Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018

Introduction

Medicaid provides health insurance coverage to more than one in five Americans, and accounting for over one-sixth of all U.S. health care expenditures.¹ The Medicaid program constantly evolves, as policy makers in each state make changes to improve their programs, respond to economic conditions, come into compliance with new federal requirements, and implement other state budget and policy priorities. As fiscal year (FY) 2018 began in most states, legislative proposals to repeal major portions of the Affordable Care Act (ACA), including the Marketplace and Medicaid coverage expansions, were under consideration in Congress. These proposals would also have fundamentally restructured federal Medicaid financing, converting the current open-ended entitlement to a federal block grant or per capita cap. It is within that context that this year’s survey was conducted.

This report examines the reforms, policy changes, and initiatives that occurred in FY 2017 and those adopted for implementation for FY 2018 (which began for most states on July 1, 2017²). Report findings are drawn from the annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Family Foundation (KFF) and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). This was the 17^th annual survey, which has been conducted from FY 2002 through FY 2018. (Copies of previous reports are archived here.³)

The KFF/HMA Medicaid survey on which this report is based was conducted from June through September 2017. The survey was sent to each state Medicaid director in June 2017. Directors and their staff provided data for this report in their written survey response and through a follow-up telephone interview. All 50 states and DC completed surveys and participated in telephone interview discussions between July and September 2017. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis. An acronym glossary and the survey instrument are included as appendices to this report.

The survey collects data about Medicaid policies in place or implemented in FY 2017, policy changes implemented at the beginning of FY 2018, or policy changes for which a definite decision has been made to implement in FY 2018. Some policies adopted for the upcoming year are occasionally delayed or not implemented for reasons related to legal, fiscal, administrative, systems or political considerations, or due to delays in approval from CMS. The District of Columbia is counted as a state for the purposes of this report; the counts of state policies or policy actions that are interspersed throughout this report include survey responses from the 51 “states” (including DC). Key findings of this survey, along with state-by-state tables providing more detailed information, are described in the following sections of this report:

• Eligibility and Premiums
• Managed Care Initiatives
• Emerging Delivery System and Payment Reforms
• Long-Term Services and Supports Reforms
• Provider Rates and Taxes
• Benefits, Copayments, Pharmacy, and Opioid Strategies
• Challenges and Priorities in FY 2018 and Beyond Reported by Medicaid Directors