, by many standards, it also faces challenges that will need to be addressed by lawmakers in future years. These include:

dealing with Medicare’s fiscal pressures without shifting excessive costs onto beneficiaries, 

setting fair payments to providers and plans without putting the program in financial jeopardy, 

monitoring and improving the new Medicare drug benefit, 

and assessing the role and cost of Medicare Advantage plans.  In both of these areas, we’ve seen a growing role for private plans, a departure for Medicare, and we need to continue monitoring what effect this has on benefciaries’ access to services....SVHIP reauthorization.

And last, but certainly not least, improving coverage and care for those who are chronically ill and frail, assuring that health care is affordable for those with modest incomes, and doing more to help meet the long-term care needs both of aging Americans, and those with disabilities. 

## Expanding public coverage
Expansions of Medicaid/S-CHIP at the state level
National health insurance program  - “Medicare for All”

Expanding private group coverage through current employer-sponsored system
Financial incentives for employers to provide coverage
Employer mandates
New group insurance options, especially for small employers
Individual mandates

Subsidizing purchase of private health insurance through tax credits and deductions
Individual tax credits/deductions to subsidize insurance premiums
Increased utilization of Health Savings Accounts (HSAs) for certain types of health insurance

- Expansions of Medicaid/S-CHIP at the state level
- National health insurance program  - “Medicare for All”
**Expanding private group coverage through current employer-sponsored system**
- Financial incentives for employers to provide coverage
- Employer mandates
- New group insurance options, especially for small employers
- Individual mandates
**Subsidizing purchase of private health insurance through tax credits and deductions**
- Individual tax credits/deductions to subsidize insurance premiums
- Increased utilization of Health Savings Accounts (HSAs) for certain types of health insurance

- Figure 15

**Current Strategies Proposed to Expand Health Insurance Coverage**

- Figure 28

**Notes:**
So, clearly our health care system faces large challenges and we’re not the only ones to notice.  Health care is on the minds of many, notably several governors and state legislatures, which are in various stages of debating health reform options, and health care is taking national stage too, particularly with some of the many candidates running for President.   

And, we’ve seen health reform efforts before.  These are some of the major options being debated now at the state and national levels.

Expanding public coverage.  At the state level, that has been taking the form of proposals to expand Medicaid eligibility, primarily by raising the income threshold.  At the national level, there is some discussion of a Medicare for All thype model.
Building on the current employer-system and expanding coverage by getting more employers to provide coverage (as we know, most of the uninsured are in families with at least one worker).  This includes mandates for indviduals and employers and penalties for those who do not participate.  So-called pay or play laws.
And then, we’ve also seen some interest in trying to expand coverage through alterations in the tax code by offering tax credits and deductions to help make health insurance more affordable to the unisnured, and a growing interest in HDHPs with Health Savings Accounts

## Public Support for Strategies to Expand Health Insurance Coverage

**Expand state government programs for low-income people to provide coverage for people without health insurance**

**A national health plan, financed by taxpayers, in which all Americans would get insurance from  single government plan**

**Requiring businesses to offer private health insurance for their employees**

**Expand Medicare to cover people under age 65 who do not have health insurance**

**Offer businesses tax deductions, credits, or other financial assistance to help them provide health insurance to employees**

- Percent choosing as single best option for guaranteeing health insurance for more Americans:

**Offer uninsured Americans financial assistance to help them purchase private health insurance on their own **

**Public Support for Strategies to Expand Health Insurance Coverage**

- Figure 29

**Notes:**
So, there are certainly a number of different proposals on expanding coverage.  

One of the areas that we work on at KFF is public opinion polling and assessing where the public is on health care.  And, generally speaking, the public is very concerned about health care policy, both in terms of costs and coverage.  When asked, most Americans do think that government should make expanding coverage to the uninsured a major priority.  That will is clearly important and necessary for any action.  

Here, we’re looking at public support for some of the major expansion proposals that I went over, and you see that there is about the same level of support for a wide range of strategies.  And so really, the most important thing to recognize from these numbers is that there is not consensus on any one direction or strategy to undertake.  This is really a challenge from both a policy and political perspective.

## Who will be assisted? 
Targeting expansion to currently uninsured
Take-up rates based upon income

What is the scope of benefits? 
Importance of comprehensive benefit packages
Catastrophic coverage

Will coverage be affordable?
Level of subsidy 
Method of subsidy 

How much will it cost? 
Public or private financing
Efficient targeting of expansion financing 

Impact on existing system?
Adverse risk selection 
Current safety-net including community health centers and IHS
Incentives for quality/efficiency

- Targeting expansion to currently uninsured
- Take-up rates based upon income
**What is the scope of benefits?**
- Importance of comprehensive benefit packages
- Catastrophic coverage
**Will coverage be affordable?**
- Level of subsidy
- Method of subsidy
**How much will it cost?**
- Public or private financing
- Efficient targeting of expansion financing
**Impact on existing system?**
- Adverse risk selection
- Current safety-net including community health centers and IHS
- Incentives for quality/efficiency

- Figure 16

**Evaluating Expansion Proposals**

- Figure 30

**Notes:**
So, as debate over health reform continues and we hear about the assortment of different policy proposals, particularly if this issue gains traction in the Presidential election, there are a number of questions that we have to ask to evaluate these options and their impact on women.

We need to assess who will be assisted by the program.  Will the plan in question actually expand coverage to those currently without insurance or will it substitute current coverage with another program?  What will the take-up rates be  based on income?  Will those most at risk for being uninsured, that is low-income populations be assisted by the current strategy?
What will be covered under the proposal?  As we’ve seen this morning, scope of coverage matters for women.  Will the benefits package be comprehensive – covering the full range of needed preventive, diagnostic, primary, specialty, and long-term care services? Will there be incentives to obtain preventive services such as screenings and early detection services? Or, will the package be more focused on catastrophic coverage, covering only very high-end treatments after a beneficiary first meets a substantial deductible and out-of-pocket costs?
Will coverage be affordable? Will low-income be able to participate and afford the premiums?   Will there be a subsidy and will it be enough to offset the costs for lower-income groups?
And related, how much will the proposal cost?  Where will the financing come from?  From individuals, the private sector, namely employers or will it be from all of us in the form of taxes?
What impact will the plan have on the existing system that we all have to work within?  Will it avoid adverse selection or will it only draw the healthiest sectors of the population, leaving behind  sicker individuals and raise costs in the existing system?  Will there be funds for strengthening current safety-net programs, such as IHS?  And, will there be incentives to enhance quality and efficiency of care?

## But Coverage is Only Part of the Challenge for Women...

- ^Among women who are employed.  ^^ Among women with children younger than 18 years living in household.
- Source: Kaiser Family Foundation, *2004* *Kaiser Women’s Health Survey*.

- *

- *

- *

- *

- Percent reporting they delayed or went without  care they thought was needed in the past 12 months due to:

- Figure 23

**But Coverage is Only Part of the Challenge for Women...**

- Figure 31

**Notes:**
But as I said earlier insurance is not the only reason that women delay or postpone care. For many it’s often difficult to find time for their own health needs between balancing their work and their family responsibilities. In fact, lack of time affected about 20% of women in all of the categories that we looked it, it was one of these kind of universal coverage regardless of race, ethnicity, regardless of income, insurance status, almost all groups of women said that they couldn’t find time, the one exception was women over 65. For low income women however taking the time from work, getting child care, gaining transportation, are all significant obstacles in getting care and really issues that they need assistance with. 
So where does that leave us?

One of the priority issues facing women health is how we extend coverage to the nations 45 million uninsured..  There is widespread agreement from both sides of the aisle, that wee need to address the problem of the uninsured. There is considerable disagreement, however,  on how to do it, whether to extend existing public programs such as Medicaid or S-CHIp or to put incentives in to the private system to make private coverage more affordable.  

Scope of coverage is also an important issue for women. There are still important gaps in what is covered, contraceptives, mental health, reproductive health and preventive services are all vital to women, but coverage is uneven from plan to plan and state to state.

WE also have few effective strategies at hand to address the crisis of growing health care costs.  While we hoped managed care would be a silver bullet, it is obvious that we have no better ability to get a handle on costs, then we did a decade ago.  

And finally, we need to come up some innovative approaches to finance long-term care.  As patients and care givers, women have much at stake.  We’ve developed few effective strategies and the costs can be devastating for families and seniors.