A Discussion with Leading Medicaid Directors: As FY 2013 Ends, Looking toward Health Care Reform Implementation in 2014

In May 2013, a group of leading state Medicaid directors met outside Denver, Colorado to discuss the current opportunities and challenges facing state Medicaid programs as they prepare to implement the Affordable Care Act (ACA) coverage expansions and enrollment simplifications that will take effect in January 2014. Medicaid directors described a time of focused attention on their preparation for the implementation of significant and complex system and policy changes.

Key findings include:

States participating in the discussion varied with regard to their decisions on the ACA Medicaid expansion. Debate over the decision included a number of factors beyond just the fiscal impact.

The discussion clearly illustrated how widely divergent state decisions and approaches are on expanding Medicaid. Directors indicated that the debate on whether to move forward with the Medicaid expansion included a number of factors, many of which were specific to state circumstances. Beyond the fiscal impact of the decision, other factors mentioned as part of the debate included: how the expansion would be implemented, past experiences with coverage expansions, as well as potential action to reduce the federal deficit, and the funding commitment to Medicaid, in the future.

Regardless of where states stood on the Medicaid expansion, all the directors reported that they were actively working to have new streamlined eligibility and enrollment processes ready for 2014.

As part of health care reform implementation, all states are preparing to implement major changes to simplify and streamline eligibility and enrollment processes. By January 1, 2014, state Medicaid programs are required to use Modified Adjusted Gross Income (MAGI) to determine eligibility for most non-elderly Medicaid applicants and to have simplified enrollment policies and updated eligibility systems in place that interface with the new marketplaces. However, because the new marketplace will begin enrollment on October 1, 2013, there is an additional push to have Medicaid enrollment systems ready earlier. These changes are significant and complex, and they are required even if states do not adopt the ACA Medicaid expansion. Overall, there was broad consensus among the participants that they were working hard to be ready for open enrollment, but that eligibility and enrollment-related issues would inevitably occur at the start despite the best efforts of states and the federal government. As such, they stressed the importance of setting realistic expectations for January 2014.

In addition to implementation of the ACA, states continue to improve their existing Medicaid programs, by continuing to pursue payment and delivery reforms and by building on previous successes.

States are continuing to pursue significant payment and delivery system reforms to better coordinate care for complex and high need populations. Discussion group participants cited a number of new and ongoing initiatives in their states, which illustrated their commitment to improving health outcomes and controlling costs.

Directors also noted the importance of recognizing the successes of Medicaid, particularly at a time when there are many missperceptions about the program. There was consensus that as the Medicaid expansion is implemented and states continue to make delivery and payment reforms to the program, it will be important to both share the program’s achievements, innovations, and impact, and to communicate its effectiveness in connecting people to the care they need.