Medicaid Managed Care - U.S. Senate Special Committee on Aging

268
If enrollment of eligible individuals does drop, one result may be that some of the poor may dela%
seeking <strong>Medicaid</strong> coverage until confronted with an acute episode, especially a costly inpatient stay.
This situation is especially problematic if it means these individuals also defer preventive care because
they lack coverage. <strong>Medicaid</strong> managed-care plans could be affected as well if delayed enrollment into
<strong>Medicaid</strong> causes the mix of beneficiaries to be more expensive. States may base capitation rates on the
lower utilization levels of the previous enrolled population. If so, plans drawing an average mix of
enrollees would be more expensive than the healthier population on which capitation payments are
based (United Hospital Fund 1996a; NHPF 1997).
As noted above, there is already a gap between eligibility and enrollment. The Commission last year
reiterated its longstanding call for monitoring access in the <strong>Medicaid</strong> program (PPRC 1996). That
recommendation called for the Department of Health and Human Services to monitor access and to
report to the Congress on a yearly basis. As part of its recommendation, the Commission called for
continued development of a uniform <strong>Medicaid</strong> claims and encounter data system, a requirement that
states participate in that system, and development and administration of a periodic access survey of
<strong>Medicaid</strong> beneficiaries and other low-income persons. The enactment of welfare reform heightens the
urgency of monitoring access to health care and reemphasizes the need to determine whether there is
an increase of eligible, but not enrolled, beneficiaries.
Spending by Enrollment Group
Patterns of service use and overall expenditures differ dramatically among the three major populations
served by <strong>Medicaid</strong> (Figure 20-1). Children and adults in families with dependent children accounted
for 72 percent of <strong>Medicaid</strong> beneficiaries in 1995, but only 33 percent of program payments. 4 By
contrast, the elderly, only II percent of beneficiaries, accounted for 30 percent of total spending. Blind
and disabled persons constituted 17 percent of beneficiaries and 38 percent of payments (Kaiser
Commission 1996c; 1997a).
Viewed another way, <strong>Medicaid</strong> expenditures for each elderly beneficiary in 1995 were almost seven
times those for each child and almost five times those for every adult in a low-income family
(Figure 20-2). This difference is attributable largely, but not exclusively, to spending for long-term
care for the elderly population; levels of acute spending are much more similar among these groups.
Spending on blind and disabled beneficiaries is somewhat lower than that for elderly beneficiaries and
includes a larger amount of acute care services than the other groups.
' This analysis excludes administrative expenses and payments to disproportionate share hospitals, which cannot be
allocated by enrollment group.
417 Physician Payment Review Commission