Medicaid, the provider of health insurance coverage for about one in five Americans and the largest payer for long-term care services in the community and nursing homes, continues to be a key part of health policy debates at the federal and state level. Key Medicaid issues to watch in 2020 include: Medicaid expansion developments; Section 1115 waiver activity; enrollment and spending trends; benefits, payment and delivery system reforms, and the implications of the 2020 elections.
At the start of 2020, 37 states had adopted the ACA Medicaid expansion. This total includes Idaho and Utah, which implemented the expansion on January 1, 2020, and Nebraska, where the expansion was adopted but not yet implemented. A review of over 300 studies points to positive effects of expansion on coverage, access to care, service utilization, and state budgets and economies. Millions of adults could gain Medicaid eligibility if additional states expanded their programs. Expansion activity is ongoing in a number of states that have not adopted the expansion. Initiatives are underway in Oklahoma and Missouri to put Medicaid expansion on the ballot in November 2020, while Kansas announced an agreement between the Governor and the Senate Majority Leader to adopt the Medicaid expansion in the 2020 legislative session. In addition, North Carolina came close to passing the Medicaid expansion through the state legislature during the 2019 session, but ultimately failed to do so, adjourning the session without a budget. Since the Governor continues to support expansion, the issue may come up again in 2020.
Some states are seeking waiver authority to implement a new expansion or make changes to an existing expansion. After Nebraska voters approved a Medicaid expansion ballot measure in November 2018, the state delayed implementation until October 1, 2020 to allow time for the state to seek a Section 1115 waiver to implement expansion. The waiver calls for a tiered benefit package; to access enhanced benefits, enrollees must meet certain wellness and personal responsibility requirements as well as work/community engagement requirements. Georgia submitted a waiver to the Centers for Medicare and Medicaid Services (CMS) seeking approval for a Medicaid expansion with enhanced ACA funding with coverage up to 100% of the federal poverty level (FPL) for individuals who meet work requirements. However, the state acknowledges recent CMS guidance indicating that the enhanced match rate will be available only to states that cover the entire adult expansion group (up to 138% FPL). The waiver proposal also contains other provisions that would restrict eligibility and benefits.