Alabama Health Update: Wellness Coalition Conference May 1, 2013

1. Alabama Health Update:Wellness Coalition ConferenceMay 1, 2013 Mary G. McIntyre, MD, MPH, SSBB Acting State Epidemiologist and Assistant State Health Officer

2. Presentation Overview Alabama Medicaid Agency and Funding Impact Affordable Care Act (ACA): Where Are We? Review of trends in chronic diseases and related conditions in Alabama Examination of Alabama county health rankings Thoughts on reducing the burden of disease in Alabama Opportunities to make a difference

3. Alabama Medicaid Agency

4. Impact of level funding Medicaid • Level funding of $615m GF will present difficult challenges • Strategies must include hard choices • Increases in provider assessments • Cuts in provider payments/rates • Increases in recipient co‐pays • To achieve general fund savings, three dollars in cuts are required to save one dollar of state share • Cuts will have consequences

5. Drivers for state share • Enrollment • Medical inflation • Benefit changes • Matching rate changes • Utilization

6. Medicaid’s Impact on Alabama Citizens 2011 • 22% of the state’s population qualified for some type of Medicaid for at least one month during FY 2011 • 53% of births paid by Medicaid • Approximately two-thirds of all nursing home residents are covered by Medicaid • 47% of all Alabama children are eligible

7. Medicaid Expenditures FY 12 $ 5.6 billion

8. Medicaid Funding

10. Budget Observations • Provider assessments and CPEs are critical components of the state share • Without those funds to maintain the program, greater than $800m additional state funds required • No state funds (other than hospital assessments) are used in the hospital program • The nursing homes provide 1/3 of their match through the nursing home assessment • Since no general fund is used in hospital payments, reducing utilization saves no state dollars

11. Enrollment Growth

12. Alabama Medicaid Inflation

13. Alabama Cost Per Eligible Data from Kaiser Foundation 2009 Alabama has the 3rd lowest PMPY cost

14. General Fund Appropriations Related to FMAP

15. Hospital Utilization Source: Kaiser State Health Facts, 2010 data

16. 2010 How did the Patient Protection and Affordable Care Act (PPACA) change the U.S. health system?

17. PPACA enacted March 2010 • Several health reform bills debated in 2009 • H.R. 3590 is the bill that became PPACA • Senate (60-39 vote): Dec 24, 2009 • House (219-212 vote): Mar 21, 2010 • President signed: Mar 23, 2010 • Reconciliation bill (HCERA) enacted March 30, 2010

18. ACA’s major coverage provisions

19. Why was coverage reform necessary?

20. Closing the coverage gap: Four interrelated ACA approaches

21. Putting it all together: How the ACA will cover the uninsured • Of the 49.1 million currently uninsured (as of 2010)… • Of course, people who already have (or can get) employer based insurance – they can still do that!

22. A closer look at insurance reforms: Protecting access, controlling costs Insurers MAY NOT: Insurers MUST: • Deny coverage due to pre-existing conditions • Rescind coverage over simple paperwork mistakes • Set lifetime caps on coverage • Charge women more than men (gender rating) • Cover “essential health benefits” • Cover young adults on their parents’ plan through age 26 • Spend more on services, less on profits (80/20) • Justify double-digit rate increases

23. ACA’s major public health provisions

24. A need for reliable public health funding • Pre-ACA, less than 5% of U.S. health dollars go to public health • All public health funding discretionary (in danger of reduction or elimination each budget cycle) • The U.S. spends far more on health care than any other similarly developed country, but trails in terms of health outcomes. • Partly due to our focus on “sick care” instead of “health care”?

25. The Prevention and Public Health Fund • The U.S.’s first mandatory funding for public health • $15 billion over fiscal years10-19, then $2B per year • Still…this is only 2% of ACA spending over the next decade • And H.R. 3630 (in 2012) cuts $5B over nine years

26. The Prevention and Public Health Fund: Four major funding goals

27. 2013 Where are we now? ACA Implementation in the U.S. and Alabama

28. Progress in Alabama:Creating insurance exchanges • States are in various stages of progress regarding setting up their exchanges • Alabama is one of 26 states defaulting to the Federal Exchange (as of April 1, 2013)

29. Progress in Alabama: Expanding Medicaid eligibility • Alabama is one of 26 states that challenged the Affordable Care Act and the Medicaid expansion • Alabama is one of 20 states that continue to oppose Medicaid expansion (as of April 16, 2013)

33. Expanded Coverage under the ACA • Approximately 670,000 – 700,000 uninsured in Alabama • More 50% have incomes of less than 138% of the FPL ($32,500 per year for family of 4) and would be covered by Medicaid expansion • Approximately 346,000 eligible for premium tax credits and coverage through a health insurance exchange • Tax credits available for 100 – 400% FPL based on income and plan selected

36. Medicaid Expansion • Newly- eligible parents & childless adults <65 years old up to 133% FPL • No deadline on expansion decision • Individuals <100% FPL not eligible for subsidy under exchange • No match for 2014 – 2016 for expansion group • Expansion group match in 2017 @ 5% increasing to 10% by 2020. • Can drop out at any time after expansion

37. Medicaid Expansion

38. Alabama’s Health:Where are We Now? May 1, 2013

39. Diabetes in Alabama Approximately 430,000 adults in Alabama have diabetes. Approximately 240,000 adults in Alabama have pre-diabetes. BRFSS, 2011

40. Percentage of Adult-Diagnosed Diabetes in Alabama and the U.S., 2000-2011 * The BRFSS 2011 prevalence data are not directly comparable to previous years of BRFSS data because of changes in methodology and the addition of the cell phone sampling frame.

41. Cardiovascular Disease (CVD) CVD is the leading cause of death among Alabama citizens. Alabama’s death rate exceeds the U.S. rate. Death rate is trending downward. Risk factors are increasing in Alabama. CDC Wonder

42. Obesity Percentages in Alabama and the U.S., 2000-2011 (BMI 30.0-99.8) * The BRFSS 2011 prevalence data are not directly comparable to previous years of BRFSS data because of changes in weighting methodology and the addition of the cell phone sampling frame.

43. Obesity Among Alabama Youth • Results of the 2011 Youth Risk Behavior Surveillance System showed • 17% of youth in grades 9-12 were obese • 15.8 % of youth in grades 9-12 were overweight • This rate of obesity was the highest in the nation.

44. Health Behaviors

45. Four Specific Health Behaviors • Avoid Tobacco • Avoid Excessive Alcohol Use • Improve Nutrition • Engage in Physical Activity http://www.cdc.gov/Features/LiveLonger/

46. County Health Rankings and Roadmap

47. Alabama health outcomes rankings • Includes data on mortality (length of life) • Includes data on morbidity (quality of life) • “Healthy days” questions ask about the number of physically and mentally unhealthy days per month • Map ranks Alabama counties by quartile (next slide)

49. Alabama health factors rankings • Includes data on health behaviors (smoking, diet and exercise, alcohol use, and sexual activity) • Includes data on clinical care (access to care and quality of care)

50. Alabama health factors rankings • Includes data on social and economic factors (education, employment, income, family and social support) • Includes data on the physical environment (environmental quality and the built environment)