Massachusetts Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the implementation of the Medicaid program, Massachusetts operated a comprehensive benefit program that covered low-income seniors under the Kerr-Mills legislation. Massachusetts initially began the state’s Medicaid program in September of 1966 becoming the 23rd state to implement the program. When the program began, it was estimated that approximately 7% of Massachusetts residents would be eligible for Medicaid in the first few years that the program was implemented. In 1968 the federal government proposed reducing the matching rate for wealthier states which would have led to $40 million less in federal dollars for Massachusetts. In response to fiscal pressures in 1969 the governor reduced eligibility levels through executive order. One of the main issues in the early years of Medicaid implementation in the state was how providers would be paid. The Massachusetts Medical Association objected to the new payment paperwork designed to work with the new computing system. Physicians also argued for Blue Shield to be the fiscal agent for the program.

Key Medicaid Political Issues: The state has had a history of adopting broad health care reforms. In 1988, then governor Michael Dukakis signed the Health Security Act into law which would have provided health insurance to all residents by 1992. It had an employer mandate and provided Medicaid coverage to former welfare recipients. In 1995 through 1997 the state implemented its first 1115 waiver that extended health care and created additional cost efficiencies. At the same time the state renamed their Medicaid program MassHealth. The state also took major early efforts to provide personal care attendant services and home care options to seniors and people with disabilities through a variety of programs. In 2006 then governor Mitt Romney signed the Masssachusetts Healthcare Reform Bill which included an individual mandate, a state health insurance program, employer fair share contributions and an expansion of the Medicaid program. The latest focus of the MassHealth program has been on cost containment after the state after the passage of the cost containment strategy bill through delivery system reforms.

Medicaid Expansion Implementation: Massachusetts’s 2006 reforms were used as the blueprint for the national 2014 health coverage reforms. However, there were significant changes that required the state to make changes to their eligibility and enrollment systems. The state was not prepared for these changes at the time of the open enrollment period starting in October 2013 and requested a waiver to provide applicants with Medicaid fee-for-service coverage while their eligibility was being determined by the state.

General facts about Massachusetts Medicaid:

Medicaid program name: MassHealth

CHIP Program name: MassHealth

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.6 million (2018 estimate)

Total Medicaid Spending: $17.3 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 23% (estimate)

Share of Children covered by Medicaid: 33%

Share of Medicaid that is Children and Adults: 70% (estimate)

Share of Spending on Elderly and people with disabilities: 58% (estimate)

Share of Nursing Facility Residents covered by Medicaid: 66% (estimate)

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 398,300

Work Requirement: No

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Maryland Medicaid History and Facts

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Initial Medicaid Implementation: Maryland initially began their Medicaid program on July 1, 1966. In the first year the state enrolled 113,000 people. When Medicaid began, it was estimated that 9.7% of the state’s population would be eligible. In the end by 1969 7.2% of the population or approximately 260,000 people signed up for Medicaid in the first years of the program. In 1967 when federal legislation created a cutoff of 150% AFDC for eligibility for federal funding, Maryland decided to reduce their eligibility levels. In 1968 the program was facing budgetary pressures and substantial portions of the payments were being made to non-welfare patients and there were costs attributed to high costs of hospitals that led the governor to reduce eligibility levels from $3,120 to $3,000 for a family of four. This cut approximately 22,000 people from the program or approximately 10% of the beneficiaries. These beneficiaries were restored eligibility within 6 months of being cut off of coverage. The hospitals continued to be paid at usual and customary levels which meant that the Medicaid program depleted their funds early in the year and hospitals experienced many unpaid bills. The state began taking additional action against finding overpayments and fraudulent charges by physicians, pharmacists, and dentists and 10 physicians were found to have made fraudulent charges and were prosecuted for the crime. It was later found that 28 physicians received a combined $800,0000 and through the convictions $68,000 were returned to the state.

Key Medicaid Political Issues: For the first nine years of the Medicaid program the state operated exclusively through a fee for service model. Then in 1975 six HMOs in the state began offering coverage for preventive services to Medicaid beneficiaries. In 1997 the state implemented the HealthChoice program, a mandatory managed care program that covered 80% of the state’s Medicaid beneficiaries. In 2006 the state began offering pharmacy and primary care services to adults earning 116 percent of the federal poverty level or below, paving the way for more enhanced benefits to the same population through Medicaid expansion. Maryland’s unique payment model for hospitals means that Medicare and private payers pay the same rate as Medicaid.

Medicaid Expansion Implementation: Maryland expanded Medicaid in January 2014 with enrollment beginning in October of 2013. Despite the fact that Maryland was one of several states that switched gubernatorial party control in 2015, no significant changes have been made to the state’s Medicaid expansion program, in part due to the Democratic control of the legislature. In 2012 the state wrote that the potential for increased economic activity resulting from the infusion of federal dollars was a main reason that they decided to expand coverage. Additionally, the state made the argument that many existing programs could be ended because they would be duplicative, therefore there was the potential of saving the state money in the short term even if the program would require the state to pay 10% of the medical costs in the long run. The state also argued that reduced uncompensated care would reduce costs for private market consumers and that expanding Medicaid would ensure that there are no gaps in coverage.

General facts about Maryland Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Maryland Children’s Health Program (MCHP)

Separate or combined CHIP: Medicaid Expansion

Medicaid Enrollment: 1.3 million (2018 estimate)

Total Medicaid Spending: $11.2 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 16% (estimate)

Share of Children covered by Medicaid: 30% (estimate)

Share of Medicaid that is Children and Adults: 83% (estimate)

Share of Spending on Elderly and people with disabilities: 58% (estimate)

Share of Nursing Facility Residents covered by Medicaid: 60% (estimate)

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 277,000

Work Requirement: No

Maine Medicaid History and Facts

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Initial Medicaid Implementation: Maine initially implemented its Medicaid program in July of 1966. Like many other states, initially Maine did not take up the option to offer care to the medically indigent. Maine’s Medicaid program has largely been focused on responding to the needs of rural residents. The state, aside from the Portland area, is primarily rural and lower income which makes access a greater concern for many Mainers.

Key Medicaid Political Issues: Maine has had experience with expanding coverage prior to the passage of the Affordable Care Act. In 2003 the state expanded MaineCare through a program called Dirigo Health that was financed through a cigarette taxes. Critics have argued that the expansion of the benefit did not significantly change the insurance rate however this period was accompanied by a recession and a decreasing reliance on paper products, a major economic center of the state, both of which would have increased the uninsurance rate had the safety net of MaineCare not existed. The policy included an insurance product available to small businesses, the self-employed, and individuals. The plan also allowed other large purchases to support joint purchasing agreements that would strengthen the bargaining power of the state’s program. The program ended due to a combination of fiscal and political pressures in the state. The state faced significant budgetary pressures as the recession hit the state and the Medicaid program experienced payment delays which led to political calls to end the program. Governor LePage ended key portions of the program after taking office in 2011 including the policy that provided coverage to adults without dependents. LePage has advocated for further reductions in the Medicaid program through additional eligibility requirements, reductions in eligibility limits for parents and elderly individuals and a termination of coverage for 19 and 20 year olds that the state had previously covered.

 Medicaid Expansion Implementation: The Maine Legislature voted to expand Medicaid six times, all of which were vetoed by Governor LePage. Over the period of these votes (2012-2016) the legislature switched from Democratic control of the Senate to Republican control while Democrats maintained control of the House. In November of 2016 voters in Maine approved Medicaid expansion through a veto-proof ballot initiative with 59 percent of the vote. LePage refused to implement the Medicaid expansion and was sued by the state to submit an expansion application. The Court ruled that the state had to expand coverage by a certain date but the governor did not implement Medicaid expansion still. Upon losing appeal the governor finally submitted an application for expansion but asked the federal Centers for Medicare and Medicaid Services (CMS) to not approve the application. At the same time the state had submitted an 1115 waiver application in 2017 to institute work requirements and time limits for the existing Medicaid adult population. Both the waiver application and the state plan amendment that would expand coverage are still under review at the federal CMS. While the 1115 waiver can be rejected or significantly amended based on policy decisions of the administration, it is less clear that the administration would be able to reject the expansion application except for on grounds that it does not meet the legal standard or the state has asked for policy outside of federal law.

General facts about Maine Medicaid:

Medicaid program name: Medicaid

CHIP Program name: MaineCare

Separate or combined CHIP: Combination

Medicaid Enrollment: 261,000 (2018 estimate)

Total Medicaid Spending: $2.6 billion (2016 estimate)

Share of total population covered by Medicaid: 21%

Share of Children covered by Medicaid: 44% (estimate)

Share of Medicaid that is Children and Adults: 60%

Share of Spending on Elderly and people with disabilities: 68%

Share of Nursing Facility Residents covered by Medicaid: 66% (estimate)

FMAP: 64.5%

Expansion state: Yes* (Governor refuses to implement)

Number of people in expansion: N/A

Work Requirement: No* (Waiver under consideration)

Louisiana Medicaid History and Facts

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Initial Medicaid Implementation Louisiana began the state’s Medicaid program in July of 1966. The state began the program with generous benefits which later were reduced for Medicare beneficiaries and limits were placed on inpatient stays and drugs. While the state reduced benefits, it maintained usual and customary fees for providers. In essence, the state’s cuts were felt more by the beneficiary rather than the provider. At the onset of the Medicaid program the state was one of a handful of states that did not take up the medically needy benefit option.

Key Medicaid Political Issues: One significant area that distinguishes the Medicaid program in Louisiana from other most other states is the extent to which Medicaid was instrumental in response to natural disasters, specifically Medicaid has helped with the response to the 2005 Hurricane Katrina. As part of the Affordable Care Act, Louisiana received additional federal matching money following the natural disaster and the state received an 1115 waiver to help additional federal aid rebuild the health care infrastructure. Aside from the disaster response the Medicaid program has played a significant role in a state with high poverty and poor health. The state had relatively generous Medicaid benefits and eligibility levels through the 1970s, 1980s and early 1990s, continually expanding coverage along with federal mandates. Over the course of the late 1990s the Medicaid program experienced a period of retrenchment and benefits and eligibility levels were reduced to often meet federal minimums. At the same time, the state experienced a period of fiscal constraint and the state’s health rankings put the state near or at the bottom. 

Medicaid Expansion Implementation: Louisiana did not participate in Medicaid expansion while Governor Jindal ran the state. In 2015 Louisiana elected Democratic Governor Bel Edwards who campaigned on expanding Medicaid. The legislature had approved a plan that allowed the governor to elect to expand Medicaid without further action from the legislature. At the time, there were questions of whether the legislature ceded budgetary authority improperly but it was ultimately determined that the legislature’s intentions were to allow the expansion of Medicaid and the legislature has since adopted funding for the program. The state has reported data on the impact of Medicaid expansion on the health of state residents through monthly reports on the uptake of certain procedures and diagnoses of various diseases. The Medicaid expansion is primarily financed through a fee assessed to hospitals. Prior to the expansion of Medicaid several hospitals in the state closed and many experienced significant uncompensated care costs. Shortly after the announcement of the community engagement or work requirement policy by the Trump administration, Governor Edwards indicated that he was exploring instituting these requirements for the state. Since then there has been no movement toward adding work requirements to the Medicaid expansion despite several legislative attempts in the 2018 session.

General facts about Louisiana Medicaid:

Medicaid program name: Medicaid

CHIP Program name: LaCHIP

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.45 million (2018)

Total Medicaid Spending: $8.64 billion (FY 2016 estimate)

Share of total population covered by Medicaid: 25%

Share of Children covered by Medicaid: 50% (estimate)

Share of Medicaid that is Children and Adults: 72%

Share of Spending on Elderly and people with disabilities: 68%

Share of Nursing Facility Residents covered by Medicaid: 75% (estimate)

FMAP: 65%

Expansion state: Yes

Number of people in expansion: 324,000

Work Requirement: No

Kentucky Medicaid History and Facts

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Initial Medicaid Implementation: Prior to the passage of Medicaid, Kentucky participated in the MAA program (Kerr-Mills). The state set up a vendor payment plan that included 6 days of hospital coverage. After the 6th day the state expected that either the patient or charity would pay or the hospital would discharge the patient. Kentucky originally implemented the Commonwealth’s Medicaid program in July 1966. The state’s initial Medicaid program was more generous than other states. In the early years of the program it was estimated that 10% of the population of Kentucky received Medicaid services. Following a change in the Medicaid law in 1967 that reduced payments to states for people eligible over 150% of the state’s AFDC levels, Kentucky reduced eligibility in the Medicaid program. Other early challenges to the Medicaid program included a dispute between specialists and general practitioners over a difference in fees. Several physicians in the early years of the program received outsized amount of payment through the Medicaid program leading to federal regulators increasing the oversight of the program. These allegations were later confirmed with the federal government finding that solo practitioners made nearly $120,000 in 1968.

Key Medicaid Political Issues: The state implemented a new set of changes to the state’s CHIP program in 2008. The reforms simplified the application process and increased awareness about the CHIP program in an effort to increase enrollment. Despite these efforts the state faces challenges providing access to dental care services because there are many parts of the state that do not have dentists that take CHIP. 

Medicaid Expansion Implementation: Kentucky expanded Medicaid through an executive action by then Governor Steve Beshear. The plan was considered successful not only because the state instituted their own exchange and the state’s Medicaid program was able to process transactions between the exchange and the Medicaid agency but also because the state had previously covered very few adults through their Medicaid program so the expansion of Medicaid saw a large increase in coverage in the state. There was evidence that the state saw an increase in the number of physicians and other providers that accept Medicaid following the expansion of Medicaid, a decrease in the rate of uninsurance, and an increase in the financial security of low-income residents. Governor Bevin was elected in 2015 on the promise that he would end the state’s Marketplace and Medicaid expansion. He ended the Kynect Marketplace but has yet to end the Medicaid expansion. Instead he applied for a waiver in 2017 that would require beneficiaries to work in order to maintain their Medicaid coverage. The Trump Administration approved Kentucky’s proposal in January of 2017. A lawsuit was brought against the state to the District Court in DC and in July the court ruled that the approval of the work requirement waiver violated federal law. The state stopped the implementation of the waiver pending an appeal by the state. There are several other provisions of the waiver, some of which were allowed to take effect, others of which were struck down including the elimination of retroactive eligibility, some non-emergent transportation benefits and increased premiums and copayments for beneficiaries.

General facts about Kentucky Medicaid:

Medicaid program name: Medicaid

CHIP Program name: KCHIP (Kentucky Children’s Health Insurance Program)

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.24 million (2018)

Total Medicaid Spending: $9.66 billion (FY 2016 estimate)

Share of total population covered by Medicaid: 21%

Share of Children covered by Medicaid: 40% (estimate)

Share of Medicaid that is Children and Adults: 74%

Share of Spending on Elderly and people with disabilities: 53%

Share of Nursing Facility Residents covered by Medicaid: 66% (estimate)

FMAP: 71.67%

Expansion state: Yes

Number of people in expansion: 462,000 (2017 estimate)

Work Requirement: Yes* (Invalidated by the court)