View Research by Author - Lisa Clemans-Cope

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This report presents data on changes in Medicaid's enrollment and spending between federal fiscal year 2007 and federal fiscal year 2010, a period which includes the worst economic downturn in the United States since the Great Depression of the 1930s. The paper also examines what factors drove Medicaid spending over the period, and concludes that overall spending growth from 2007 to 2010 was driven largely by the enrollment growth that resulted from many people losing jobs and income during the recession. However, on a per enrollee basis, Medicaid spending has grown more slowly than other sectors of the health system.

Racial and ethnic differentials in uninsurance rates could be greatly reduced under the Affordable Care Act, potentially cutting the black-white differential by more than half and the Hispanic-white differential by just under one-quarter. Improving coverage for these populations will depend on states adopting policies that promote high enrollment in Medicaid/CHIP and new insurance exchanges. Coverage gains among Hispanics will depend on policies in California and Texas (where almost half of Hispanics live). If the projected coverage gains are realized, long-standing racial and ethnic differentials in access to care and health status could shrink considerably. This research was funded in part by the Annie E. Casey Foundation.

At 40 percent of Medicare's and of Medicaid's costs, the 9 million dual eligibles who receive benefits from both programs, are a focus of efforts to slow growth in entitlement spending. But, given the two programs' responsibilities, policy-makers are relying far too heavily on states to find the solution. Dollars spent on dual eligibles are overwhelmingly federal; potential savings come from better management of Medicare-financed acute care services; and enhanced state, rather than federal, responsibility for overall spending increases the risk of cost-shifting to Medicare and may undermine quality of care for vulnerable beneficiaries.

Health care for over 9 million elderly and disabled people enrolled in both Medicare and Medicaid ("dual eligibles") is complicated by an inefficient and fragmented system. In each program, dual eligibles account for about one sixth of enrollment but almost 40% of spending. Despite health-care costs exceeding $315 billion in 2011, of which Medicare pays about 55%, both Medicaid and Medicare have shown a striking lack of leadership in coordinating care for dual eligibles. We suggest ways in which the CMS's recently proposed models could be modified to improve both the quality and cost-effectiveness of care for this population.

This report examines Medicaid spending growth nationally during the last decade, with a focus on growth during the recession of 2007 to 2009. The recession-driven enrollment growth in recent years drove program spending to increase faster than national health spending overall, but on a per enrollee basis the growth in Medicaid spending has remained lower than the rise in private insurance premiums and overall national health expenditures. The recession-driven increase in Medicaid enrollment has been the primary cause of the increase in overall Medicaid spending.

This brief provides new insights about health insurance coverage gaps among racial and ethnic minority groups, focusing on parents with employment in small firms or nonstandard employment. Compared with white parents, a disproportionate share of Latino and black parents have nonstandard employment, and Latino parents are more likely to have employment in small firms. These work arrangements increase the risk of being uninsured since they are less likely to come with an offer of health insurance compared to regular large firm employment. Few uninsured Latino parents could obtain coverage under existing Medicaid programs. Potential impacts of health reform are discussed.

In this brief, we estimate that the annual cost of uncompensated health care for the uninsured would decrease from $61 billion to $25 billion under health reform legislation passed in the House. Because the government finances about three-quarters of uncompensated care, up to $27 billion per year could be used to offset the expansion of Medicaid and subsidies to employers and individuals. Overall, employers' net costs would increase by 2.9 percent over the current system, but small employers' net costs would decrease 8 percent due to employer subsidies, the expansion of Medicaid, and exemptions from penalties for not offering insurance.

Using the Urban Institute's Health Insurance Policy Simulation Model (HIPSM), we estimate coverage, costs, and household financial burdens under legislation proposed by the Senate Finance Committee and under two alternative subsidy schedules: those specified in the Senate Leadership bill, and those specified in H.R. 3962, passed by the House of Representatives. This analysis shows that health care cost burdens can be substantial for those with modest incomes and significant health care needs. It shows how enhanced premium and cost-sharing subsidies could reduce burdens, while increasing overall coverage and government costs.

Under contract to the State of New York, researchers conducted in-depth micro-simulation analyses of four types of health care reforms being considered for state implementation: a single payer public health insurance option, Assembly Member Gottfried's New York Health Plus proposal that provides an option for all New Yorkers to enroll in Family Health plus, public-private hybrid options that simplify and expand existing public programs and reform private health insurance, and a market-based option that relies on regulatory flexibility and tax credits. The cost and coverage implications of state reform options falling into these four categories are presented in this report.

Many have suggested that reducing or eliminating the tax exclusion of employer-sponsored health insurance (ESI) could generate significant additional tax revenue to fund expansions in health insurance coverage. In this paper, we focus on two specific policy design elements: (1) a cap, or dollar limit, on the amount of employer-sponsored health insurance premiums excluded from taxable income; and (2) an index that determines how this cap might grow over time. Our analysis shows that limiting the tax exclusion would provide substantial funding for health reform and mitigate the huge inequities built into the current treatment of employer premiums.

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