Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014

The dominant forces shaping Medicaid during FY 2013 and heading into FY 2014 were the implementation of the Affordable Care Act (ACA) and the development and implementation of an array of delivery and payment system reforms. These changes represent some of the most significant changes to Medicaid since its enactment in 1965, and taken together, are transforming the role of Medicaid in the health care system in each state.  At this time, the intensity of fiscal pressures and the focus on cost Medicaid containment were somewhat lessened as the economy slowly recovers; however, controlling costs and improving program administration are still important priorities for Medicaid program. The findings in this report are drawn from the 13th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates (HMA). The report highlights trends in Medicaid spending, enrollment and policy initiatives for FY 2013 and FY 2014 with an intense focus on eligibility and enrollment changes tied to the implementation of the ACA as well as payment and delivery system changes. The report provides detailed appendices with state-by-state information and a more in-depth look at four case study states:  Arizona, Florida, Kentucky and Washington. Key findings from the survey include the following:

• Improvements in the economy resulted in modest growth in Medicaid spending and enrollment in FY 2013.  In FY 2014, national enrollment and spending growth are expected to rise.  States moving forward with the Medicaid expansion are expected to see higher enrollment and total spending growth driven by increases in coverage and federal funds.
• The implementation of the ACA will result in major changes to Medicaid eligibility and enrollment for all states whether they are implementing the ACA Medicaid expansion or not.
• Nearly all states are developing and implementing payment and delivery system reforms designed to improve quality, manage costs and better balance the delivery of long-term services and supports across institutional and community-based settings.
• Improvements in the economy have enabled states to implement more program restorations or improvements in provider rates and benefits compared to restrictions, but states also adopted policies to control costs and enhance program integrity.
• Looking ahead, FY 2014 will be a transformative year for Medicaid.