Enrollment

Another important factor is that Medicaid enrollment increases slowed substantially. After increasing by 7.9 percent annually between 1988 and 1992, enrollment growth slowed to 5.3 percent per year in the following three years (Table 2). Table 3 shows that the rate of growth in enrollment of Medicaid beneficiaries slowed between 1991 and 1995. Enrollment growth increased by 11 percent in 1992 but by only 1.8 percent in 1995. Enrollment growth among the aged slowed from 7.2 percent in 1992 to 1.2 percent in 1995. In 1995 the blind and disabled grew by 6.8 percent, a substantial decrease from the 10.7 percent seen in 1992. Finally, among adults and children, Medicaid growth increased by 11.7 percent in 1992 and 9.1 percent in 1993, but by only 0.8 percent in 1995.

Enrollment growth slowed for a number of reasons. First, there was a decline in AFDC rolls in recent years following an improved economy, as well as efforts in many states to reduce welfare program participation primarily through tougher work requirements. Second, growth in coverage for pregnant women and children has also declined. One reason for the faster growth in the early 1990’s was the relatively new coverage mandates affecting pregnant women and children. This program now has relatively high participation, and growth in this group has slowed considerably as would be expected.

Third, the growth in the blind and disabled population has also begun to slow down. Much of the growth in the early 1990’s was due to court decisions and regulatory changes that resulted in dramatic increases in enrollment of disabled children. Since the initial burst of new enrollment, growth rates in enrollment of the disabled population in the last three years in Medicaid has slowed. Program data reveal that the growth in the SSI disabled, at more than 10 percent per year in the early 1990’s, fell to about 5.8 percent in 1995.⁹ Finally, there has also been a slowdown in growth among the elderly. Much of the rapid enrollment increase among the elderly in recent years was due to the introduction of the QMB program. The program experienced rapid growth initially, but again as would be expected in any new program, increases in participation have slowed. Moreover, the number of elderly receiving cash assistance through SSI continues to decline.

Spending per Enrollee

Another set of causes of lower Medicaid growth rates is due to controls on spending per enrollee. Growth in spending per enrollee fell from 9.5 percent to 4.9 percent per year. It is too soon to know why this has happened but there seem to be a number of possible reasons. The first is the rapid growth in managed care which seems to be achieving at least short term savings in several states. Initially, participation in Medicaid managed care was voluntary on the part of the enrollee. The evidence on the success of these voluntary programs in containing costs is mixed in part because the favorable selection into managed care plans makes it difficult to measure savings.¹⁰ Recently, there has also been a rapid expansion of mandatory managed care through both Section 1915(b) “Freedom of Choice” and Section 1115 “Research and Demonstrations” waiver programs. Managed care enrollment has growth dramatically from 3.6 million beneficiaries in 1992 to 11.6 million-one third of Medicaid enrollment-in 1995. The Section 1915(b) waivers are more numerous, but are typically limited to a geographic area in a state. Managed care can be mandatory for eligible beneficiaries residing in that area. Thirty three states have obtained Section 1915(b) waivers for managed care.

The Section 1115 waivers permit states to move substantially further in enrolling Medicaid beneficiaries in managed care.¹¹ The most prominent of the early Section 1115 waiver programs have been in Hawaii, Oregon, and Tennessee. These programs often extend coverage to uninsured people in the state up to higher income levels than typically included in Medicaid. Hawaii essentially extended coverage to all uninsured persons (excluding the disabled) below 300 percent of the federal poverty line. Oregon extended coverage to all non-disabled individuals below 100 percent of poverty. Tennessee embarked on a major expansion with the intent of covering all of the uninsured below 400 percent of the poverty line. Expansions by these states were financed through savings derived from capitated payments to managed care plans and the use of the state’s DSH payments.

Today, 15 states have received HCFA approval for Section 1115 waiver programs, and 11 have implemented these programs.¹² One major change in the evolution of Section 1115 waiver programs is that they have moved away from expansion of eligibility and consolidation of existing non-Medicaid programs that finance health care for the poor. Instead, in later waiver programs, the major emphasis is less on eligibility expansion and more on achieving savings through managed care.

The growth of managed care and the changes in federal DSH policy cannot explain all or even most of the slowdown in Medicaid spending growth. For example, the growth in spending per enrollee fell more for the elderly and blind and disabled than for families (Table 2), the population most affected by the growth in managed care. One explanation is the drop in average annual medical price inflation from 8.2 percent from 1988 to 1992, to 5.1 percent from 1992 to 1995. States also appear to have successfully adopted other policies to limit expenditure growth, particularly for long-term care (Table 1). Many states also seem less willing to use Medicaid as the vehicle through which to funnel state spending for a wide range of social service programs. While the basic financial incentives in Medicaid have not been changed and a return to Medicaid maximization efforts could reappear, for the moment these efforts appear to have stalled.

CBO’s April 1996 Baseline

In their April 1996 baseline estimate, CBO forecast an average annual increase in federal Medicaid spending of 9.7 percent between 1996 and 2002. Medicaid enrollment would rise from 36.8 million to 43.1 million, and program spending would increase from $95.7 billion to $166.4 billion. In August 1996, the CBO issued a partially revised (total spending only) Medicaid spending baseline, where projected 1996 spending was reduced by approximately $4 billion. The CBO is currently considering a substantial revision to this baseline.

We use the April 1996 CBO baseline as a reference point, however, given that it was the most recently available set of detailed CBO estimates. Because the growth rates for 1997 to 2002 were unchanged, a lower level of 1996 spending does not significantly affect our conclusions. However, the reader should bear in mind that the absolute levels in CBO baseline and in our alternative simulation are overstated.

As shown in Table 4, the number of beneficiaries were assumed to grow by 2.7 percent per year and spending on benefits by 10.2 percent per year between 1996 and 2002. The CBO assumed a 5.0 percent average annual growth in DSH payments each year and a 10.2 percent annual growth in administrative costs. The CBO forecast of beneficiary growth represented an assumption of slower enrollment growth than in past periods. Similarly, spending per beneficiary was also assumed to be lower (7.3 percent per year). The growth in DSH payments represented a substantially slower growth than experienced from 1988 to 1992 because of federal legislation in 1991 and 1993 affecting these expenditures.

Why Medicaid Spending Growth Will Remain Slow in the Near Future

There are many reasons to believe that Medicaid spending growth will be even less than that under the current CBO baseline. First, the growth in enrollment of persons living in low-income families is likely to be below rates seen in the early 1990’s. As shown in Table 3, there have been sharp declines in the growth of adults and children receiving Medicaid. The mandated coverage expansions of pregnant women and children have relatively high participation; continued rapid growth in this group should not be expected apart from the incremental inclusion of poor children under age 18. In addition, there has been a decline in AFDC rolls in recent years in part because of the improved economy as well as the widespread efforts to reduce welfare program participation. Recent welfare reform legislation will also probably depress Medicaid enrollment. While current rules for Medicaid eligibility largely remain, the work requirements and the establishment of separate enrollment procedures for the Temporary Assistance to Needy Families (TANF) program and for Medicaid are likely to result in lower participation rates. CBO projected growth in enrollment of adults and children to be 2.4 percent per year between 1996 and 2002 (Table 4). This is more than double the likely growth in the poverty population and seems high given the recent experience.

Second, the current CBO forecast assumes slower growth in enrollment than actually experienced in the early 1990’s, but their projections are higher than experienced in the most recent year. For example, the QMB program experienced rapid growth initially, but as would be expected in any new program increases in participation have slowed. Moreover, the number of elderly receiving cash assistance through SSI and, thus, Medicaid coverage continues to decline. As shown in Table 3, enrollment growth of the elderly is declining and grew by less than 1.0 percent in 1995. Enrollment of the elderly in Medicaid should continue to grow faster than the growth of the elderly population (about 1.8 percent). However, CBO assumed it would increase by 2.8 percent between 1996 and 2002, significantly faster than growth in the elderly population.

Third, the growth among the blind and disabled is also likely to slow. As shown in Table 3, there has been a slowdown in enrollment of the disabled in Medicaid in the last three years following dramatic increases due to court decision in the early 1990’s. Program data reveal that the growth in the SSI disabled between 1994 and 1995 fell to about 5.8 percent in 1995 and increased by only 2.1 percent in the first half of 1996.¹³CBO estimated that the disabled would grow by only 3.8 percent per year between 1996 and 2002 (Table 4), a seemingly modest growth rate but one that still may be too high, given recent trends. Recent legislation affecting SSI eligibility for disabled children and those with substance abuse problems will also lower enrollment rates.

Fourth, the current CBO forecast does not seem to adequately account for reductions in the growth in spending per enrollee that have occurred in the 1992 to 1995 period and are likely to continue. CBO assumes that federal spending per beneficiary will grow by 7.4 percent per year, about 4.6 percentage points faster than the rate of general inflation. This is higher than recent experience; for example, spending per beneficiary grew by 5.0 percent between 1992 and 1995. The CBO forecast for increased spending per beneficiary for the elderly and disabled was well above that of the previous four years. Much of the recent growth is among QMBs and modestly disabled children. Since both of these groups that are growing the fastest also have relatively low expenditures, this seems unwarranted. CBO assumes that long-term care spending per beneficiary will increase by about 6.3 percent annually (not shown). Finally, CBO assumes spending on acute care services per beneficiary would grow at about 7.5 percent between 1996 and 2002 (not shown). This is faster than most states are reportedly experiencing through the increased use of managed care, reductions in benefits, and other aggressive cost containment policies.

Finally, CBO assumes that DSH spending will continue to grow by 5 percent per year, despite the fact that many states with high levels of DSH spending are constrained by 1991 and 1993 legislation affecting DSH payments.

An Alternative Forecast

In Table 5, we present a hypothetical baseline that makes different assumptions about continuation of recent trends. In this baseline, we make the following assumptions: the number of elderly beneficiaries will grow by 2.5 percent per year; the number of disabled beneficiaries will grow by 3.5 percent per year; and the growth of adults and children in families will be 1.0 percent per year. These are all consistent with trends in recent years and still faster than the growth in the projected poverty populations of the relevant groups. We then assume that spending per beneficiary for acute care services would slow to 5.0 percent per year for all groups; these assumptions are consistent with projections of Medicaid managed care savings and recent experience (1992-1995). Long-term care spending per beneficiary is assumed to increase at 6.0 percent, again consistent with recent experience. Finally, we assume that DSH payments will grow no faster in each state than permitted by current law.

The result of these changes are shown in Table 5. Federal Medicaid spending would increase by 7.4 percent annually and grow to only $147.3 billion by the year 2002. Federal Medicaid spending over the 1996 to 2002 period would be $59.3 billion lower than the CBO April 1996 baseline. Medicaid enrollment would be 2.7 million below the April 1996 CBO estimate. Acute care spending would increase more slowly than long-term care spending, reflecting the growth in managed care.

Earlier we mentioned that the 1996 spending level used as the basis of our projections was too high because of the unexpected (yet still preliminary) 3.2 percent growth in Medicaid spending between 1995 and 1996. This would result in 1996 spending levels of $91.7 billion instead of $95.8 billion. Applying our growth assumptions to this lower 1996 base reduces federal Medicaid spending in the year 2002 to $141.4 billion and reduces spending over the 1996-2002 period by another $35.0 billion.

We believe these growth rate assumptions are in line with the experience of the past few years. The CBO has to date been more conservative in their recent baseline forecasts. They have implicitly assumed that recent cost containment success will not continue and that Medicaid will return to a higher spending growth path. While one cannot rule this out, it seems likely that most of the reasons for Medicaid’s extraordinary growth in the 1988-1992 period-eligibility expansions, both AFDC and SSI growth as well as federal and state eligibility expansions, and DSH payments-are unlikely to have the same effects in the future. The recent welfare reform legislation, the Personal Responsibility and Work Opportunity Act of 1996, increases the odds of slower Medicaid growth in the near future.

Implications

While a conservative forecast like CBO’s is arguably prudent, the implications are significant-particularly if the “true” baseline is in fact lower. The first is that Medicaid spending growth would be substantially slower than has been experienced in the recent past and lower than now being projected by CBO. A lower baseline means that there is less of a need for major changes in the program in order to meet budget targets because Medicaid’s contribution to the federal budget deficit would be smaller. It would also suggest that states have been able to contain spending growth without the additional flexibility Congressional or Clinton proposals would have provided.

A lower baseline would also mean that the changes in policies that would be required to live within a block grant or per capita cap could be much less than has previously been believed. Of course, if Medicaid spending growth has fallen because states have already adopted policies that would allow them to reduce expenditures, then further cuts would still prove quite difficult. Furthermore, achieving the savings in absolute dollar terms envisioned by the 1995 proposals would be quite difficult, given the lower baseline. Consideration of increased flexibility and some limits on Medicaid spending may still be advisable, but these can be achieved with less significant changes in policy than a block grant would represent.

A final implication follows from the fact that an important share of the reduction in spending under our hypothetical baseline is achieved because of lower enrollment growth. We suggest that Medicaid enrollment would be about 2.7 million lower than had been projected by the CBO. Policy makers need to be concerned about the insurance coverage of those who otherwise would have Medicaid coverage; recent evidence suggests these individuals may not secure private coverage.¹⁴ If they do not, the number of uninsured in 2002 will increase even without further erosion of employer-sponsored coverage. If employer-sponsored coverage continues to drop as it has recently at the same time as Medicaid enrollment growth slows, the number of uninsured persons could rise precipitously by 2002. Thus, there is still considerable reason for caution before making significant reductions in Medicaid spending growth.

Return to top

Where is Medicaid Spending Headed?:Press Release Fact Sheet Report Part One Part Two Tables and References

Medicaid Enrollment and Spending Growth

Overview

In 1995, Medicaid provided health and long-term care for 34.8 million low-income, elderly, and disabled Americans at a cost of $157.3 billion, $151.8 billion for services and $5.5 billion for administration. After expanding considerably in the early 1990’s, Medicaid spending and enrollment growth have slowed markedly. Medicaid spending growth has declined from 22.4 percent per year to 9.5 percent per year between 1992 and 1995. Preliminary data suggest the growth rate for 1995-96 has fallen dramatically to about 3 percent; however, spending from 1996-2002 is projected by the Urban Institute to grow at 7.4 percent.

Beneficiary Growth: 1988-1995

Medicaid enrollment growth has risen steadily over the last seven years. Between 1988 and 1995, the number of Medicaid beneficiaries grew 58 percent, from 22.0 million to 34.8 million (Figure 1). In part, the recession increased welfare and thus Medicaid enrollment. But much of this growth occurred between 1992 and 1994 and resulted largely from federal and state expansions in coverage of low-income pregnant women and children.

In addition, greater coverage of people with AIDS and actions that expanded SSI eligibility for disabled children increased coverage of disabled Medicaid beneficiaries. Eligibility expansions to assist low-income Medicare beneficiaries also increased the number of elderly Medicaid beneficiaries.

In recent years enrollment growth has leveled off. From 1992 to 1994, the number of beneficiaries grew 7.6 percent per year; the growth rate was only 1.8 percent between 1994 and 1995.

Future Medicaid Enrollment:

During the next six years, Medicaid enrollment is predicted by the Urban Institute to continue to grow at 1.6 percent, a rate similar to that of 1994-95. This would result in a total of 40.4 million beneficiaries in 2002.

Cost Explosion: 1988-1992

Between 1988 and 1992, Medicaid’s total (state and federal) costs more than doubled, growing from $53.5 billion in 1988 to $119.9 in 1992 (Figure 2). This growth rate of 22.4 percent per year made it one of the fastest growing components of state and federal budgets during that time. In 1988, federal spending on Medicaid accounted for about 2.5 percent of all federal spending; by 1992, Medicaid made up more than 5 percent of the federal budget.

Reasons Behind the Cost Explosion:

The rise in Medicaid’s costs between 1988 and 1992 was equally attributable to three factors: health care inflation, state financing practices (including the use of provider taxes and donations and disproportionate share hospital (DSH) payments) and expansions in enrollment due to legislative changes and the recession. Expansion in coverage of low-income women and children, the lowest cost Medicaid beneficiaries, accounted for most of the enrollment growth but only a fraction of the spending growth.

Spending Growth Slowdown: 1992-1995

Since 1992, Medicaid’s spending growth has slowed dramatically. Total Medicaid spending grew from $119.9 million in 1992 to $157.3 million in 1995–an average growth rate of 9.5 percent per year, substantially less than the 22.4 percent rate during the previous five years (Table 1).

Table 1: State and Federal Medicaid Expenditures, 1988-1995Spending (billions) Ave. Annual Growth Type of Spending 1988 1992 1995 1988-92 1992-95Total $53.5 $119.92 $157.3 22.4% 9.5% Benefits $50.6 $98.5 $132.8 18.1% 10.5% Acute $25.4 $55.5 $80.4 21.6% 13.1% Long-Term $25.1 $42.9 $52.3 14.3% 6.8% DSH $0.4 $17.5 $19.0 149.9% 2.7% Admin. $2.4 $3.9 $5.5 12.2% 12.6%

Reasons For Cost Slowdown:

Although it is difficult to quantify the precise contribution of each factor, the slowdown in the growth of Medicaid’s costs appears to be related to the following factors:

• Limitations on DSH: Federal legislation capped money available to states through DSH payments. After rising by more than 250 percent between 1991-92, DSH payments actually fell by 1 percent in 1992-93. Provider taxes and donations as financing mechanisms were also limited.
• Slower Enrollment Growth: After increases averaging 7.9 percent annually between 1988 and 1992, enrollment growth fell to 5.3 percent in the following three years. The earlier bursts in enrollemnt due to expanded eligibility for children and pregnant women have largely subsided. The improved economy and changes in AFDC also contributed to a slowing of enrollment growth.
• Slower Growth in Spending per Beneficiary: Declines in medical price inflation, enrollment of women and children into capitated managed care and limits on long-term care spending may have accounted for some of the slowdown in the growth of spending per beneficiary found among all beneficiary groups (Table 2).

Table 2: Average Spending per Beneficiary, 1988-1995Cost per Beneficiary Ave. Annual Growth Type of Beneficiary 1988 1992 1995 1988-92 1992-95All $2,298 $3,303 $3,816 9.5% 4.9% Elderly $5,794 $8,848 $10,166 11.2% 4.7% Blind & Disabled $5,619 $8,099 $8,685 9.6% 2.4% Families $848 $1,416 $1,728 13.7% 6.8%

Projected Spending: 1996-2002

Although preliminary data show a slowdown in Medicaid spending growth from 1995 to 1996 to 3 percent, it is unlikely to remain this low in the future. Urban Institute projects Medicaid spending will increase 7.4 percent per year and will grow to $147 billion by 2002–$59 billion lowerthan CBO’s April 1996 baseline. If 1996 spending remains below the CBO baseline, total federal savings using the 7.4 percent growth rate could reach $94 billion from 1996 to 2002 (Figure 3). These findings suggest that Medicaid’s contribution to the federal deficit would be substantially smaller than predicted.

Source: Where is Medicaid Spending Headed? By John Holahan and David Liska, the Urban Institute, November 1996. Prepared for the Kaiser Commission on the Future of Medicaid.

Return to top

Where is Medicaid Spending Headed?:Press Release Fact Sheet Report

The Kaiser Survey on Public Knowledge and Attitudes about STDs other than AIDS

Questionnaire and Toplines

November 20, 1996

Conducted for The Henry J. Kaiser Family Foundation by Market Facts, Inc.

Number of Interviews: 707 men and women ages 18-64 Margin of Error: plus or minus 4 percentage points Dates of Interviewing: November 8-10, 1996

1. Can you tell me the names of any sexually transmitted diseases or S.T.D.s, which also used to be called V.D. or venereal diseases? (Probe once:) What others can you name? (Do not read list. Enter all that apply.)

Gonorrhea 68% AIDS or HIV or human immunodeficiency virus 60% Syphilis 53% Herpes or genital herpes or herpes simplex virus or HSV 37% Chlamydia 24% Warts or genital warts or human papilloma viruses or HPVs 7% HBV or Hepatitis-B virus 4% Pubic lice 4% Crabs 3% Trich or trichomoniasis 2% BV or bacterial vaginosis 1% Chancroid 1% Other 4% None 7% Don’t know 4% Refused/No answer 1%

As you may know, HIV or AIDS is one of the most serious sexually transmitted diseases. Now I am going to ask you a few questions about sexually transmitted diseases OTHER than HIV or AIDS.

2. To the best of your knowledge are there ways that sexually active people can avoid getting sexually transmitted diseases?

Yes 93% No 6% Don’t know 1% Refused/No answer *

3. To the best of your knowledge, are all sexually transmitted diseases curable?

Yes 17% No 80% Don’t know 3% Refused *

4. Of every 100 people in this country, how many do you think will become infected with a sexually transmitted disease at some point in their lives? Just give me your best guess by responding with any number between 1 and 100 (Enter number from 1 to 100. Do not accept a range.)

1-10 16% 11-20 12% 21-30 16% 31-40 7% 41-50 20% 51-60 6% 61-70 4% 71-80 11% 81-90 4% 91-100 3% Don’t know 11% Mean answer given: 42% Percent responding with correct answer (21 to 30): 16%

5. Do you know anyone who has had a sexually transmitted disease? Again we are asking about sexually transmitted diseases other than HIV or AIDS.

Yes 45% No 54% Don’t know * Refused * 6. Do you think the number of people getting infected with sexually transmitted diseases has gone up, gone down or stayed about the same over the last 10 years? (Do not read list. Enter only one response.)

Gone up 72% Stayed about the same 17% Gone down 9% Don’t know 2% Refused *

7. Do you think the average person is more likely to get HIV or AIDS or some other sexually transmitted disease like herpes or gonorrhea? (Do not read list. Enter only one response.)

HIV/AIDS 25% Other STD like herpes or gonorrhea 55% Both just as likely 12% Don’t know 7% Refused/No answer 1%

8. Does having a sexually transmitted disease, other than HIV or AIDS, make a person more vulnerable to being infected with HIV or AIDS, less vulnerable, or does it have no effect? (Do not read list. Enter only one response.)

More vulnerable 44% No effect 43% Less vulnerable 3% Don’t know 10% Refused *

9a. If you wanted to get tested to see if you were infected with a sexually transmitted disease, which one of the following would be the most important factor in choosing where to get tested? (Read and randomize list.)

Expertise of the person giving the test 56% Confidentiality 29% Convenience 7% Cost 6% Don’t know (do not read) 2% Refused/No answer (do not read) * (Delete answer given in QU. 9a. before displaying answers for QU. 9b. Keep QU. 9b. in same order as QU. 9a.)

9b. Of those items remaining, what would be the next most important? (Read list. Enter only one response.)

Confidentiality 44% Expertise of the person giving the test 27% Cost 14% Convenience 14% Don’t know (do not read) 1% Refused (do not read) *

10. If you were to get tested or treated for a sexually transmitted disease, would you be reluctant to use your normal health insurance arrangement?

Yes 29% No 68% Don’t know 2% Refused/No Answer 1%

11. A test is being developed that can be used at home to test for a sexually transmitted disease, other than AIDS or HIV. To use this test, you would buy a kit in a drug store, provide a urine sample, and send your sample to a laboratory. Then, you would get the results by calling a confidential telephone number. If you thought there was a chance you might have a sexually transmitted disease, how likely would you be to use this home test, very likely, somewhat likely, not too likely, or not at all likely? (Do not read list. Enter only one response.)

Likely (net) 57% -Very likely 34% -Somewhat likely 23%

Not Likely (net) 42% -Not too likely 14% -Not at all likely 28%

Don’t know 1% Refused/No answer *

12. Do you think most people really do each of the following, or not? Do you think most people really (insert phrase), or not?

Yes No Don’tKnow Refused Ask a new sexual partner if he or she is infected with any sexually transmitted diseases 12% 85% 3% * Tell a new sexual partner if they are infected with a sexually transmitted disease 11% 86% 3% * Use condoms each time they have sex with this new sexual partner 22% 75% 3% * Use protection when they have oral sex, like using a condom 4% 89% 7% * Get tested for sexually transmitted diseases before they have sex for the first time or stop using condoms 11% 85% 4% * Use condoms to prevent sexually transmitted diseases if they are already using a different kind of birth control to prevent pregnancy 31% 65% 4% *

13. Do you think the government should require that all health insurance plans pay for tests for sexually transmitted diseases?

Yes 66% No 32% Don’t know 2% Refused/No answer *

14. Do you think teens should have to get their parents’ permission to get tested and treated for sexually transmitted diseases, or not?

Yes 32% No 67% Don’t know 1% Refused/No answer *

15a. Do you think high schools should provide teenagers with information about sexually transmitted diseases and how they are spread?

Yes 95% No 4% Don’t know 1% Refused/No answer *

15b. Do you think high schools should make condoms available to those teenagers who want them to protect themselves against sexually transmitted diseases? (Do not read list. Enter only one response.)

Yes 53% No 44% It depends 1% Don’t know 2% Refused/No answer *

95-1773A-04b

Return to top

The Kaiser Survey on Public Knowledge and Attitudes about STDs other than AIDS:Report Survey

Sexually Transmitted Diseases in America: Exposing the Epidemic

Provides some context about the STD epidemic, including taking a closer look at the prevalence of STDs in the United States, the long-term health consequences, and the public and private responses tothe epidemic, particularly, innovations in prevention, diagnosis and treatment.

• Fact Sheet
• Q&A
• Resource List
• Resource List

Sexually Transmitted Diseases In America:

Exposing the Epidemic

November 20, 1996

Briefing Participants:

Peggy ClarkePresidentAmerican Social Health AssociationP.O. Box 13827Research Triangle Park, NC27709919/361-8400Press contact: Sharon Broom919/361-8416

Jacqueline Darroch Forrest, Ph.D.Vice President for ResearchThe Alan Guttmacher Institute120 Wall StreetNew York, NY 10005Press Contact: Susan Tew212/248-1111 ext. 208

Helene D. Gayle, M.D., M.P.H.Director, National Center forHIV, STD,and TB PreventionCenters for Disease Control and Prevention MSEO71600 Clifton RoadAtlanta, GA 30333Press contact: Melissa Shepard404/639-8890

Penelope Hitchcock, D.V.M., M.S.Chief, STD Branch, NIAIDNational Institutes of HealthRm. 3A21, Solar Building6003 Executive Blvd.Rockville, MD 20892301/402-0443

Azadeh Khalili Executive DirectorHIV/AIDS Technical Assistance Project131 Livingston St.Brooklyn, NY 11201718/935-5606

Felicia H. Stewart, M.D.Director of Reproductive HealthProgramsKaiser Family Foundation2400 Sand Hill RoadMenlo Park, CA 94025Press Contact: Tina Hoff,Communications Program Officer415/ 854-9400, ext. 106

Kathleen Toomey, M.D.State Epidemiologist andDirector, Epidemiology andPrevention BranchDivision of Public HealthDepartment of Human Resources2 Peachtree Street, NWAtlanta, GA 30303404/657-2588Press contact: Joyce Goldberg404/656-4937

Judith Wasserheit, M.D.Director, Division of STD/HIV PreventionCenters for Disease Control and Prevention MSEO21600 Clifton RoadAtlanta, GA 30333404/639-8260Press contact: Melissa Shepard404/639-8890

Other References:

American College of Obstetriciansand GynecologistsDepartment of Public InformationPO Box 96920Washington, DC 20090-6920Media Inquiries: (202)484-3321

Barbara LevineDirector of Government Relations and Affiliate AffairsAmerican Public Health Association1015 15th Street, NWWashington, DC 20005Press office: 202/789-5677Week of 11/17 – 11/19 only:212/261-6365

Marie BassProject Director, Reproductive Health Technologies ProjectBass and Howes1818 N Street, NWSuite 450Washington, DC 20036202/530-2900

Leslie Wolfe, Ph.D.PresidentCenter for Women Policy Studies1211 Connecticut Ave., NWSuite 312Washington, DC 20036202/872-1770

Tom Eng, W.M.D., M.P.H.Study DirectorInstitute of MedicineNational Academy of Sciences2101 Constitution AvenueWashington, DC 20418Press contact: Molly Galvin202/334-2138

Susan Wysocki, R.N.C., M.P.PresidentNational Association ofNurse Practitioners in ReproductiveHealth1090 Vermont Avenue, NWSuite 800Washington, DC 20005202/408-7025

Marilyn KeefeDirector of ServicesNational Family Planningand Reproductive Health Association122 C Street, NWSuite 380Washington, DC 20001202/628-3535

Carolyn PatiernoCo-ChairpersonSTD Prevention PartnershipDirector of Program ServicesSexuality Information andEducation Council of the UnitedStates (SIECUS)130 West 42nd Street, Suite 350New York, NY 10036-7802212-819-9770, ext.305

For information about local/regional spokespeople on STDs, call:Joan CatesAmerican Social Health Association919-361-8417

Return to top

Sexually Transmitted Diseases in the United States: Exposing the Epidemic:Fact Sheet Q & A Resource List

A summary and toplines from a national survey conducted for the Foundation by Market Facts, Inc. of public knowledge about STDs overall and their attitudes towards policy options to confront the spread of STDs. This survey was released at a briefing on Sexually Transmitted Diseases: Exposing the Epidemic.

Table 1Medicaid Beneficiaries by Group, 1988-1994 United States Beneficiaries (thousands) Average Annual Growth (%) Beneficiary Group 1988 1990 1992 1993 1994 1988-1994 1988-90 1990-92 1992-94 1988-94 All Beneficiaries 22,014 24,066 29,811 32,441 34,183 7.6 4.6 11.3 7.1 9.2

Cash Assistance 15,945 16,144 18,460 19,475 19,847 3.7 0.6 6.9 3.7 4.5

Other Beneficiaries 6,068 7,922 11,351 12,966 14,336 15.4 14.3 19.7 12.4 18.8 Elderly 3,130 3,167 3,547 3,680 3,828 3.4 0.6 5.8 3.9 4.1

Cash Assistance 1,664 1,532 1,573 1,564 1,574 -0.9 -4.1 1.3 0.0 -1.1

Other Beneficiaries 1,466 1,635 1,974 2,116 2,254 7.4 5.6 9.9 6.8 9.0 Blind and Disabled 3,443 3,717 4,471 4,991 5,381 7.7 3.9 9.7 9.7 9.3

Cash Assistance 2,753 2,966 3,517 3,906 4,223 7.4 3.8 8.9 9.6 8.9

Other Beneficiaries 690 750 954 1,085 1,159 9.0 4.3 12.8 10.2 10.9 Adults 5,081 5,696 6,982 7,451 7,860 7.5 5.9 10.7 6.1 9.1

Cash Assistance 3,867 3,865 4,379 4,568 4,571 2.8 0.0 6.4 2.2 3.4

Other Beneficiaries 1,214 1,831 2,603 2,884 3,288 18.1 22.8 19.2 12.4 22.0 Children 10,360 11,486 14,811 16,319 17,115 8.7 5.3 13.6 7.5 10.6

Cash Assistance 7,662 7,781 8,992 9,437 9,479 3.6 0.8 7.5 2.7 4.3

Other Beneficiaries 2,698 3,706 5,820 6,882 7,635 18.9 17.2 25.3 14.5 23.1 Source: Urban Institute calculations based on HCFA 2082 data. Does not include the US Territories. Totals may not add due to rounding. “Cash” refers to beneficiary groups who receive AFDC or SSI. “Other” groups (non-cash, poverty-related) include the medically needy, poverty-related expansion groups, and 1115 waiver eligibles (where identifiable). Beneficiaries are defined as individuals enrolled in the Medicaid program who actually receive medical services.

Over 4 million Southern Children have no Health Insurance

Embargoed for release until: 8:30 am, ET, Monday, December 9, 1996

For more information contact: Chris Ferris (202)347-5270

New Study:

Despite Recent Gains, South Still Home to Disproportionate Share ofNation’s Uninsured Children

Washington, D.C. — A new report, sponsored by the Kaiser Family Foundation and prepared by the Southern Institute on Children and Families, finds that the South was home to 4.1 million uninsured children in 1993. The number of uninsured children in the South declined 3 percent between 1989 and 1993, at the same time the number of uninsured children in the country on the whole increased 9 percent (Figure 1). Over a third (36 percent) of the nation’ children live in the South, but the region accounted for a disproportionatelyhigh share (43 percent) of America’uninsured children (Figure 2).

“Although we witnessed a reduction in the number of uninsured children in the South,” said Sarah Shuptrine, principal author of the study, “in some states as many as one in four children are still uninsured.” The proportion of uninsured children in the South ranged from 25 percent in Louisiana to 10 percent in North Carolina and Missouri. Nineteen percent of the children in Texas, the largest state in the region, were without insurance. These 1 million uninsured Texan children accounted for one-fourth of all uninsured children in the South.

The reductions in the number of uninsured children in the South were due in part to changes in federal Medicaid laws that required states to expand income eligibility levels for children and to increase gradually the minimum eligibility age. All but three Southern states expanded eligibility levels beyond the federal requirements, making even more children eligible for coverage under Medicaid.

The number of uninsured children under age 6–the focus of Medicaid expansion efforts–decreased by 37 percent in the South during this period. In contrast, the number of uninsured teenagers (age 13-18) increased 31 percent (Figure 3). That more younger children have insurance is closely related to the targeted extension of Medicaid coverage to these age groups.

“The impact of Medicaid expansions is clear when the changes in number of uninsured children between 1989 and 1993 are examined by age groups,” said Diane Rowland, Senior Vice President of the Kaiser Family Foundation. “Medicaid has filled many of the gaps in health insurance for children, but not all children eligible for Medicaid are currently covered.” Lack of information about the availability of Medicaid coverage and eligibility barriers leave many Southern children outside of the program’s reach.

The report suggests steps that states could take to increase enrollment in Medicaid that do not require federal waivers: raising age and income eligibility levels even further; eliminating the Medicaid assets test for children; and engaging in outreach to enroll children already eligible for Medicaid.

The study analyzed 1994 Current Population Survey (CPS) data for 17 Southern states and the District of Columbia. Because of recent revisions to the CPS questionnaire, the 1994 CPS–which provided 1993 data–is the latest that can be reliably compared to earlier years. The report provides estimates of the number of uninsured children in 1993, trends in the number of uninsured children between 1988 to 1993, and 1996 Medicaid eligibility levels for each of the states. Data from the following states, along with the District of Columbia, were included in this report’s analysis: Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

The Kaiser Family Foundation, based in Menlo Park, California, is a non-profit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.

Single copies of Uninsured Children in the South are available by calling the Kaiser Foundation’s publication request line at 1-800-656-4533.

Return to top

Uninsured Children in the South:Press Release Fact Sheet

Medicaid Expenditures and Beneficiaries: 1994 Update

October 1998

Medicaid is the nation’s major public financing program for low-income Americans. After several years of rapid increase in the early 1990s, enrollment and spending growth have moderated and returned to historical levels. For the second consecutive year, annual growth in Medicaid spending was under 10 percent. The estimates presented in this policy brief are based on analyses prepared by The Urban Institute and update previous analyses conducted for the Kaiser Commission on the Future of Medicaid.

Medicaid in 1994

In 1994, Medicaid financed health care services for 34.2 million low-income individuals at a cost of $137.1 billion federal and state dollars. Spending including administrative costs and other adjustments totaled $143.7 billion. Medicaid serves multiple roles for the populations it covers. For adults and children in low-income families, it provides health care coverage for medical care. For persons with special needs and disabilities, and for the nursing home elderly, it also finances long-term care assistance. For low-income elderly and disabled Medicare beneficiaries, it pays for Medicare’s premium and cost-sharing requirements and can provide coverage for additional services.

• Adults and children in low-income families continue to comprise nearly three quarters of Medicaid enrollment, yet account for only 28 percent of program spending.

  In 1994, the Medicaid program covered health care services for 17.1 million children and 7.9 million low-income adults at a cost of $23.3 billion and $15.5 billion, respectively (Figure 1, Tables 1 and 2). This low-income population is generally comprised of adults and children in AFDC families; low-income infants, children and pregnant women; medically needy individuals, and those with coverage extended through Section 1115 Demonstration waivers.

• Blind and disabled persons comprise 16 percent of Medicaid enrollment, but spending on their acute and long-term care account for one third of program costs.

  In 1994, 5.4 million nonelderly people with developmental disabilities, severe mental illness, and physical disabilities received Medicaid assistance. Because of their complex health care needs, they often require both expensive acute and long-term care assistance. Spending on services for this population was $45.3 billion in 1994.

• The elderly population accounts for 11 percent of enrollment and 26 percent of program spending.

  Medicaid financed services for 3.8 million elderly persons at a cost of $36.1 billion. In addition to financing acute and long-term care services, Medicaid also pays Medicare’s cost sharing, premiums, and deductibles for approximately 3.7 million low-income Medicare beneficiaries (QMBs and SLMBs).

• The eligibility groups covered by Medicaid have very different per beneficiary costs because of their diverse health care needs. Average spending per beneficiary was $1,360 per child and $1,974 per low-income adult (Figure 2). In contrast, average spending was $8,421 for blind and disabled persons and $9,437 for elderly people. Because of their often extensive acute care as well as long-term health care needs, per beneficiary spending is considerably higher for the elderly and disabled than for low-income adults and children.

Medicaid pays for a wide spectrum of services including acute medical and long-term care services. It also pays for HMO and Medicare premiums, as well as special payments to hospitals that care for a disproportionately large share of uninsured individuals and Medicaid beneficiaries, known disproportionate share hospitals (DSH).

• Slightly over half (52%) of Medicaid spending on services for beneficiaries was for acute care.

  Inpatient hospital care spending accounted for 19 percent of spending; prescription drug payments, 6 percent; and physician and outpatient care, 13percent of spending (Figure 3). About 7 percent of Medicaid spending paid for premiums to HMOs and other managed care plans as well as to Medicare.

• Long-term care services constitute over one third (36 percent) of Medicaid costs.

  In 1994, about 21 percent of spending went to nursing homes and 6 percent covered home care expenses for persons living in the community. Another 7 percent financed care in intermediate care facilities for the mentally retarded (ICF-MR) and the remaining 2 percent covered mental health services.

• Payments to disproportionate share hospitals accounted for 12 percent of total program spending for services.

  Medicaid spent $16.9 billion on DSH payments in 1994. DSH payments are declining as a share of Medicaid spending.

Recent National Trends

Enrollment

Medicaid enrollment has risen steadily in recent years. Over the past four years, enrollment has increased by 10 million people from 24 million in 1990 to over 34 million in 1994 (Figure 4). From 1990 to 1992, Medicaid enrollment rose an average of 11.3 percent per year. This growth occurred in response to federal and state expansions in eligibility and the economic recession that increased the number of people eligible for Medicaid coverage. Enrollment is growing more slowly, increasing 5.4 percent from 1993 to 1994 compared to an 8.8 percent increase from 1992 to 1993 (Table 1).

• Medicaid enrollment grew by 1.8 million persons in 1994.

  Two thirds of the new enrollment in 1994 was among children (46 percent) and low-income adults (23 percent). While the number of persons eligible for Medicaid increased, the rate of growth in enrollment has generally slowed (Table 1). Enrollment among the disabled population rose 7.8 percent, marking a reduction from 11.6 percent in 1993. Although low-income children and adults accounted for the majority of the new beneficiaries, enrollment in these populations only rose 5.5 percent and 4.9 percent, respectively.

• The share of beneficiaries who qualify for Medicaid because they receive Aid to Families with Dependent Children (AFDC) or Supplemental Security Income (SSI) is declining.

  In 1988, nearly three quarters (72 percent) of Medicaid beneficiaries qualified for Medicaid because they received cash assistance (Figure 5). By 1994, this number had fallen to 58 percent. This is occurring because Medicaid was expanded in recent years to extend eligibility to certain populations who are low-income, but do not qualify for cash assistance. Although enrollment in both populations is rising, average annual growth in the cash assistance population was 3.7 percent between 1988 and 1994 compared to 15.4 percent for populations who qualify because of poverty-related eligibility such as pregnant women, infants, young children, and Qualified Medicare Beneficiaries (QMBs), or through the medically needy option.

Costs

The rapid rate of Medicaid spending growth seen in the early 1990s has largely subsided. From 1993 to 1994, Medicaid spending rose only 7.6 percent, substantially lower than earlier projections exceeding 10 percent annual growth. In the early 1990s, growth in Medicaid spending peaked at 28 percent. Earlier Kaiser Commission analyses found that this rapid growth was equally attributable to three major factors: medical price inflation, rapid enrollment growth, and state financing mechanisms that permitted states to receive additional levels of federal support.

• The rate of Medicaid spending growth has slowed dramatically.

  From 1993 to 1994 , Medicaid spending increased 7.6 percent, rising from $127.4 billion to $137.1 billion (Figure 6). This was the smallest annual net increase in the past four years. Reductions in spending growth reflect federal limits on state use of provider taxes and donations, caps on DSH payments, a slowing in the rate of medical price inflation, and lowered enrollment growth.

• Payments to disproportionate share hospitals fell nearly 1 percent from 1993 to 1994, dropping from 17.0 billion to 16.9 billion.

  This marks a dramatic departure from 1991 when growth in payments for DSH peaked, increasing over 250 percent in one year (Table 2). Federal legislation enacted in 1991 which capped DSH spending has effectively curtailed the growth in these payments.

• The relative contribution of the factors that drive growth in spending have changed.

  Growth in Medicaid spending can be attributed to three basic factors: enrollment, the average amount spent per beneficiary, and DSH payments. DSH payments, which had accounted for nearly half of the increase from 1991 to 1992 when growth was fastest, were a negative contributor to growth (-1.3 percent). In other words, if the decline in DSH payments had been the only change in Medicaid, spending would have actually fallen by $125 million. Because DSH payments were down, the relative contribution of enrollment to spending increase was larger at 71 percent, even though actual enrollment growth was only 5.4 percent.

• The rapid growth in Medicaid managed care enrollment is influencing the distribution of costs.

  From 1993 to 1994, the share of spending growth attributable to hospital inpatient care, hospital outpatient, clinic and physician care either fell or stayed the same. In contrast, payments to HMOs accounted for 18 percent of the total growth in Medicaid spending, up from 10 percent in the prior year. While this may not reflect actual changes in spending, it does represent a shift in how Medicaid accounts for its expenditures. As growth in managed care continues, particularly in capitated payments, it will become increasingly difficult to know how spending is allocated by service.

State Variations: 1992 to 1994

Medicaid is jointly financed by the states and federal government, but states administer the program and have considerable latitude in setting eligibility levels, scope of benefits, and provider payment rates. Consequently, sizable variation is evident in enrollment and spending growth and per beneficiary costs at the state level.

• The rate of enrollment growth differs considerably from state to state.

  Every state reported an increase in enrollment in the 1992 to 1994 period, but the size of the increase varied measurably. Although the average for the nation was a 7.1 percent increase in the number of beneficiaries, in states such as Tennessee and Montana, enrollment growth exceeded 20 percent (Table 4). In contrast, the rise in enrollment was under 2 percent in Massachusetts and Minnesota, states that already had relatively broad programs.

• Broad variation is seen in average state spending per beneficiary.

  Average spending per beneficiary is determined in large part by the breadth of the state’s program, the composition of the Medicaid population, and local costs for health care services. Overall, spending per beneficiary was lowest in the South and highest in the Northeast. The US average was $4,011. States ranged from a low of $2,167 per beneficiary in Tennessee to a high of $6,447 per beneficiary in New York.

• Because states have made different decisions in program structure, there are also large differences in the rate of growth in Medicaid spending.

  Nationally, program spending on services grew at an average annual rate of 9.1 percent between 1992 and 1994, ranging from a high of 20.7 percent in Hawaii and low of a reduction of 0.2 percent in Rhode Island. State policies on scope of benefits, eligibility, provider payment levels, DSH payments, and use of managed care all affect the growth in Medicaid spending.

This policy brief is based on an analysis conducted by the Urban Institute for the Kaiser Commissionon the Future of Medicaid. The full report “Medicaid Beneficiaries and Expenditures: National and State Profiles and Trends, 1988 to 1994” can be obtained from the Kaiser Commission by calling 1-800-656-4533.

The Kaiser Commission on the Future of Medicaid was established by the Henry J. Kaiser Family Foundation in 1991 to serve as a forum for analyzing, debating, and proposing future directions for Medicaid reform. The Commission and the Foundation are wholly separate from The Kaiser Permanante Medical Care Program and the Kaiser Industries.

Return to top

Medicaid Expenditures and Beneficiaries:Policy Brief Tables Chart Pack

This policy brief analyzes Medicaid enrollment and spending in 1994. It examines changes in program enrollment and spending between 1992 and 1994 and explains the factors behind the spending growth. Detailed tables and trend information can be found in Medicaid Expenditures and Beneficiaries: National and State Profiles and Trends, 1984-1994 (#2045).This data book provides extensive informationon Medicaid expenditures and beneficiaries nationally and for each state in 1994. Information is included by type of service and beneficiary group (children, adults, elderly, and disabled). Trend informationon growth in beneficiaries and expenditures in each state is also included, as well as an analyses of the factors contributing to increases in Medicaid expenditures over the 1988-1994 period.

• Policy Brief
• Policy Brief