50-67% = AL, AZ, AR, CA, DC, FL, GA, IN, IA, KY, LA, MS, MT, NV, NM, NY, PA, RI, SC, TN, VT, WV
Updated 10/13/16 (KY)
SOURCES: 70,000 or 80,000 are the numbers reported in the press, some say the numbers come from the same Office of Fiscal and Program Review but we weren’t able to track down the original source when we drafted the ME expansion brief. Seems like there is confusion in the press about this too.
Matthew Dunlap, Maine Citizens Guide to the Referendum Election, (Augusta, ME: State of Maine Office of the Secretary of State, August 2017), http://www.maine.gov/sos/cec/elec/upcoming/citizensguide2017.pdf
L. Antonisse, R. Garfield, R. Rudowitz, and S. Artiga, The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review (Washington, DC: Kaiser Family Foundation, September 2017), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-september-2017/
Updated 6/2017 (AV)
Emerging Trends in Medicaid
Emerging Trends in Medicaid
Health Care Unscrambled 2018
January 11, 2018
Robin Rudowitz, Associate Director
Kaiser Program on Medicaid and the Uninsured
Kaiser Family Foundation
The basic foundations of Medicaid are related to the
entitlement and the federal-state partnership.
Eligible Individuals are
entitled to a defined set
States are entitled to
Medicaid plays a central role in our health care system.
Health Insurance Coverage
For 1 in 5 Americans
State Capacity to Address Health
Support for Health Care System
Assistance to 10 million
> 50% Long-Term Care
Nationally, Medicaid is comparable to private insurance for
access and satisfaction – the uninsured fare far less well.
Well-Child Checkup Doctor Visit Among Adults Specialist Visit Among
Adults Satisfied With Their
Medicaid ESI Uninsured
NOTES: Access measures reflect experience in past 12 months. Respondents who said usual source of care was the emergency
room are not counted as having a usual source of care.
SOURCE: KCMU analysis of 2015 NHIS data.
Percent reporting in the last year:
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total Medicaid Spending Medicaid Enrollment
Annual Percentage Changes, FY 1998 – FY 2018
NOTE: For FY 1998-2013, enrollment percentage changes are from June to June of each year. FY 2014-2017 reflects growth in average monthly
enrollment. Spending growth percentages refer to state fiscal year. FY 2018 data are projections based on enacted budgets.
SOURCE: Enrollment growth rates for FY 1998-2013 are as reported in Medicaid Enrollment June 2013 Data Snapshot, KCMU, January 2014. FY
2014-2017 are based on KFF analysis of CMS, Medicaid & CHIP Monthly Applications, Eligibility Determinations, and Enrollment Reports,
accessed September 2017. Historic Medicaid spending growth rates are derived from KCMU Analysis of CMS Form 64 Data. FY 2017-2018 data
are derived from the KCMU survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2017.
Medicaid enrollment and spending peaked during economic
downturns and after implementation of the ACA.
In Georgia, Medicaid covers 17% of the population, but 3 in
4 nursing home residents.
1 in 12 adults <65
2 in 5 low-income individuals
2 in 5 children
3 in 4 nursing home residents
2 in 5 people with disabilities
SOURCE: Kaiser Family Foundation estimates based on the Census Bureau's March Current Population Survey (CPS: Annual Social
and Economic Supplements), 2014-2017.
NOTES: Includes non-institutionalized children ages 0-17 with special health care needs with Medicaid/CHIP only and Medicaid/CHIP and
SOURCE: Kaiser Family Foundation analysis of the 2016 National Survey of Children’s Health, Topical File.
Medicaid covers nearly half of all children with special
health care needs.
35-49% (22 states)
23-34% (7 states)
50-67% (22 states)
U.S. = 48%
Share of children with special health care needs covered by Medicaid/CHIP:
Children Pregnant Women Parents Childless Adults Seniors & People
GA US (Median)
Eligibility levels are based on the FPL for a family of three for children, pregnant women, and parents, and for an individual for
childless adults and seniors & people w/ disabilities. Seniors & people w/ disabilities eligibility may include an asset limit.
Eligibility levels are highest for children and pregnant
Eligibility Level as a Percent of FPL, as of January 1, 2017
In FY 2016, Medicaid spending in Georgia was $9.8 billion. Adults
and children accounted for 3 in 4 enrollees but 55% of spending.
SOURCE: KFF analysis of CMS (Form 64) data for Medicaid spending. KFF estimates of based on analysis of data from the 2014
Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports for distribution of enrollees
Spending per enrollee for the aged and individuals with
disabilities is lower than average in Georgia.
$1,520 (NV) $1,657 (AR)
$9,448 (AL) $8,623 (SC)
Children Adults Individuals with
Per capita spending by enrollment group
SOURCE:KFF estimates based on analysis of data from the 2014 Medicaid Statistical Information System (MSIS) and Urban
Institute estimates from CMS-64 reports. https://www.kff.org/medicaid/state-indicator/medicaid-spending-per-full-benefit-
NOTE: The June 2012 Supreme Court decision in National Federation of Independent Business v. Sebelius maintained the Medicaid
expansion, but limited the Secretary's authority to enforce it, effectively making the expansion optional for states. 138% FPL =
$16,643 for an individual and $28,180 for a family of three in 2017.
The Medicaid expansion was designed to fill the gaps in
….but gaps in coverage for adults remain for adults in
states that do not adopt the ACA Medicaid expansion.
NOTE: An estimated 2.3 million fall into the coverage gap. In Georgia, and estimated 240,000 are in the coverage gap. Another
75,000 uninsured are eligible but not enrolled in Medicaid and 148,000 uninsured are may be eligible for Marketplace coverage
between 100-138% FPL
In Georgia, 240,000
fall into the
NOTES: Current status for each state is based on KFF tracking and analysis of state executive activity. *AR, AZ, IA, IN, MI, MT, and NH have
approved Section 1115 waivers. ME adopted the Medicaid expansion through a ballot initiative in November 2017; the ballot measure requires
submission of a state plan amendment within 90 days and implementation of expansion within 180 days of the measure’s effective date. WI
covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion.
SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated November 8, 2017.
To date, 33 states have adopted the Medicaid expansion.
Adopted (33 States including DC)
Not Adopting At This Time (18 States)
• Administration Actions on Waivers
• Congressional Actions
– Action on Entitlements
• State Actions
Medicaid: What’s Next?
• New era of federal/state Medicaid partnership implemented
• Use taxpayer $ to serve “truly vulnerable”…seniors, children,
people with disabilities
• Return Medicaid to its welfare roots
– Deserving poor vs able-bodied adults
– Work requirements and “community engagement”
– Time limits on coverage and other restrictions
• Align Medicaid policies and commercial health insurance
products to facilitate beneficiary transitions
CMS: The New Direction
Seema Verma 11/7/17
As of January 8, 2017 there were 42 approved waivers in 34
states and 23 pending waivers in 22 states.
MLTSS Other Targeted
(42 in 34 states)
(23 in 22 states)
Notes: Some states have multiple approved and/or multiple pending waivers, and many waivers are comprehensive and may fall into a few different areas.
“MLTSS” = Managed long-term services and supports.
Own Work Status, 24.6 Million Medicaid
NOTE: Totals may not add due to rounding. Includes nonelderly Medicaid adults who do not receive Supplemental Security Income
(SSI). SOURCE: Kaiser Family Foundation analysis of March 2017 Current Population Survey.
More states are seeking waivers to condition Medicaid on work
requirements, but most not working face barriers to work.
Not Employed = 9.8 Million Medicaid Adults
Main Reasons for Not Working
• Coverage through Medicaid supports enrollees’ ability to work.
– Many of the jobs held by enrollees do not offer health insurance.
• Addressing barriers to work requires adequate funding and
– TANF spending on work activities and supports is critiqued by some as
too low, but it exceeds estimates of state Medicaid program spending
to implement a work requirement.
• Implementing work requirements can create administrative
– States can incur additional costs and demands on staff, and eligible
people could lose coverage.
SOURCE: KFF, Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience (August 2017).
The TANF experience with work requirements can provide
some lessons for Medicaid.
SOURCE: The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings, Kaiser
Family Foundation, June 2017. http://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-
States are also seeking waivers to impose premiums and cost sharing,
but research shows negative effects of policies for low-income
• Decreased enrollment and renewal in coverage
• Largest effects on lowest income
• Many become uninsured and face increased barriers to
care and financial burdens
• Even small levels ($1-$5) decrease use of services,
including needed services
• Increased use of more expensive services (e.g., ER)
• Negative effects on health outcomes
• Increased financial burdens for families
• States savings are limited
• Offset by disenrollment, increased costs in other
areas, and administrative expenses
• What is the waiver doing? What are the stated goals and objectives?
– Have similar waivers been approved in other states? What have we learned?
• What provisions of the law are being waived? What populations are affected by
• What are the state estimates for PMPM costs and coverage with and without the
• Does the state have an implementation plan?
– What are the administrative costs and challenges?
• What is the process to receive public input? If the waiver was open for public
comment, did the waiver incorporate these comments?
• What are the requirements for reporting and evaluation?
– How often do states need to submit data?
Key questions to ask about new waiver proposals and
• Reauthorization of CHIP???
• Deficit reduction and entitlement reform in 2018
– Reframing the scope and reach of Medicaid
– Reducing federal Medicaid costs
– Restructuring Medicaid financing
What Congressional Actions?
SOURCE: Kaiser Family Foundation CHIP Survey of Medicaid Officials conducted by Health Management Associates, Summer 2017
with November 2017 update. *Indicates state did not provide updated projections in November.
In December, Congress temporarily extended CHIP funds which may
push back estimates of when states expect to exhaust funds.
February - March 2018 (21 states, including DC)
April 2018 or later (11 states)
By end of January 2018 (16 states)
Not Reported (3 states)
Medicaid block grants or per capita caps, designed to cap
federal spending could be part of entitlement reform
Current law: Reflects increases
in health care cost, changes in
enrollment, and state policy
Block grant: Does not account
for changes in enrollment or
changes in health care costs
Per capita cap: Does not account
for changes in health care costs
• Shift costs and risks to states, beneficiaries,
and providers if states restrict eligibility,
benefits, and provider payment
• Lock in past spending patterns
– If expansion funding is cut, the impact
could be even greater for the 32 states
that expanded Medicaid
• Limit states’ ability to respond to rising
health care costs, increases in enrollment
due to a recession, or a public health
emergency such as the opioid epidemic, HIV,
Reducing and capping federal Medicaid funds could:
Total State Spending
(State & Federal Funds)
(General & Other Funds)
Medicaid Elementary & Secondary Education Other
SOURCE: Kaiser Family Foundation estimates based on the NASBO’s November 2017 State Expenditure Report (data for Actual FY 2016.)
Medicaid accounts for nearly half of all federal funds in
Georgia’s state budget.
/ Limited Medicaid
Poor Health Status
High Cost Health
Low Spending and
Low Tax Capacity
Certain characteristics put some states at higher risk than
others under federal Medicaid cuts and caps.
People in the
High Rate of
NOTE: Eleven states rank in the top five for five or more risk factors (AL, AZ, FL, GA, KY, LA, MS, NM, SC, TX, WV).
Georgia ranks in the top 5 for multiple risk factors in responding to
federal Medicaid reductions.
Evidence from over 150 studies suggest that the Medicaid
expansion has positive effects for beneficiaries and states.
Increased Economic Activity
Increased Access to Care
and Service Utilization
Reduction in the Number
↓ Uncompensated care costs
↓ State-funded health programs
(e.g. behavioral health and
Increased State Savings
Federal + State
↑ General fund revenue and GDP
↑ or neutral effects on employment
↑ Affordability and Financial Security
SOURCE: L. Antonisse, R. Garfield, R. Rudowitz, and S. Artiga, The Effects of Medicaid Expansion under the ACA: Updated Findings from a
Literature Review (Washington, DC: Kaiser Family Foundation, September 2017), https://www.kff.org/medicaid/issue-brief/the-effects-of-
• New opportunities for states
– New flexibility through waivers
– Re-examination of Medicaid expansion
• Uncertainty about state fiscal issues
– Extension of CHIP
– Implications of the tax legislation
– New debate on entitlement reform and Medicaid cuts
• Key policy priorities
– Cost containment
– Improving outcomes
– Addressing opioid epidemic and substance use disorders
– Rural health
Key Priorities and Issues for States in 2018
NOTE: Don’t know/Refused responses not shown. Question wording abbreviated. See topline for full question wording.
SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted June 14-19, 2017)
Would you say the current Medicaid program is working well for most low-income people covered by the program, or
Majorities across political parties say Medicaid is working well
for most low-income people covered by the program.
By Political Party ID
…in the nation, overall? …in your state?
Working well Not working well
Source: Faces of Medicaid. http://kff.org/medicaid/video/faces-of-medicaid/
There are many “Faces of Medicaid”.