Medicare Drug Benefit Enrollment Update

This enrollment update breaks down and explains the statistics related to enrollment under the new Medicare drug benefit and the separate low-income subsidy program that provides additional assistance. The enrollment update summarizes the latest enrollment figures released by the Centers for Medicare & Medicaid Services and the Social Security Administration and compares them with earlier enrollment projections.

Issue Brief (.pdf)

In early 1996, the Health Resources and Services Administration (HRSA) contracted with the National Alliance of State and Territorial AIDS Directors (NASTAD) to conduct the first ever survey of state AIDS Drug Assistance Programs; a follow-up was conducted six months later. These early survey reports, provided here, were the pre-cursors to the National ADAP Monitoring Project, a joint initiative of the Kaiser Family Foundation and NASTAD which began the following year.

The Fiscal Status of State AIDS Drug Assistance Programs: Findings from a January 1996 National Survey of State AIDS Directors (.pdf)

Fiscal Status Update of State AIDS Drug Assistance Programs: Preliminary Findings from an August 1996 National Survey of State AIDS Programs (.pdf)

Citizenship Documentation Requirements in The Deficit Reduction Act Of 2005: Lessons From New York

New York State is one of only four states in the nation that already requires documentation of citizenship for Medicaid applicants (the others are Georgia, Montana and New Hampshire), and the only state with significant implementation experience. New York’s citizenship documentation requirement has been in place since the mid-1970s, and provides a solid base of experience that can inform the implementation of the new documentation requirement in the Deficit Reduction Act of 2005, as well as planning in state Medicaid programs that will be documenting citizenship for the first time.

Drawing on legal research, interviews with Medicaid officials, and a roundtable discussion with front-line enrollers who provide Medicaid application assistance, this report provides an in-depth assessment of the New York State Medicaid program experience with citizenship documentation requirements.

Report (.pdf)

A few recent state Medicaid initiatives have emerged that take the program into new directions. States have expressed a number of objectives in developing these approaches, including offering beneficiaries greater choice, promoting personal responsibility and healthier behaviors among enrollees, and, in some cases, relying more heavily on the private marketplace. In addition, states have sought to shape their initiatives in ways that could help them better predict and limit their exposure to costs.

This brief examines how these approaches change financial risk and responsibility for states, the federal government, beneficiaries and providers.

Issue Brief (.pdf)

This report — coauthored by J. Stephen Morrison (Center for Strategic and International Studies) and Jennifer Kates (Kaiser Family Foundation) — highlights the potential role of the G8 in addressing the Eurasian HIV/AIDS epidemic and further engaging Russia, China and India in the global HIV/AIDS response.

Report — English Language (.pdf)

Report — Russian Language (.pdf)

The Deficit Reduction Act (DRA) of 2005 was signed into law in February 2006 with several significant changes to the Medicaid program affecting both health and long-term care coverage as well as new citizenship requirements.

States were granted greater flexibility in charging copayments and premiums and modifying the benefit package for certain Medicaid beneficiaries. Changes of this type previously required a waiver and now can be done by amending the state plan. The first two states to modify their Medicaid programs in response to the DRA were West Virginia and Kentucky; other states are likely considering changes.

On Monday, June 19, 12 p.m., ET, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) is holding a background briefing for reporters across the country on understanding what changed for Medicaid in the DRA, how West Virginia and Kentucky are planning to modify their Medicaid programs and what are the implications of DRA-related state actions. The briefing features Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of KCMU, and other Kaiser experts.

To dial in to the briefing, call 800-379-9582. The password is KCMU.

Presentation (.pdf)

New Developments in Medicaid Coverage: Who Bears Financial Risk and Responsibility?Deficit Reduction Act of 2005: Implications for Medicaid

Medicaid Long-Term Services Reforms in the Deficit Reduction Act

New Requirements for Citizenship Documentation in Medicaid

Citizenship Documentation Requirements in the Deficit Reduction Act of 2005: Lessons From New York

Washington Post/Kaiser Family Foundation/Harvard African-American Men Survey

The Washington Post, the Kaiser Family Foundation and Harvard University have released a new, comprehensive survey looking at how African-American men view their lives in the United States and their outlook for the future. The survey gauges the views and experiences of African-American men on marriage and family, education, careers and health, among other issues, and includes comparisons to the views and experiences of African-American women and white men and women.

The African-American Men Survey is the 15th survey in a series generated under a three-way partnership between The Washington Post, the Kaiser Family Foundation and Harvard University. The three organizations work together to pick the survey topics, design the survey instruments and analyze the results. The survey’s findings were published in the June 4, 2006, edition of The Washington Post.

This survey was conducted by telephone from March 20 to April 29, 2006, among 2,864 randomly selected adults nationwide, including: 1,328 black men; 507 black women; 437 white men and 495 white women. Results for total respondents have been weighted so that black respondents are represented in proportion to their actual share of the population. Margin of sampling error is plus or minus 3 percentage points for results based on all respondents or black men, 5 percentage points for black women and 6 percentage points for white men or women. Hispanics and Asians were interviewed along with white and black respondents, but because of the relative size of those populations, there were not enough respondents to break out separately. The complete survey results and detailed methodology description are available in the toplines document.

Toplines (.pdf)

This chart pack is a supplemental report based on a subset of the Survey of Americans on HIV/AIDS and provides additional analysis on public opinion on HIV testing. A full survey report, including full question wording for results presented in this report is available here.

Chartpack (.pdf)

This chartpack is a supplemental report based on a subset of the Survey of Americans on HIV/AIDS and provides additional analysis on the opinions and experiences of 18- to 25-year-olds on HIV/AIDS. A full survey report, including full question wording for results presented in this report is available here.

Chartpack (.pdf)

How much people should pay out-of-pocket for health care is a much-debated issue in health policy. New health insurance products with higher out-of-pocket shares are becoming more evident in the private market, and some states are considering ways to increase enrollee financial responsibility in state Medicaid programs.  This paper presents information about current out-of-pocket spending by individuals with the purpose of providing context for future health policy discussions.

Current proposals suggest that increasing the amount that people must pay directly out-of-pocket for their health care at the point of service will encourage them to make more efficient and better health care decisions, leading to an overall reduction in health care expenditures. Discussions about out-of-pocket responsibility often focus on the overall percentage of health expenditures that are paid out-of-pocket — roughly 20% based on the 2003 Medical Expenditure Panel Survey (MEPS).¹ There is, however, considerable variation in the amounts and percentages that people pay out-of-pocket for health care today. The paper breaks out total and out-of-pocket expenditures along several dimensions, including level of spending, service type and poverty level for two population groups — all people and nonelderly people with private health insurance.² Our goal is to enhance public understanding of how total and out-of-pocket health care expenditures are distributed across the population.

The information below is based on data from the 2003 Medical Expenditure Panel Survey (MEPS), Household Component. MEPS is a national probability survey of the U.S. civilian population residing outside of institutions, conducted by the Agency for Healthcare Research and Quality. The survey provides detailed information on the demographic characteristics, health care use and health care expenditures costs for this population. See http://www.meps.ahrq.gov/Puf/PufDetail.asp?ID=194/ for additional description of the 2003 MEPS consolidated file.

This paper focuses on expenditures paid for health care services and not on premiums paid by families. Current discussions about changing health benefit design focus on out-of-pocket payments for services, so this paper looks at out-of-pocket costs in that context. Premium payments are clearly an important part in considering the overall out-of-pocket health care burden on families (and premium levels will interact with changes in benefit design). We will be looking at the broader issue of overall out-of-pocket burden and family budgets in later work.

Share of Total Expenditures Paid Out-of-Pocket

Figure 1 shows that about 20% of total health expenditures are paid out-of-pocket. This percentage is consistent across the two populations presented here.³

Average Out-of-Pocket Share

Figure 2 shows the percentage of expenditures that the average person who has spending on health care pays out-of-pocket, which is 35% and 34% for each of the two populations. These percentages are higher than the 20% and 19% presented above because health expenditures are not distributed evenly across the population — a small percentage of people account for most health expenditures, and these high spenders have relatively low out-of-pocket shares. More information on out-of-pocket shares by level of total spending is presented below.

Out-of-Pocket Shares By Poverty Level

Figure 3 shows that, among people with health spending, the average out-of-pocket share for people under poverty is somewhat lower (28% v. 35-36%) for all people than the average out-of-pocket share above poverty. This difference may result from cost sharing protection provided for some of the poor by Medicaid and other public programs. Average out-of-pocket shares do not vary by family poverty level for the nonelderly group with private insurance.

Out-of-Pocket Shares by Level of Total Spending

A relatively small percentage of the population accounts for most health expenditures — the 5 percent with the highest spending account for about 49% of the total health expenditures, while the 20 percent with the highest spending account for around 80% of total expenditures.⁴ This distribution does not vary considerably by population group.

As Figure 4 shows, out-of-pocket spending accounts for a smaller proportion of total spending as the overall level of spending on health increases. Figure 4 shows average out-of-pocket shares for people based on their level of overall health spending.⁵ For example, looking at all people, the one percent with the highest health care spending had an average out-of-pocket share of seven percent and the four percent of people with the next highest level of spending (between one and five percent) had an average out-of-pocket share of 13%. There are several potential reasons for this pattern — high spenders are more likely to exceed the maximum out-of-pocket limits in their insurance, after which most of their costs are completely covered, low spenders are likely to have more of their spending in the deductible portion of their coverage, and high spenders are more likely to be using services, such as hospital care, where the out-of-pocket share of expenditures tends to be low (see next section).⁶Figure 5 shows the corresponding average out of pocket spending amounts by percentile of health spending. Note that the people with the lowest average out of pocket spending are still paying a substantial amount out-of-pocket because of their high overall spending. ⁷

Out-of-Pocket Shares by Type of Service

Public and private insurance plans vary their coverage and payment arrangements by type of health care service, resulting in differences in the share of expenses that are paid out-of-pocket by people for different services. Figure 6 shows the share that the average person with expenses in a health category pays out-of-pocket for health care services in that category. (Figure 6 shows information for all people; for comparable information for the nonelderly with private insurance) As the figure shows, out-of-pocket shares are low for inpatient and outpatient hospital services, which are relatively expensive, and higher for office-based, prescription drugs and other services.

Table 1 shows the same information broken out by people’s level of spending.⁸People with the highest expenditures on average pay relatively low shares of the costs for hospital, outpatient and office-based services; the average out-of-pocket shares for these services tend to rise as overall spending falls. People at all spending levels on average pay a relatively high share of the costs for prescription drugs, dental and vision services. (Table 1 provides information for all people by spending category; for comparable information for the nonelderly with private health insurance)

Table 1: Average Share Paid Out-of-Pocket by People with Health Spending,by Type of Service and Spending Level, All People, 2003

Proportion Each Category of Service Adds to Average Person’s Out-of-Pocket Spending

Figure 7 shows how out-of-pocket spending is distributed to the average person with health care spending. Just over 40% of the average person’s out-of-pocket spending is for prescription drugs, and another quarter is for office-based visits. (Figure 7 shows information for all people; for comparable information for the nonelderly with private insurance)

Table 2 shows the same information broken out by people’s level of spending. For the people with the highest spending, hospital out-of-pocket spending makes up a larger share of their average out-of-pocket expenditures than it does for the people in lower spending categories. This is not surprising because people in the highest spending category have more hospitalizations on average and longer average hospital stays than people who spend less. For the average person in all spending categories, however, out-of-pocket spending for prescription drugs makes up the largest share of their out-of-pocket spending.  (Table 2 provides information for all people by spending level; for comparable information for the non-elderly with private health insurance)

Table 2: Distribution of Out-of-Pocket Spending for Average Person with Health Spending,by Spending Level, All People, 2003.

Table 1a: Average Share Paid Out-of-Pocket by People with Health Spending,by Type of Service and Spending Level, Nonelderly with Private Insurance, 2003

Table 2a: Distribution of Out-of-Pocket Spending for Average Person with Health Spending,by Spending Level, Nonelderly with Private Insurance, 2003.

Notes:

1. The estimated percentage of out-of-pocket spending for personal health care published by the Centers for Medicaid and Medicare Services for the National Health Accounts (NHA) is slightly lower at 15% in 2004. The NHA estimate accounts for some expenditures not included in MEPS, such as nursing home care and other institutional settings. (See Borger et al, Health Spending Projections Through 2015. Health Affairs 25(2006): w61-w73. Accessed at:http://content.healthaffairs.org/cgi/reprint/hlthaff.25.w61v1.pdf)

2. Nonelderly with private health insurance are people who are age 64 and under and have more than six months of either of these three general types of coverage: 1) private employer group or TRICARE; 2) private nongroup or private self employed group of one; or 3) private other group, private don’t know, or private coverage from someone outside of the household.

3. The category “health coverage and other sources” includes any spending by Medicare, Medicaid, private insurance, Veteran’s Administration, TRICARE, other federal sources, other state and local sources, workers’ compensation, other private, other public, or other unclassified sources.

4. The Kaiser Family Foundation. Trends and Indicators in the Changing Health Care Marketplace.The Kaiser Family Foundation: Menlo Park.

5. Spending levels are calculated in a multi-step process. First we identify the expenditure values that are associated with the following percentiles: 99%, 95%, 90%, and 80%. For instance, the 99 th percentile of spending for all people is $36,278. People whose expenditures are at that level or higher are considered to be in the top 1% of spending. We identified people in the 5% to 1% (but not including 1%) spending category by using the expenditure level associated with the top 95 th percentile of spending (those who spend at least $12,041) and subtracting out those who spend $36,278 or more. This process continues until all people have been grouped according to spending level. People with no (zero) expenditures in the year fall in the ‘lowest 80 th percentile of health spending’.

6.  People with no (zero) health expenditures are included in the calculation of percentiles of health spending (see footnote #5) but only people with health expenditures are included when calculating the percentage of expenditures that are out-of-pocket.

7. People with no (zero) health expenditures are not included in the average out-of-pocket spending amounts.

8.  As noted earlier, people with no (zero) health expenditures are included in the calculation of percentiles of health spending (see footnote #5) but only people with health expenditures are included when calculating the percentage of expenditures that are out-of-pocket.