The data on Medicaid beneficiaries and expenditures by state and type of service from the federal Centers for Medicare and Medicaid Services is not out yet, and for the usual reason. Twelve of the states, including the adjacent states of Massachusetts and Pennsylvania, haven’t finished their homework and completed their quarterly data submissions for that year. Even so, with the New York State budget to be released shortly and Medicaid likely to be a big issue, I’ve decided to compile the data that is available. The attached spreadsheet was downloaded from the Medicaid Statistical Information System (MSIS) State Summary Datamart located here: http://msis.cms.hhs.gov/, with the help of the helpful Research, Statistics, Data & Systems group at that organization. The program they have set up there is so easy to use that even I can use it. Micro-data is also available for even more in depth analysis, which makes me wonder why we haven’t seen detailed analyses of our Medicaid system being undertaken and published — aside from biased reports from the health care industry itself.
Despite the missing states, the data show some similarities with past years. With 8.5% of the population in the 38 states (and the District of Columbia) that have thus far reported, and 9.6% of the poor people in those states, New York State accounted for 18.5% of their Medicaid expenditures. Those expenditures per beneficiary were 72.6% higher than the average of available states, and the third highest among them behind the District of Columbia and Maine. There are some differences from past years as well, however.
First, a few words about how the available states and D.C. compare with the entire U.S., based on Census Bureau poverty data from 2005. Medicaid was intended to be a program for the poor, but has ended up being as much a program for the old. The poverty rate for the 38 available states and D.C. was 12.8%, compared with a national average of 12.6%, and the share of their population age 65 and over was 12.3%, compared with a national average of 12.1%. Pretty comparable, except that these state’s share of the people over 65 who were also poor was 13.3%, compared with a national average of just 10.1%. Actually, for ascertaining which states ought to have a higher Medicaid burden, the poor population age 75 or 80 plus would be a better comparison, since those are the ages at which institutionalization becomes more likely, but that data was not readily available. Bearing in mind that any changes from past years may be a function of who has and has not reported, here are some differences that I observed.
Whereas in the past New York State had relatively few Medicaid beneficiaries relative to its number of poor people, spending more entirely because of higher spending per beneficiary, in 2004 it accounted for 9.6% of the poor people living in available states and a higher 10.7% of Medicaid beneficiaries. I’ll do a compilation of eligibles, beneficiaries, and expenditures by age, rather than just by type of service, when all the data is in.
In some cases spending more per beneficiary on a given type of service has become less important than having more people using services that are expensive everywhere. For example, when I first started compiling this data New York State’s Inpatient Hospital spending per beneficiary was 90% higher than the national average; in 2002 it was 54% higher than the national average: but in 2004 it was only 25% higher than the average of available states. That is not an unreasonable figure given that much of the state’s hospital spending was Downstate, where even excluding the high-paid Finance and Insurance sector the average private sector worker earns 25% to 35% more than average depending on the year. Still, it might be work waiting until all the data is in before concluding New York’s hospitals are charging Medicaid less: three large states, Pennsylvania, Ohio and Michigan, have not reported for 2004, and all had below average hospital expenditures per beneficiary in 2002. The actual national average may be significantly lower than the average of states available as of today.
On the other hand, there are even more Medicaid beneficiaries receiving hospital services: New York accounted for 15.7% of the beneficiaries of such services among available states, and thus nearly 20% of the hospital spending. Perhaps the issue is excess capacity, which has led to too many people at the hospital. Or perhaps too many people get their Medicaid-funded care in the emergency room. Or perhaps sick poor people from the low-tax, prosperous South Atlantic states come here for operations on our dime. Those are all explanations I have heard.
New York State continues to stiff physicians, with its payments per beneficiary just half the average of available states, less than every other one of them. Not surprisingly, few New York physicians take Medicaid patients, and New York accounted for only 7.0% of the beneficiaries of such services. On the other hand, New York State accounts for 11.7% of beneficiaries of more expensive outpatient hospital services, for which it pays 17.5% more than average. Of course, outpatient hospital services may be more costly because their beneficiaries require more care. New York State also accounts for 11.0% of those receiving Medicaid-funded services at clinics, which are also more expensive than physicians even in states where physicians are better compensated. New York State’s spending per beneficiary at Clinics is more than double the average of the available states, and fourth highest among them.
The data continues to make me skeptical that throwing more money at non-poor seniors for alternative services will reduce Medicaid nursing home expenditures. New York State accounted for 15.8% of the Medicaid nursing home beneficiaries in available states, far above its share of poor people (9.6%), seniors (9.0%), or poor seniors (11.4%). Its spending per beneficiary was 35% above the average of these states by a simple calculation, but as I’ll write in an additional post it was actually much higher if certain anomalies are excluded.
New York, however, also accounted for 22.3% of the beneficiaries of home health care Services, and spent 37.4% more per beneficiary than average on this service. (In past years, though New York’s share of U.S. home health care beneficiaries was high, its spending per beneficiary was low). It thus accounted for over 30% of the expenditures of these states. For “personal care” expenditures, New York State accounted for 12.8% of the beneficiaries, but its expenditure per beneficiary was far more than double the average, so New York accounted for nearly 29% of the spending by these states. Finally, New York State accounted for 14.5% of the beneficiaries, and spent 39% more than average per beneficiary, on transportation services for Medicaid recipients.
All this additional Medicaid spending on additional Medicaid beneficiaries apparently didn’t bring the number of people in nursing homes paid for by Medicaid down at all. Do more seniors require care here? Do seniors who could get by on their own get care here? Do seniors from elsewhere who require care get care here? Is “Medicaid Planning” more common here? Are family members less likely to care for their elderly relatives here? Something is going on. What New York doesn’t spend more on is hospice care, on which its spending per beneficiary was 14% below the average of available states. I guess the dead don’t actually vote, regardless of what you hear.
Finally, the non-profit health care sector in New York and its unions are politically powerful in New York, while corporations like drug companies are politically unpopular. But if those corporations are ripping us off, they are not ripping us off much more than average. New York State paid 18.8% more than the average of these states per Drug beneficiary, and 11.2% less per beneficiary than average for Lab and X-Ray services.
Good data lags, but in the past, whenever I’ve tried to jump the gun somehow, I’ve been sorry when the all the facts were in. But for what it’s worth, that’s the story as it can be told today.