Virginia Medicaid History and Facts

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Initial Medicaid Implementation: Virginia initially implemented their Medicaid program in July of 1969. The decision to establish a Medicaid program was pushed by physician groups who also advocated for payment rates that were at least equal to the payment rates in Medicare. The governor of Virginia in early years made an appeal to physicians to use restraint for utilization of all services because of the cost of providing these services. 

Key Medicaid Political Issues: Virginia implemented a primary case management program in 1991 that gave people who had Medicaid managed primary care services. The program was implemented in five counties and then later expanded to the whole state. The program, named Medallion and Medallion 2, provided more extensive managed care services in later years of the program’s development. The state also implemented a premium assistance program for families who would qualify for CHIP coverage. Before the state implemented Medicaid expansion the state took advantage of a provision of the Affordable Care Act that allowed states to enroll people in prison in Medicaid coverage if they were eligible.

Medicaid Expansion Implementation: Virginia expanded Medicaid through their legislature in May of 2018 a few months following the 2017 election which brought the state a Democratic governor and a majority in the House and a near tie in the Senate. While the state had a Democratic governor from 2014-2018, the legislature blocked all attempts to expand coverage. The bill that included a Medicaid expansion also called for the state to request implementation of a work requirement as a condition of the Medicaid expansion. The state was allowed to implement the Medicaid expansion while the work requirement waiver was being processed by the state and federal government. It was anticipated that 400,000 people would be eligible for Medicaid expansion.

General facts about Virginia Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Family Access to Medical Insurance Security (FAMIS)

Separate or combined CHIP:  Combination

Medicaid Enrollment: 1.039 million (2018 estimate)

Total Medicaid Spending: $9.04 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 12%

Share of Children covered by Medicaid: 25% (estimate)

Share of Medicaid that is Children and Adults: 72%

Share of Spending on Elderly and people with disabilities: 66%

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

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 233,000 (as of February 2019)

Work Requirement: Under Review


Vermont Medicaid History and Facts

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Initial Medicaid Implementation: Vermont passed the implementation of Medicaid in July 1966 and implemented their Medicaid program in January of 1967. The state participated in the Kerr Mills program that proceeded the Medicaid program. Approximately 63 people participated in the program accounting for less than 0.1 percent of all Kerr-Mills beneficiaries but 0.14 percent of the aged on the program’s rolls. Their program included a family responsibility provision which required other members of the family to be interviewed and for a social worker to determine whether the applicant’s family could contribute to their medical expenses. Since the program requirements were already low, families were expected to contribute heavily in addition to the individual in order for the state to provide financial assistance for medical services.

Key Medicaid Political Issues: Vermont has a largely rural and older population and the state has been affected by the opioid epidemic in recent years. The state’s response to the problem has been a focus of how other states could emulate their model. The plan includes a hub and spoke model of care delivery. In 1995 the state implemented the Vermont Health Access Plan and Dr. Dynasaur which covered children and pregnant women. This program provided coverage to children up to 300 percent of poverty, pregnant women up to 200 percent of poverty, parents up to 185 percent of poverty and other adults up to 150 percent of poverty. The state also created a program called Catamount Health which allowed people to purchase subsidized coverage if their incomes were below 300 percent of poverty. The programs were terminated at the end of 2013 as the Affordable Care Act’s coverage expansions began.

Medicaid Expansion Implementation: Vermont expanded Medicaid on January 1, 2014 with enrollment beginning on October 1, 2013. The state did not have a seamless rollout of their exchange website which meant that beneficiaries that had coverage through VHAP would not be able to smoothly transition to the health insurance marketplace. The state has taken several efforts to go beyond the coverage expansions of the Affordable Care Act, first undertaking the planning to institute a single payer program, then requesting a waiver for all payer rate setting. This means that the same rate is set for all Medicaid, Medicare and privately insured patients within a hospital. The state put forward the goal of capping costs for health care in the state at 3.5 percent. In total 9 of the state’s 14 hospitals are participating although some of the hospitals are only participating with Medicaid patients.

General facts about Vermont Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Dr. Dynosaur

Separate or combined CHIP:  Medicaid Expansion

Medicaid Enrollment:159,000 (2018 estimate)

Total Medicaid Spending: $1.6 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 25% estimate

Share of Children covered by Medicaid: 55% estimate

Share of Medicaid that is Children and Adults: 75%

Share of Spending on Elderly and people with disabilities: 71%

Share of Nursing Facility Residents covered by Medicaid: 64%

FMAP: 53.86%

Expansion state: Yes

Number of people in expansion: 60,600 (2017 estimate)

Work Requirement: No

Utah Medicaid History and Facts

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Initial Medicaid Implementation: Utah began their Medicaid program in July of 1966. When the program began, it was estimated that 20% of the population would be eligible for coverage. By the time the program was up and running, 4% of the Utah population was utilizing the program. The program focused on acute and long-term care at the beginning, later adding more services that would focus on chronic and care for other populations.

Key Medicaid Political Issues: In the early 2000’s Utah’s Governor Mike Leavitt negotiated a waiver demonstration for certain eligible adults up to 150 percent of the poverty line. The demonstration included cost-sharing for low-income individuals and primary care services. It was a limited hospital benefit with limited ability for hospital treatment outside of the emergency department. One interesting aspect of this waiver and the role of Governor Leavitt as CMS Administrator following his time as governor is that during the Clinton Administration, Utah and Governor Leavitt were opposed to block granting Medicaid because that would put states up for extra costs, but this waiver had limitations on the benefits and the amount of services that were available to beneficiaries in a way that would be similar to what a block grant would look like.

Medicaid Expansion Implementation: Utah expanded Medicaid through their initiative process that was later amended through a waiver. The state had made several attempts to expand prior to the introduction of the ballot initiative and had passed a waiver that would expand services to certain low-income individuals who would be ineligibile for Medicaid previously. The plan had significant barriers to enrollment including work requirements and a proposal to block grant the Medicaid program. The state submitted this waiver plan to CMS prior to the November vote. After the initiative was passed in November of 2018 it appeared that the state would implement the Medicaid expansion without changes, but then the legislative trigger of the initiative having an expected expense of 25% greater than the estimated cost. The legislature voted to require the state to submit an 1115 waiver that would ask for a partial Medicaid expansion or a Medicaid expansion up to 100% of the federal poverty level instead of 138% level but with the full expansion federal funding. Previously, CMS has rejected state requests for the partial expansion. The waiver request requirements also included other limits on Medicaid expansion eligibility including a work requirement and limits on retroactive eligibility. The plan defaults to Medicaid expansion to the full 138 percent of poverty if the state does not receive a waiver from the federal government. The waiver also included a block grant proposal and enrollment caps. The original plan to add work requirements to Medicaid did not include refugees in the requirement, the only state to do so.

General facts about Utah Medicaid:
Medicaid program name: Medicaid
CHIP Program name: CHIP
Separate or combined CHIP: Separate
Medicaid Enrollment: 285,000 (2018 estimate)
Total Medicaid Spending: $2.5 billion (FY 2017 estimate)
Share of total population covered by Medicaid: 10%
Share of Children covered by Medicaid: 20% (estimate)
Share of Medicaid that is Children and Adults: 84%
Share of Spending on Elderly and people with disabilities: 53%
Share of Nursing Facility Residents covered by Medicaid: 50% (estimate)
FMAP: 68.19%
Expansion state: Yes*
Number of people in expansion: NA
Work Requirement: Under development

Texas Medicaid History and Facts

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Initial Medicaid Implementation: Texas first implemented their Medicaid program in September of 1967. When the state started the Medicaid program, the state did not include a medically indigent category. In 1968 the federal department in charge of Medicaid released a report that found that Texas engaged in practices that cost the federal government nearly $50,000 a month in lost interest income. The federal expansions of Medicaid eligibility in the 1980s and 1990s led to a tripling of enrollment in the Medicaid program. Between 1990 and 1995 an additional one million people became eligible for Medicaid.

Key Medicaid Political Issues: Texas has a high rate of uninsurance, rural populations, and a high rate of immigrants. All of these issues are key political issues for the state. In 1991 the state expanded coverage to more children under the age of 18. In 2002 the state made the Medicaid eligibility system more simple which led to an increase in enrollment. The bill also changed the eligibility system so that all beneficiaries had six months of continuous eligibility. These reforms were in part a result of criticism and legal action that the state of Texas faced for the difficulty that the state imposed with their Medicaid enrollment applications. At one point, Texas required Medicaid applicants to submit a 50 page application that required original copies of many documents. This burdensome application requirement was made fewer people sign up for coverage that were eligible for Medicaid benefits. In total, the state has seen a growth in Medicaid caseloads of 80 percent following the 2002 reforms although some of that growth is attributed changing economic conditions. The state has recently focused on cuts to certain eligibility categories focused on children with disabilities and problems with the state’s managed care contracts.

Medicaid Expansion Implementation: Texas has not expanded Medicaid as part of the Affordable Care Act. The state has made several attempts to pass Medicaid expansion. The first attempt included copays and deductibles for beneficiaries as well as proposed work requirements and asset tests for the existing Medicaid program. In 2014 the Governor appointed a medical board to make health care recommendations and the group found that the state should expand Medicaid. The Texas legislature meets every other year. Bills were introduced in 2015 but no bills were introduced in the 2017 session. A bill has been introduced in the 2019 session and local Texas groups have organized to encourage the legislature to consider the plan. Organizers are also considering expanding coverage using the state’s initiative process. One poll found that 60% of Texans support Medicaid expansion. Texas became a center piece in the battle between the Obama Administration’s CMS and the state when the state requested an extension of their 1115 waiver without the inclusion of a Medicaid expansion. Ultimately, the waiver was agreed to without CMS requiring the state to expand in order to consider to receive waived federal funds.

General facts about Texas Medicaid:
Medicaid program name: Medicaid
CHIP Program name: CHIP
Separate or combined CHIP: Separate CHIP
Medicaid Enrollment: 4.3 million (2018 estimate)
Total Medicaid Spending: $36.3 billion (2017 estimate)
Share of total population covered by Medicaid: 16%
Share of Children covered by Medicaid: 37.5% (estimate)
Share of Medicaid that is Children and Adults: 77%
Share of Spending on Elderly and people with disabilities: 63%
Share of Nursing Facility Residents covered by Medicaid: 62.5% (estimate)
FMAP: 60.89%
Expansion state: No
Number of people in expansion: N/A
Work Requirement: None