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

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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

North Carolina Medicaid History and Facts

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Initial Medicaid Implementation: North Carolina initially implemented their Medicaid program in January of 1970. The Medicaid program was initially implemented through the Department of Social Services with a contract with the North Carolina Blue Cross Blue Shield. The program was moved to the Health Applications System, a private groups to manage the operations and financial risk. Within a year the contract was canceled after the company experienced financial losses. In 1979 the program was moved under the now North Carolina Department of Health and Human Services and began to be administered by Barbara Matula who would administer the program for 19 years. North Carolina began covering people who did not receive cash assistance in 1987 as the state began to expand services to more groups.

Key Medicaid Political Issues: North Carolina has a low cost and less generous Medicaid program in terms of eligibility. The state ranks 42nd among states in terms of spending per a beneficiary and 40th among states in generosity of benefits. North Carolina uses a county cooperation agreement with the state funding approximately 85% of the state costs and the counties covering approximately 15% of the share of the FMAP. In the early 1990’s the state made several enhancements to eligibility and benefits in addition to enhancing the state’s managed care program. The managed care program was introduced to be statewide by December 2005. The reforms included several efforts to reduce costs through limits on prescription drugs, reductions in physician payment rates and inflationary growth, and a reduction of eligibility through income and asset limits primarily for the elderly and people with disabilities. In 2016 the state took a number of steps aimed at reducing benefits and costs, despite the Medicaid program running under budget, including instituting waitlists for children with disabilities. In 2018 the state received an 1115 waiver for delivery system reform among their hospitals and to improve the care of social determinants of health.

Medicaid Expansion Implementation: North Carolina has yet to expand Medicaid as part of the Affordable Care Act. Until 2015 the state had a Republican controlled legislature and governor. The Democratic Governor has pushed Medicaid expansion but is unlikely to receive votes in the legislature. The legislature has discussed adding a work requirement to the existing Medicaid program which could be used as leverage for negotiations to pass a Medicaid expansion in future years. According to one poll in 2016 72% of North Carolina residents supported Medicaid expansion. Currently, parents must make under 44% of the poverty level to qualify for coverage in North Carolina. It is estimated that approximately half a million people would be eligible for Medicaid expansion.

General facts about North Carolina Medicaid:

Medicaid program name: Medicaid

CHIP Program name: NC Health Choice for Children

Separate or combined CHIP: Combination

Medicaid Enrollment: 2,033,474 (estimate 2018)

Total Medicaid Spending: $13.5 billion (FY 2017 Estimate)

Share of total population covered by Medicaid: 18%

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

Share of Medicaid that is Children and Adults: 72%

Share of Spending on Elderly and people with disabilities: 64%

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

FMAP: 67.16%

Expansion state: No

Number of people in expansion: N/A

Work Requirement: No

New York Medicaid History and Facts

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Initial Medicaid Implementation: New York began their Medicaid program in May 1966. New York’s existing medical assistance program under the Kerr Mills law was one of the largest in the country. Under the program the average annual cost for beneficiaries was $700 per beneficiary. When Governor Rockefeller signed the Medicaid legislation he called the program the most significant social welfare advances since the New Deal. After the bill was passed hostility grew in the public, especially in the more rural areas of upstate New York against the generosity of the benefit. The legislature held hearings on the new benefit which was opposed by farming groups, employer groups, and the medical industry, but not the medical society. The main hostility was coming from counties which had a lower average income than New York City and it was estimated that up to 70% of residents of some of these counties would be eligible for Medicaid. This opposition continued as the Department of Health and Welfare (HEW) was in the process of approving the plan. There was no reason that the federal officials could legally not approve the plan but it was estimated that the New York plan would cost the entirety of the budget of the national Medicaid program. Ultimately HEW approved the plan despite significant calls to action from Congress. Once the program began, it was estimated that two million beneficiaries or 11% of the state’s population were beneficiaries of the program. A majority of the services provided in New York City were provided by public facilities. As the new Medicaid plan was being implemented it was met with criticism from physician groups who opposed the plan to have penalties for physicians who overbill or use the program fraudulently. The program provided medical services at relatively low costs compared to states such as California that also provided generous benefits. However, the law was amended in 1967 to allow states to reduce benefits. New York took up this option and reduced eligibility to 150% of the top welfare benefit line. By this point the state had run into considerable financial difficulties and political difficulties in implementing the program. The state provided the most generous Medicaid program in the country yet the eligibility level stood at $5,000 after the state lowered the eligibility level and eliminated nearly a million people from the roles. In the end it was confirmed that 11 percent of the population of the state used the program in the first years. The state covered every optional service that was eligible for federal reimbursement. Despite this, the program suffered from a difficulty of accessing providers. Only approximately 1/3rd of New York City physicians and dentists accepted Medicaid payments.

Key Medicaid Political Issues: New York was one of the first states to receive an 1115 waiver for reform to the delivery system to reward more integrated care and social supports with the state’s hospital systems. In 2014 the DISRIP waiver promised $8 billion in federal savings that would be reinvested to improve social services. The primary goal was to reduce avoidable hospital use by 25 percent over 5 years. The state has maintained a generous and expensive Medicaid program and has over the years shifted many human services programs to the Medicaid program in order to receive the federal matching rate. The state also had high eligibility levels, reimbursement rates, and benefit coverage of all mandatory and optional benefits. At the same time the state has financed the Medicaid program through non-traditional resources such as revenue sharing in order to support existing state activities such as mental health and alcoholism treatment and fund the Medicaid program over the course of the quarter. The practice was initiated following several years of depressed state revenue. Congress has taken several measurers to end this practice by putting greater definitions on what Medicaid would reimburse.

Medicaid Expansion Implementation: New York began their Medicaid expansion with enrollment beginning in October of 2013 and coverage beginning in January 2014. New York is one of two states that has implemented a Basic Health Program for people earning less than 200% of the poverty level. The program replaced an existing state program that provided health care coverage to low-income residents who were unable to get Medicaid coverage due to immigration status. This meant that the state was able to shift a significant amount of state resources to the federal government to cover these individuals. Additionally, this population is often lower cost than the general population and that added stability to the program. During the debate over the Affordable Care Act repeal legislation, the unique way that New York finances their Medicaid program gained attention. The state, like Nevada, has counties pay for a portion of the Medicaid expenditures rather than using state general revenue.

General facts about New York Medicaid:

Medicaid program name: Medicaid

CHIP Program name: Child Health Plus (CHPlus)

Separate or combined CHIP: Combination

Medicaid Enrollment: 6.5 million

Total Medicaid Spending: $77.8 billion

Share of total population covered by Medicaid: 24%

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: 63%

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

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 2,071,000 (2018 estimate)

Work Requirement: No

New Mexico Medicaid History and Facts

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Initial Medicaid Implementation: New Mexico began their Medicaid program on December 1, 1966. In the early years of the program, the state legislature refused to fund even a bare bones version of the Medicaid program. The state decided to not cover the medically indigent category of coverage making the program significantly cheaper but the legislature still would not fully fund it. Despite these limitations, the cost of the program continued to rise in the initial years. The state cut provider payments by 25% but these cuts were not enough to control spending in the program. On May 1, 1969 New Mexico became the first and only Medicaid program to shut down their program. For nine days the state ended their Medicaid program while the state tried to withdraw their current program and create a less generous program. This tactic was not allowed by federal law but was later added by New Mexico Senator Clinton Anderson. The provision would allow states to reduce benefits and ended the requirement that states extend benefits to all medically needy individuals by 1975. The amendment passed with little debate in the House but was eventually amended to require states to cover medically needy individuals by 1977, giving states two additional years to comply with this requirement. The amendment outlined services that the state could reduce and services that it had to maintain. This began the distinction of the mandatory and voluntary set of benefits. Prescription drugs were delineated as voluntary benefits and continue to not be mandatory to this day. This was the first major contraction of eligibility and benefits in the Medicaid program. Later it came out that the state’s Medicaid financial problems that led to these reforms and contraction of benefits available to beneficiaries was caused by profit seeking doctors and a lack of control over providers bilking the system. New Mexico politicians argued that the requirement to cover the medically needy would put significant strain on the budget of the state yet the state provided generous benefits to individuals who would have qualified for the medically needy provision including home health, vision and dental, benefits that are rarely covered for these populations.

Key Medicaid Political Issues: New Mexico has one of the highest portions of the population covered by Medicaid. Combined with Medicare and the Indian Health Service, only 41% of the population is covered by private insurance. Medicaid covers 31% of the population, the highest rate in the country. This is likely due to the fact that the state has a large number of low-income residents and New Mexico has a high number of Native Americans, many of who may receive both Medicaid and Indian health care services. Native Americans are not automatically enrolled in the Medicaid program but may enroll if they meet the income criteria. The state has struggled with mental health contracts and network adequacy around mental health care services for Medicaid beneficiaries. In 2013 the state ended contracts with 15 behavioral health providers over allegations of Medicaid fraud.

Medicaid Expansion Implementation: New Mexico implemented Medicaid expansion as part of the Affordable Care Act with enrollment beginning in October of 2013 and coverage beginning in January 2014. Republican Governor, Susan Martinez was the second Republican governor to accept the Medicaid expansion six months following the Supreme Court decision. As part of the Medicaid expansion, the state renamed their Medicaid program “Centennial Health” beginning on January 1, 2014. The renaming was accompanied by a shift from fee-for-service Medicaid to a more capitated program through integration of some pay for performance measures.The state was the first to pass a bill establishing a study committee on Medicaid Buy-In and may be going forward with the policy in future years. The state’s new governor, Michelle Lujan Grisham introduced legislation at the federal level that would allow states to elect to run Medicaid Buy-In programs. The state is also exploring avenues that would allow for auto-enrollment in Medicaid through eligibility in other state programs.

General facts about New Mexico Medicaid:

Medicaid program name: Centennial Health

CHIP Program name: New Mexikids/Mexiteens

Separate or combined CHIP: Medicaid expansion

Medicaid Enrollment: 727,000 (2018 estimate)

Total Medicaid Spending: $4.8 billion

Share of total population covered by Medicaid: 31%

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

Share of Medicaid that is Children and Adults: 80%

Share of Spending on Elderly and people with disabilities: 36%

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

FMAP: 72.26%

Expansion state: Yes

Number of people in expansion: 253,000 (2018 estimate)

Work Requirement: No

New Jersey Medicaid History and Facts

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Initial Medicaid Implementation: New Jersey initially implemented Medicaid in January 1970, the deadline for states to begin their Medicaid programs if they wanted to maintain their funding for low-income individuals. In the early years of Medicaid, Congress debated the funding level of the FMAP after it was determined that the cost of the Medicaid program was higher than anticipated. A measure was passed that would have reduced the federal share of the payments to as low as 25 percent for some wealthier states. Since New Jersey would likely fit that definition of states that would receive a lower federal match, their senator was the only one to object to the bill and it passed as part of a tax bill in the Senate. At the time, New Jersey was also a very fiscally conservative state and waited until the “deadline” of the end of the Kerr Mills federal dollars in order to accept the Medicaid program. At the implementation of the program, the state elected not to provide for medically indigent category of eligibility.

Key Medicaid Political Issues: In the early to mid-1990s the state went through a retrenchment in its Medicaid program with reductions in hospital spending accompanied with deregulation and mandatory managed care enrollment for cash assistance beneficiaries. These changes were largely due to a change in the political makeup of the legislature and economic conditions in the state. Republicans took control of the legislature at the same time that periodic recessions affected the state budget. This created a climate for reductions in Medicaid spending. New Jersey has taken many steps to address more public health and social determinants of health through its Medicaid program. The state has run programs to provide supportive housing which benefits the Medicaid program. In 2012 the state passed a waiver that created several integrated managed care programs addressing behavioral and social factors that affect health. Maternal mortality and the racial differences in maternal mortality rates have been a concern for the state in recent years.

Medicaid Expansion Implementation: New Jersey began their Medicaid expansion with enrollment beginning in October of 2013 and coverage beginning in January of 2014. New Jersey was one of the five states that decided to expand Medicaid coverage prior to 2014 using a flexibility within the law that allowed states to expand coverage early. However, the state only extended coverage for adults up to 23% of the federal poverty level beginning in April of 2011. Chris Christie was the governor of New Jersey at the time and there was some concern that he may not implement the program as a Republican governor. In the early days of the Medicaid expansion in New Jersey, the state had significant issues redirecting the Medicaid applications from the federal HealthCare.gov website to the state Medicaid program which led to delays in Medicaid beneficiaries receiving a determination of whether they were able to enroll in Medicaid.

General facts about New Jersey Medicaid:

Medicaid program name: Medicaid

CHIP Program name: NJ Family Care

Separate or combined CHIP: Combination

Medicaid Enrollment: 1.8 million (2018 estimate)

Total Medicaid Spending: $15 billion (FY 2017 estimate)

Share of total population covered by Medicaid: 17%

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

Share of Medicaid that is Children and Adults: 79%

Share of Spending on Elderly and people with disabilities: 64%

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

FMAP: 50%

Expansion state: Yes

Number of people in expansion: 563,000 (2018 estimate)

Work Requirement: No