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
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
Initial Medicaid Implementation: Tennessee initially implemented Medicaid in June of 1969, three years following the initial implementation start date. In the first few years of the program, the state struggled with physician participation. The Tennessee Medical Association stated that their doctors were seeing low-income patients but were not filing the paperwork for Medicaid. In response the state doubled the reimbursement rate to encourage participation. When the state began the their Medicaid program they did not cover people who were “medically indigent.”
Key Medicaid Political Issues: Tennessee is most known for their TennCare program which was established through a waiver in 1994. The plan eliminated the state’s fee-for-service program and would put all existing Medicaid beneficiaries in managed care plans. Originally, the plan was available to all residents that qualified for Medicaid and for state residents who could not purchase private insurance for a number of reasons including because of a pre-existing condition. The program grew rapidly and within the first year the program began limiting eligibility to people who were eligible for Medicaid or ineligible for private insurance because of a pre-existing condition and met income requirements. In 2003 after a change in Governors the TennCare program was determined to not be financially viable and in 2005 the program guidelines were changed to reduce the number of people who would be covered by the program. 190,000 people were removed from the TennCare roles. The changes also reduced the number of medical services and prescription drugs that the remaining beneficiaries could use.
Medicaid Expansion Implementation: As of January of 2019, Tennessee has not implemented Medicaid expansion. The state has debated whether to take up the Medicaid expansion several times and came close to expanding in 2015. The state has proposed work requirements for the existing Medicaid populations, primarily parents and certain adult caregivers, that would require them to work or meet community engagement requirements for a minimum of 20 hours per a week. The bill was criticized for the inclusion of a provision that would use TANF funds to pay for the administrative costs of work requirements. CMS has not approved work requirements for any state that has not expanded Medicaid. In the past, Tennessee law makers have proposed other restrictive Medicaid expansion policies including block granting Medicaid. During the initial rollout of the Affordable Care Act’s coverage expansion and HealthCare.gov the Tennessee Medicaid eligibility system faced some challenges and there were significant delays transferring applications from HealthCare.gov to be processed by the state.
General facts about Tennessee Medicaid: Medicaid program name: TennCare CHIP Program name: CoverKids Separate or combined CHIP: Combination Medicaid Enrollment: 1.38 million (2018 estimate) Total Medicaid Spending: $9.1 billion (FY 2017 estimate) Share of total population covered by Medicaid: 20% Share of Children covered by Medicaid: 43% (estimate) Share of Medicaid that is Children and Adults: 72% Share of Spending on Elderly and people with disabilities: 54% Share of Nursing Facility Residents covered by Medicaid: 60% FMAP: 65.21% Expansion state: No Number of people in expansion: N/A Work Requirement: Under Review
Initial Medicaid Implementation: South Dakota began their Medicaid program in October of 1967. When the program began the state did not provide coverage for people who were “medically needy.” As of 1963 South Dakota had not participated in the Kerr Mills program that proceeded the Medicare program. The state had submitted a plan to begin a program that would provide medical aid to seniors using federal funding, however the program had not been approved by the federal government by the time that conversations about beginning the Medicare program were in full swing. The plan proposed by the state would provide people who were eligible for coverage under the MMA program health insurance rather than directly paying for the services and expenses that these beneficiaries accrue. Key Medicaid Political Issues: South Dakota has a high portion of the population living in rural parts of the state. This makes access to health care services difficult. South Dakota also has a high portion of the population who are Native Americans and receive Medicaid through categorical eligibility. South Dakota provides one of the lowest eligibility levels for pregnant women, infants, children and lower-middle income families through CHIP. South Dakota has a high rate of providers who accept Medicaid coverage with 100% of primary care physicians and hospitals accepting Medicaid in 2009. Most nursing homes and dentists in the state also accepted Medicaid patients. The state ranks second lowest in Medicaid administration expenditures. Due to the state’s small population, pilot programs in long-term care are able to affect a small population of beneficiaries that represent a larger share of the state’s expenditures. Medicaid Expansion Implementation: As of January 2019, South Dakota has not expanded their Medicaid program under the Affordable Care Act. The state has been controlled by both a Republican governor and legislature since the option was made available in 2012. It is estimated that roughly 26,000 people are in the coverage gap or fall below 100% of the federal poverty level. The issue has been at the center of statewide politics in both the 2014 and 2018 gubernatorial elections. In 2014 Governor Daugaard requested an expansion of Medicaid up to 100% of the federal poverty level, or what is known as a partial expansion. CMS decided that Medicaid expansion was only available to states that expanded Medicaid up to the 138% of FPL. At the same time that Governor Daugaard was making this request, the state was running a budget surplus because the Medicaid enrollment was 10% lower than expected in the existing Medicaid program, even following the expansion of coverage due to the implementation of the Affordable Care Act. In 2014 a state panel also decided that South Dakota would not become the first state in the nation to allow people to vote on whether or not the state could expand Medicaid coverage. The Senate Affairs committee must determine whether or not ballot initiatives can appear before the voters.
General facts about South Dakota Medicaid: Medicaid program name: Medicaid CHIP Program name: CHIP Separate or combined CHIP: Combination Medicaid Enrollment: 116,000 (2018 estimate) Total Medicaid Spending: $859 million (FY 2017 estimate) Share of total population covered by Medicaid: 15% (estimate) Share of Children covered by Medicaid: 33% (estimate) Share of Medicaid that is Children and Adults: 76% Share of Spending on Elderly and people with disabilities: 63% Share of Nursing Facility Residents covered by Medicaid: 50% (Estimate) FMAP: 57.62% Expansion state: No Number of people in expansion:N/A Work Requirement: Under review
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
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
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