Wyoming Medicaid History and Facts

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Initial Medicaid Implementation: Wyoming first implemented their Medicaid program on July 1, 1967. When the program began, the state did not offer a program for the medically indigent. The state did provide transportation services for people who needed medical services because of their medically indigent status. Wyoming participated in the Kerr-Mills program that pre-dated Medicaid. A small number of people participated in the program and the program faced no major issues with payment or billing.

Key Medicaid Political Issues: Wyoming is a largely rural state with one of the smallest populations in the country. Unlike most states with large rural populations, the state has less of a problem with access since 99% of providers accept Medicaid. All of the state’s nursing facilities and hospitals are also enrolled in Medicaid. Nearly all of the state’s pharmacies and 79% of dentists also participate, much higher than the national average of 42%.  Since 2011 Wyoming has had a matching rate of 50%, similar to states like California and New York. This is because the state has a high income ratio, due in part to the state’s energy resources. Since 2012, Wyoming has been working on reducing the number of people who are on their waiting lists for disabled populations. The state has also been focused on improved maternal care and improving care for people who use more services in the Medicaid program. Wyoming has the highest per-member spending rate for people over the age of 65 who use long-term care services. Their per-enrollee spending is higher for disabled beneficiaries and adults than the national average, but they have lower per-child spending than national averages. The state has looked to establishing buy-in options in existing programs. In 2018, Wyoming passed an unusual law that attempts to recoup the cost of maternal care covered under the Medicaid program from unwed fathers. The legislation does not apply to married fathers.

Medicaid Expansion Implementation: Wyoming has not expanded Medicaid as part of the Affordable Care Act. Governor Matt Mead had initially been opposed to Medicaid expansion in 2012 but by 2013 was exploring the possibility of Wyoming expanding to save the state money. In 2016 his budget included a proposal to expand Medicaid, but the plan was ultimately rejected by the legislature. Hospitals in the state have been supportive of the expansion. Wyoming saw a large increase in the number of people enrolled in the program following the implementation of the coverage expansion in the Affordable Care Act. Since then, the state has seen a decline in enrollment to levels that pre-date the Recession. This could be a result of the improved economy in the state, but the state also implemented a new eligibility system that may have led to reduced enrollment. 56% of Wyoming residents support Medicaid expansion. In 2018 the state proposed a work requirement on the population of adults who are eligible based on having children enrolled in Medicaid. The plan ultimately failed to pass the legislature. The legislature also considered Medicaid expansion along with work requirements and that legislation has also failed to pass.

General facts about Wyoming Medicaid:

Medicaid program name: Medicaid

CHIP Program name: KidCare CHIP

Separate or combined CHIP:  Separate

Medicaid Enrollment:56,000 (2018 estimate)

Total Medicaid Spending: $600 million

Share of total population covered by Medicaid: 13%

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

Share of Medicaid that is Children and Adults: 79%

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

Share of Nursing Facility Residents covered by Medicaid: 62.5% (estimate)

FMAP: 50%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: No

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Wisconsin Medicaid History and Facts

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Initial Medicaid Implementation: Wisconsin first implemented Medicaid in July of 1966, one of the first opportunities for a state to begin their Medicaid program. The state previously ran a program under the Kerr-Mills legislation. The state paid the most monthly per beneficiary on medical care at $43.93. When Medicaid was enacted, 6.3% of the population or 262,000 people became eligible for Medicaid coverage. The state was home to the architect of the Medicaid program, HEW Secretary Wilbur Cohen. Cohen later returned to the University of Wisconsin, Madison where he wrote about the early years of the Medicaid program.

Key Medicaid Political Issues: In July of 1999 the state launched BadgerCare. The program was originally aimed at children who were transitioning off of welfare benefits following the 1996 federal reforms to welfare. Families could enroll if their incomes were less than 185% poverty and if their income fluctuated and rose to less than 200% of poverty, they could remain in the program. There was no asset test for qualification. In 2006 a proposal entitled “Healthy Wisconsin” would have expanded BadgerCare similar to how Massachusetts expanded coverage and would mandate insurance coverage. The program was unpopular among the Republican controlled Assembly and the Democratic Governor Jim Doyle. As a compromise Doyle expanded BadgerCare to all uninsured children, more pregnant women, and parents. The changes coincided with the 2009 Recession and saw a higher number of applications than the state expected.  The state suspended applications in response to this demand and put 21,000 individuals on the waiting list. The Governor proposed creating a program called BadgerCare+ Basic for childless adults. The applicants would be required to pay a premium and there would be limits on doctor, hospital, outpatient and ER visits. Certain drugs would also be limited.

Medicaid Expansion Implementation: As of April 2019, Wisconsin has not implemented the Medicaid expansion. In 2015 the state’s 1115 waiver that allowed the previous BadgerCare+ program was due to expire. The state received a waiver extension to continue the program but were required to eliminate the waiting lists and limits on coverage to continue to receive federal funding but not take the Medicaid expansion. The state does not receive the enhanced federal funding for the expansion population. The state was resistant to passing Medicaid expansion under then Republican governor Scott Walker and a Republican legislature. The state received an 1115 waiver in 2018 from the Trump administration to add work requirements to the existing eligible adult Medicaid population. The original plan also included a policy that would require the state to drug screen potential Medicaid beneficiaries. This portion of the waiver was not improved, particularly because the Medicaid program is one of the primary payers of opioid use disorder treatment.  In November of 2018 the state elected a Democratic governor who ran against the changes outlined by the waiver. The legislature met during the lame duck legislative session and required the state to maintain the work requirements that had been submitted and approved by the former governor.

General facts about Wisconsin Medicaid:

Medicaid program name:  Medicaid (certain programs are called BadgerCare).

CHIP Program name: Badgercare Plus

Separate or combined CHIP:  Combination

Medicaid Enrollment: 1.02 million (December 2018 estimate)

Total Medicaid Spending: $8.1 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 16%

Share of Children covered by Medicaid: 33% (estimate)

Share of Medicaid that is Children and Adults: 72%

Share of Spending on Elderly and people with disabilities: 69%

Share of Nursing Facility Residents covered by Medicaid: 55.6%

FMAP: 59.36%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: Yes, although not implemented

West Virginia Medicaid History and Facts

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Initial Medicaid Implementation: West Virginia initially began their Medicaid program in July of 1966 one of the first states to take up the program. When the program first began, the state did not offer a program for the medically indigent. The state had previously participated in the Kerr-Mills program prior to enacting Medicaid. The program was enacted in 1960 and beneficiaries were eligible based on having an income less than $1,500 per a year. The benefit covered hospital care for less than 12 days per a year and certain chronic conditions for which regular prescription drug coverage is required. Relatives had the legal responsibility to contribute to the health expenses of the beneficiary and if they are unable to cover the costs, the state would provide services.

Key Medicaid Political Issues: West Virginia’s Medicaid program has largely been focused on the rural population that makes up a large portion of the state. In recent years, West Virginia has been hit by the opioid epidemic and has one the highest rates of opioid related mortality in the country. The state has worked to increase the number of providers that can prescribe opioid treatment. An estimated 22,000 West Virginians have received opioid use disorder treatment under the Medicaid expansion. The state, due to its heavy mining industry, has a program through Medicaid that pays for services for people suffering from black lung, a disease that is contracted through frequent exposure to air particulates involved in mining. West Virginia has the second highest match rate in the country at nearly 75 percent. This is determined because the state has a high rate of poverty and low level of state resources.

Medicaid Expansion Implementation: West Virginia expanded Medicaid on October 1, 2013 with coverage beginning January 1, 2014. The state took advantage of certain flexibilities to allow eligible Medicaid beneficiaries to more easily enroll. The state used the SNAP enrollment records to find people who would be eligible for Medicaid based on their income. The state then sent letters to these individuals and allowed them to opt-in to automatic enrollment into Medicaid. 72,158 people enrolled through this process.  The state saw one of the largest drops in uninsurance rates in the country. The state has debated adding a work requirement to the Medicaid expansion population but the proposal failed in the legislature in 2018 and 2019. The state has seen a 40 percent reduction in uncompensated care costs since the Medicaid expansion went into effect. The decision to expand Medicaid was relatively uncontroversial in the state. West Virginia gives considerable power to the governor to change Medicaid policy without the legislature and in 2013, then-Governor Tomblin, a Democrat decided to expand Medicaid. The state elected not to run a state-based exchange.

General facts about West Virginia Medicaid:

Medicaid program name: Medicaid

CHIP Program name: CHIP

Separate or combined CHIP:  Separate

Medicaid Enrollment: 532,000 (December 2018 estimated)

Total Medicaid Spending: $4.0 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 26%

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

Share of Medicaid that is Children and Adults: 74%

Share of Spending on Elderly and people with disabilities: 61%

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

FMAP: 74.94%

Expansion state: Yes

Number of people in expansion: 181,000 (2017 estimated)

Work Requirement: No

Washington Medicaid History and Facts

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Initial Medicaid Implementation: Washington first implemented their Medicaid program in July of 1966. Before the program began, it was estimated that 8% of the population would be eligible. The state had a Kerr-Mills program that financed the care for elderly individuals. The Kerr-Mills program transitioned from providing care from the OAA program to the MAA program in 1963. Through that transition, Washington’s payments and beneficiaries increased tenfold. A large part of that increase was that the Old Age Assistance program did not cover nursing home patients and the MAA program did cover these patients so the state transferred much of the state costs to the federal government. The state was one of several that did not consistently match the needs of the patients with the income of the patients therefore allowing more people to be eligible for services than the program was originally designed. This also drove up the costs of the program for Washington. The state did place significant limitations on what could be covered and limited hospital stays and drug coverage.

Key Medicaid Political Issues: Washington has been a leader in providing care to people who were ineligible for coverage. The state implemented the basic health plan program in 1987. The program was implemented to help people who made up to 200 percent of the poverty level afford public insurance that was subsidized by the state. The program was ended in 2014 as a result of the Medicaid expansion in Washington but the program was made into a national option for all states in the Affordable Care Act. Minnesota and New York have undertaken the program and have implemented it in their states in recent years.

Medicaid Expansion Implementation: Washington began Medicaid expansion in January 2014 with enrollment beginning in October of 2013. The state was one of five states that took up the option to expand Medicaid prior to the January 1, 2014 start date using state funds. The state had previously covered this population through their basic health program. The Medicaid expansion was passed through a line item on the state budget. The state moved the individuals that were eligible for the early expansion to the newly eligible expansion category following the Affordable Care Act’s Medicaid expansion implementation in 2014.

 

General facts about Washington Medicaid:

Medicaid program name: Washington Apple Health

CHIP Program name: Apple Health for Kids

Separate or combined CHIP:  Separate CHIP

Medicaid Enrollment: 1.7 million (2017 estimate)

Total Medicaid Spending: $12.0 billion (FY 2017 estimates)

Share of total population covered by Medicaid: 22% (estimate)

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

Share of Medicaid that is Children and Adults: 83%

Share of Spending on Elderly and people with disabilities: 40%

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

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 601,000 (2017 estimate)

Work Requirement: No

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