South Carolina Medicaid History and Facts

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Initial Medicaid Implementation: South Carolina implemented their Medicaid program in July of 1968. When the program began the state did not offer a program for medically needy individuals. The state had unique needs because of the high rates of poverty. Despite this issue and the less professional state government, the state participated in the Kerr-Mills program. The state only had an average of 411 monthly members in the previous program with approximately 3,000 individuals assisted by the program annually. The program spent approximately $1.2 million over the course of the program’s existence.
Key Medicaid Political Issues: South Carolina has made significant progress in the area of Medicaid and maternal health. The state has implemented several programs including the Birth Outcome Initiative which is a project with the Medicaid agency and commercial insurers that established a policy of non-payment for early elective deliveries. The state saw significant savings from this initiative and through more community care programs that were established to treat women before, during, and after, childbirth. Despite these innovative efforts to improve maternal mortality, the state has been a leader in working to end payments to planned parenthood and other abortion providers from receiving state Medicaid funds. South Carolina has a high rate of poverty, meaning that the state receives a high matching rate for their program and more people are eligible for the income based categories of eligibility. South Carolina renamed their Department of Health and Human Services Finance Commission to the South Carolina Department of Health and Human Services in 1995.
Medicaid Expansion Implementation: South Carolina has not expanded Medicaid. The state has been under the control of both Republican governors and a Republican dominated legislature since 2012. In 2018 discussion began over whether the state would expand Medicaid through a ballot initiative following the successful attempts in other states. The ability for the state to expand through this option is doubtful because the state needs the legislature to pass the ballot initiative in order for the option to appear on the 2020 statewide ballot. In 2017 the South Carolina legislature accidentally passed a resolution in support of Medicaid expansion as part of a resolution welcoming the new governor. The legislature quickly reversed the resolution.
General facts about South Carolina Medicaid:
Medicaid program name: Medicaid
CHIP Program name: Healthy Connections Kids
Separate or combined CHIP: Medicaid Expansion
Medicaid Enrollment: 1.02 million (2018 estimate)
Total Medicaid Spending: $6.2 billion (FY 2017 estimate)
Share of total population covered by Medicaid: 19%
Share of Children covered by Medicaid: 40% (estimate)
Share of Medicaid that is Children and Adults: 77%
Share of Spending on Elderly and people with disabilities: 55%
Share of Nursing Facility Residents covered by Medicaid: 62.5%
FMAP: 70.7%
Expansion state: No
Number of people in expansion: N/A
Work Requirement: None

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Rhode Island Medicaid History and Facts

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Initial Medicaid Implementation: Rhode Island began their Medicaid program in July of 1966, within the first year that the state could implement Medicaid.
When the program was initially started, it was estimated that 8% of the population would be eligible for coverage. Following the change that limited Medicaid federal reimbursement to spending for people that earned less than 150% of AFDC rates, Rhode Island reduced Medicaid eligibility to meet those rates and continue to receive federal reimbursement. At one point early in the Medicaid implementation, a dispute arose between the optometrists and ophthalmoligists. The Boston regional office held resolve the dispute which was a rare intervention of the office in state matters. The dispute rested in differences in payment rates and coverage of services between the two professions.
Key Medicaid Political Issues: Rhode Island has had a focus on treating mental health conditions and children’s health care for a number of years. The state has focused this priority in the development on their medical home model. Rhode Island has been an early adopter to several health care benefits including transgender health care services, Hepatitis C treatment and expanded treatment for opioid addiction. Since 2009 the state has occupied under a single global waiver. The waiver has allowed the state flexibility in how it provides benefits, especially for long-term care services. The waiver has a high limit on the budget neutrality limits meaning that the state can provide enhanced benefits without having to significantly reduce services for other beneficiaries or in other parts of the Medicaid program.
Medicaid Expansion Implementation: Rhode Island expanded Medicaid with sign ups beginning in October of 2013 with coverage beginning in January of 2014. The state was under the control of a Democratic governor and legislature and is solidly Democratic in presidential voting so the choice to expand saw little debate in the legislature or governor’s office. The Rhode Island Public Expenditure Council, a non profit group that reviews economic proposals by the state, looked into the state’s decision to expand and determined that the state could save money on existing programs and increased coverage and economic activity, but the extent of the implementation of the proposal was unclear and what the expenditures would be in out years when the state had to pay could be significant depending on the enrollment effort.

General facts about Rhode Island Medicaid:
Medicaid program name: Medicaid
CHIP Program name: Rite Care
Separate or combined CHIP: Separate
Medicaid Enrollment: 308,000 (2018 estimate)
Total Medicaid Spending: $2.6 billion (FY 2017 Estimate)
Share of total population covered by Medicaid: 20% (estimate)
Share of Children covered by Medicaid: 37.5% (estimate)
Share of Medicaid that is Children and Adults: 80%
Share of Spending on Elderly and people with disabilities: 59%
Share of Nursing Facility Residents covered by Medicaid: 60% (estimate)
FMAP: 52.95%
Expansion state: Yes
Number of people in expansion: 62,000
Work Requirement: No

Pennsylvania Medicaid History and Facts

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Initial Medicaid Implementation: Pennsylvania began their Medicaid program on January 1, 1966, the first available opportunity for states to establish their Medicaid programs. Prior to the passage of the Medicaid program, Pennsylvania participated in the Kerr-Mills program. Collectively with four other states, Pennsylvania and these other large states accounted for nearly 2/3rds of the expenditures of the Kerr-Mills program. Pennsylvania set an annual income level of $4,000 for a family of four, making the program inaccessible to many low-income residents. The state’s Medicaid program was initially called “Pennsycare.” In the first year of the program’s implementation approximately 6% of the population or 583,000 people enrolled in Medicaid in the state. Following the reforms in 1967 that set a limit of 150% of AFDC levels for federal reimbursement, Pennsylvania decided to reduce eligibility to this level although Pennsylvania avoided that cutback by raising the AFDC levels in the state essentially maintaining eligibility levels and federal reimbursement. Under a proposed change that would have lowered the amount of federal reimbursement the state of Pennsylvania would have lost $30.5 million in the first year. One major change that Medicaid brought in the state was a reduction in the amount of uncompensated care. According to the Pennsylvania Medical Society, physicians provided more than $41 million in uncompensated care in 1960.

Key Medicaid Political Issues: Pennsylvania has had a generous benefit for children under their Children’s Health Insurance Program. The program would become a model for the federal legislation that would begin the CHIP program. In 1992 then Governor Robert P. Casey signed a law into the state that would provide health coverage to higher income families that are too wealthy to be eligible for Medicaid but uninsured because they do not make enough to afford health insurance. One sponsor of the bill in the state legislature included Alyson Schwartz who would later go on to become a Congresswoman in the US House and become an active leader in shaping CHIP policy in the House. Governor Corbett opposed changes to the CHIP program that would require certain income eligible enrollees to enroll in Medicaid rather than in the CHIP program. Ultimately, the governor conformed with the proposal and certain changes were made to the Medicaid and CHIP program to ensure that people who had received CHIP and moved to Medicaid benefits were not seeing a reduction in benefits. The state has also had a focus on providing wrap around services for psychiatric and substance use disorder. In 1997 the state implemented an integrated and coordinated care plan that carved out behavioral health services

Medicaid Expansion Implementation: When the Medicaid expansion went into effect and states were making decisions on whether or not to expand coverage, Pennsylvania had a Republican governor. Governor Corbett had been opposed to Medicaid expansion. He conceded in supporting Medicaid expansion, in part because his term was over in 2014 and several other Republican controlled states had expanded through a waiver. The early version of Corbett’s proposal included a work requirement that was later dropped after receiving a letter from the Obama Administration informing the governor that it would not approve a work requirement. The Republican governor nominee criticized Corbett in the general election for vetoing this policy. In August of 2014 the Centers for Medicare and Medicaid Services approved the state’s Medicaid expansion with a waiver that included benefit package changes for the expansion population and created new managed care options for Medicaid expansion enrollees. The plan would phase in premiums and additional cost-sharing in the second year of the plan. The expansion was implemented on January 1, 2015. Democratic governor Tom Wolf was elected in November of 2014 and on his first month in office, the Governor announced that the state would transition from the waiver expansion to an expansion without the complexities of the waiver. The plan would move the people who gained coverage from newly created managed care plans to managed care plans that existed through the Medicaid program prior to the implementation of the waiver.
General facts about Pennsylvania Medicaid:
Medicaid program name: Medical Assistance
CHIP Program name: CHIP
Separate or combined CHIP: Separate
Medicaid Enrollment: 2.9 million (2018 estimate)
Total Medicaid Spending: $28 billion (FY 2017 estimate)
Share of total population covered by Medicaid: 19%
Share of Children covered by Medicaid: 37.5% (estimate)
Share of Medicaid that is Children and Adults: 62%
Share of Spending on Elderly and people with disabilities: 79%
Share of Nursing Facility Residents covered by Medicaid: 66% (estimate)
FMAP: 52.25%
Expansion state: Yes
Number of people in expansion: 751,000
Work Requirement: No

Oregon Medicaid History and Facts

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Initial Medicaid Implementation: Oregon implemented their Medicaid program in July of 1967.When the state began their Medicaid program the state did not offer benefits for the medically indigent. The Medicaid program was run under the Department of Human Resources’ Adult and Family Services Division until 1990. The Medical Consultant was first established in 1933 as part of the State Relief Commission. The duties were later transferred to the title of Administrator and control of regulation of hospitals and care for children with medical needs were added. The office was moved to be under the jurisdiction of the governor in 1971.

Key Medicaid Political Issues: Oregon has consistently been a leader in addressing coverage and expanding coverage prior to federal action. The movements began in 1987 under the leadership of then state Senator and future Governor John Kitzhaber. The legislature passed a series of laws known as the Oregon Health Plan. The plan extended coverage for people under the poverty level, instituted an employer mandate, create an insurance pool for people with pre-existing conditions, created a small business marketplace, regulated medical technology, add new programs for people with disabilities, and extend mental health coverage. In 1994 the state received the funding and approval to expanded Medicaid to all residents living below the poverty level enrolling 120,000 newly insured residents. The following year the state added mental health and substance use treatment services to the plan. The state also implemented a board to oversee drug utilization. The state’s reforms were extended through 2002 following a successful implementation. Some of these services were repealed in 2003 following economic constraints in the state. The state faced a number of constraints that led to enrollees being required to pay a premium to receive Medicaid services, Oregon implemented a waiver in 2008 that expanded Medicaid coverage to low-income childless residents in the Portland area that would have not otherwise been eligible for Medicaid coverage. There has been extensive research into the effects of this Medicaid expansion on the health of the population. Most notably it was found that newly insured were more likely to use the emergency room than people who did not gain Medicaid coverage and remained uninsured. The state has worked to improve care coordination and redirect people away from the emergency room. In 2012 the state began using Coordinated Care Organizations (CCOs) to improve the delivery of care by providing mental health, dental care, and other community based services and reimburse based on performance.

Medicaid Expansion Implementation: Oregon was one of a handful of states to implement policies to allow people to enroll in coverage more quickly if they were already proven to be eligible for another state run program. In January 23 of 2018 an initiative was brought before Oregon voters on how to fund the Medicaid expansion and where the tax revenue for the expansion would come from. The initiative was approved by the public. In 2017 the state moved to cover undocumented children in their Medicaid program. In 2016 the state added long-acting birth control as part of the covered benefits for the Medicaid expansion population.

General facts about Oregon Medicaid:

Medicaid program name: Oregon Health Plan

CHIP Program name: Healthy Kids

Separate or combined CHIP: Separate

Medicaid Enrollment: 962,000 (2018 estimate)

Total Medicaid Spending: $8.4 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 24%

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

Share of Medicaid that is Children and Adults: 83%

Share of Spending on Elderly and people with disabilities: 41%

Share of Nursing Facility Residents covered by Medicaid: 57% (estimate)

FMAP: 62.56%

Expansion state: Yes

Number of people in expansion: 557,000 (2018 estimate)

Work Requirement: No

Oklahoma Medicaid History and Facts

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Initial Medicaid Implementation: Oklahoma began their Medicaid program in January of 1966, the first available time that states could participate. Senator Kerr of the Kerr-Mills legislation represented Oklahoma. It was estimated that approximately 16% of the population would be eligible for Medicaid when the program began. After Medicaid was implemented an estimated 8% of the population had signed up within a year of the program beginning or approximately 195,000 people. When the program began, the state offered generous eligibility levels. In 1967 when the federal matching rate was restricted to only people earning under 150% of AFDC levels the state decided to reduce eligibility levels instead of pay state funds to maintain levels at the same rate. In 1968 the state was facing fiscal pressures as the Medicaid program spending was running ahead of expectations. The state continued to face financial pressure and in 1968 the cash reserves of the state’s welfare program were so low that the state was forced to ask for federal funds in advance of the payments in order to meet the needs of the Department. At that time the state reduced payment rates to hospitals and physicians and reduced eligibility levels. Medicaid beneficiaries were also encouraged to reduce or “carefully use” the amount of benefits that they used.

Key Medicaid Political Issues: Oklahoma faces issues around rural access to health care and low reimbursement rates for providers. In 1993 the state created the Oklahoma Health Care Authority to oversee the Medicaid program. Before that point the state had seen a rise in the number of beneficiaries in the late 1980s and early 1990s, in part due to the economic conditions at that time. The growth in enrollment was coupled with a growth in spending that nearly doubled the state’s budget. The state had proposed an increase on providers to fund the increase in spending but the proposal was defeated. Instead the state cut provider payments by approximately 5% and instituted limits on beneficiary use and adult dental benefits were eliminated. As part of these reforms, the state also began transferring the Medicaid system from a largely fee-for-service based approach to begin contracting with managed care companies. By 2004 there were not enough providers to operate the managed care program and the state was forced to terminate the program. The state has considered restoring their managed care program several times but remains one of the few states in the country without a managed care program to administer their Medicaid program. The state instituted broad tax increases on oil and natural gas to fund increasing costs in the Medicaid program in 2005. The state has been focused on updating their IT system for the last decade. The state has had a premium assistance program since 2005. The state has the highest proportion of Native American residents. While Native residents often receive their health care services through the Indian Health Service, many low-income residents are dependent on Medicaid coverage to pay for their health care outside of the IHS network or to receive services not available at IHS facilities.

Medicaid Expansion Implementation: Oklahoma has not expanded Medicaid as of January 1, 2019. Legislators in the state had made several attempts to expand. In 2016 there was a suggestion to use cigarette taxes to fund the Medicaid expansion. Instead, the state made cuts to their existing Medicaid program that impacted approximately 111,000 residents. In May of 2018 the legislature passed a work requirement bill that would impact the adults and parents currently covered by the Oklahoma Medicaid program. As of January 1, 2019 the Trump Administration has not yet approved their waiver or any state who has not extended coverage to individuals making at least 100% of the federal poverty level.

General facts about Oklahoma Medicaid:

Medicaid program name: SoonerCare

CHIP Program name: SoonerCare

Separate or combined CHIP: Combination

Medicaid Enrollment: 803,600 (November 2016 enrollment)

Total Medicaid Spending: $5 billion (FY 2015 estimate)

Share of total population covered by Medicaid: 17%

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

Share of Medicaid that is Children and Adults: 78%

Share of Spending on Elderly and people with disabilities: 57%

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

FMAP: 59.9%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: Under review

Ohio Medicaid History and Facts

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Initial Medicaid Implementation: Ohio initially began their Medicaid program in July of 1966. At the onset of the implementation of Medicaid, Ohio did not offer the option of medically needy coverage. The state did not expand their program as much as many other states and didn’t see as many problems with the cost of the program. In the first year of the program, the state spent approximately $50 million providing services to approximately 300,000 beneficiaries. According to a GAO report, over the next 11 years the costs increased 10 fold and eligibility increased 143 percent while Medicaid costs nationwide increased 1,500 percent, although that increase is likely because of more states taking up the program.

Key Medicaid Political Issues: In 1986 Ohio created a program called the PASSPORT program. This program allows Ohio residents over the age of 60 to learn about their long-term care options and provides in home care. The state has eliminated the waitlist for their various home care programs and has transferred thousands of people from nursing facilities to the home over the last decade. Ohio has been at the brunt of the opioid epidemic that has put a strain on the state’s Medicaid program and health care resources.

Medicaid Expansion Implementation: Ohio expanded Medicaid with applications being made available in October of 2013 and coverage beginning in January of 2014. The governor utilized an existing flexibility that allowed then governor John Kasich to expand Medicaid using a budget control board made up of six legislators that oversee changes to the state’s budget. This gained opposition from the Republican controlled legislature who voted to block the Medicaid expansion that was vetoed by the governor and they raised questions of the legality of the move and filed a lawsuit against the governor. In 2013 the Ohio Supreme Court sided with the governor and the expansion was allowed to continue. Since the initial decision to expand, the continuation of the program has been a consistent point of conflict in the legislature. Prior to the expansion of Medicaid, Ohio received an 1115 waiver to expand coverage to approximately 30,000 non-elderly adults in Cuyahoga County in 2013 to up to 138 percent of the poverty level. In 2018 Ohio sent a waiver request to the federal government to add work requirements for their Medicaid expansion populations. The waiver gained national attention because of the manner in which counties with high proportions of African Americans would be subject to the waiver while rural counties with predominately white populations would be exempt. Medicaid expansion is popular in Ohio with only 14% of the population wanting to end the expansion.

General facts about Ohio Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Healthy Start

Separate or combined CHIP: Combination

Medicaid Enrollment: 2.7 million (2018 estimate)

Total Medicaid Spending: $23.2 billion (FY 2017 estimate)

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: 79%

Share of Spending on Elderly and people with disabilities: 59%

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

FMAP: 63.09%

Expansion state: Yes

Number of people in expansion: 711,000 (estimate)

Work Requirement: Under Review

North Dakota Medicaid History and Facts

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Initial Medicaid Implementation: North Dakota implemented their Medicaid program in January 1966, among the first states to begin offering coverage. North Dakota participated in the Kerr-Mills program prior to the passage of Medicaid and offered generous benefits in comparison to other states. The state was one of only five states that were determined to have offered comprehensive health care services. The state continued these generous benefits when the program began offering every available service. Despite this existing history with the program, the state saw the lowest enrollment levels of any of the early adopters in Medicaid with only 2.5% of the population enrolling.

Key Medicaid Political Issues: North Dakota, like many states in the area, is largely rural so the issues of access to care for low-income rural populations is a key concern of the state. In recent years the generosity of the benefit has decreased with budget considerations which has caused reductions in reimbursements to providers. The most recent reauthorization of the Medicaid program was passed with a stipulation that the program would work to get the highest reimbursement rates but not to exceed the current rates in an effort to alleviate concerns of providers but maintain budget constraints.

Medicaid Expansion Implementation: North Dakota expanded their Medicaid program with enrollment beginning in October of 2013 and coverage beginning in January of 2014. The state was one of a handful of Republican controlled states that expanded coverage when it was first made available. Governor Jack Dalrymple in 2013 at the signing of the bill said “We try to leave the politics out in the hallway when we make these decisions. In the end, it comes down to are you going to allow your people to have additional Medicaid money that comes at no cost to us, or aren’t you?” he said. “We’re thinking, yes, we should.” The state took advantage of some flexibilities made available to help states speed and increase enrollment in Medicaid expansion. In 2016 the state reauthorized the Medicaid expansion program with little debate. The program is set to expire and need another reauthorization in 2019.

General facts about North Dakota Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Healthy Steps

Separate or combined CHIP: Combination

Medicaid Enrollment: 92,922 (2018)

Total Medicaid Spending: $1.2 billion (FY 17 Estimate)

Share of total population covered by Medicaid: 12% (estimate)

Share of Children covered by Medicaid: 28.6% (estimate)

Share of Medicaid that is Children and Adults: 80%

Share of Spending on Elderly and people with disabilities: 59%

Share of Nursing Facility Residents covered by Medicaid: 50% (estimate)

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 21,000 (2018 estimate)

Work Requirement: No