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After Pandemic-Era Policies and Enhanced Funding End, State Medicaid Officials Report Enrollment Declines and Upward Cost Pressures
Costs are limiting states’ coverage of obesity drugs and could affect other Medicaid priorities
States expect national Medicaid enrollment to decline by about 4% and state Medicaid spending to rise by 7% in fiscal year (FY) 2025. These rates follow a larger but anticipated enrollment decline and state spending increase in FY 2024, as pandemic-era policies and federal funding expired, according to KFF’s 24th annual survey of state Medicaid directors.
While state fiscal conditions remain stable heading into FY 2025, the longer-term fiscal and policy outlook for Medicaid programs is less certain. Reduced state revenue collections, the expiration of pandemic-era federal funding, and macroeconomic uncertainties, may discourage states from increasing funding for access to behavioral health, long-term services and supports, and higher provider reimbursement rates—and could prompt spending reductions. The upcoming election also contributes to a more uncertain outlook for states and their Medicaid programs.
With some limits on their use, 12 state Medicaid programs reported covering GLP-1 drugs for obesity treatment (such as Wegovy and Zepbound) as of July 2024. Half of states without coverage are considering adding coverage, but most say that cost was a key factor in their decisions, according to KFF’s companion report, which highlights the key policy priorities and issues that state Medicaid programs focused on in FY 2024 and are prioritizing in FY 2025. Rising prescription drug costs are an ongoing concern for states and nearly three-quarters of them reported at least one new or expanded initiative to contain prescription drug costs in FY 2024 or FY 2025.
The survey was conducted in the summer of 2024 by KFF and Health Management Associates (HMA) in collaboration with the National Association of Medicaid Directors (NAMD). This year’s estimates of Medicaid spending and enrollment reflect what is assumed in states budgets in most cases, though projections always include some uncertainty.