Kaiser Family Foundation report "Medicaid Moving Ahead in Uncertain Times"

Kaiser Family Foundation report “Medicaid Moving Ahead in Uncertain Times”

With the several efforts this year by Congress and the Trump administration to repeal and replace the Affordable Care Act, and a repeal of portions of the law possible in the coming weeks, states remain uncertain about the future of their Medicaid programs. In October, Kaiser Family Foundation and partners released a report based on findings from their annual survey of Medicaid directors.

The report, “Medicaid moving ahead in uncertain times,” examines states’ changes and proposed changes to their Medicaid programs for fiscal years 2017 and 2018, and how their plans for the upcoming fiscal year have been affected by the uncertainty of their federal funding levels.

Medicaid expansion

Since 2014, 32 states have chosen to expand Medicaid coverage under a provision in the ACA. In these states, eligibility is based solely on income. People can qualify for Medicaid if their income is at or below 133 percent of the federal poverty level, regardless of other factors.

The federal government has fully paid for the costs of expansion through 2017, and will pay 90 percent of the costs through 2020. Proposed federal changes to the ACA, however, have included cuts to federal financing of Medicaid expansion and financing for Medicaid overall.

Through interviews with Medicaid directors from the 32 states that have elected to expand coverage, the report reveals that ending federal financing for Medicaid expansion would mean that states would no longer have the resources to cover all enrollees. Their coverage would be at risk due to potential budget shortfalls or a need to reduce Medicaid programs.

At a panel discussion for the release of the report, Kate McEvoy, Medicaid director for Connecticut, explained that many states rely on knowing what future resources they will have to implement their programs. She added that it makes it particularly difficult not to have even a basic premise of funding from the federal level.

With the future of funding unknown, several states — including Virginia, Idaho, Wyoming and Tennessee — noted that they are holding off on moving forward with Medicaid expansion. Eight states plan to roll back Medicaid eligibility in 2018 compared to just one state in fiscal year 2017, although it is unclear if these restrictions stem from funding uncertainties alone.

Medicaid and the opioid crisis

Many Medicaid directors also noted in their surveys that terminating federal financing of program expansions could have negative impacts on behavioral health services, which include care for people with substance abuse disorders, such as opioid addiction. Many state Medicaid programs cover behavioral health services such as inpatient detoxification, intensive outpatient services and case management or care coordination for opioid-addicted patients.

McEvoy explained that a key factor of success in curbing the opioid public health crisis is providing people with access to and coverage for services and tools to avoid dependence on opioids, which can help alleviate the spillover into heroin abuse.

In Connecticut, says McEvoy, Medicaid has been the best avenue for providing and supporting people with behavioral health services, and Medicaid expansion has allowed for huge gains in participation. According to a report published in September by Kaiser Family Foundation, enhanced federal funding from Medicaid expansion has enabled states to cover adults with opioid addictions who were previously excluded from the program.

Many states still plan to implement other initiatives to address the opioid epidemic. Thirty-four states have adopted or plan to adopt CDC guidelines for prescribing opioids in primary care settings, which include limitations on dosage. Furthermore, 37 states plan to start using at least one of the five strategies asked about in the annual survey, including imposing opioid quantity limits and requiring prescribers to check their state’s Prescription Drug Monitoring Program prior to prescribing opioids.

Yet as states move forward with these plans, McEvoy emphasized that a top priority for Connecticut’s Medicaid program will be getting as much certainty as possible from the federal level regarding funding.

States want to “have the wherewithal to…continue and to amplify programs about which we’re proud of,” she said.