Key Takeaways

The coronavirus pandemic has generated both a public health crisis and an economic crisis, with major implications for Medicaid, a countercyclical program. During economic downturns, more people enroll in Medicaid, increasing program spending at the same time state tax revenues may be falling. To help both support Medicaid and provide broad fiscal relief as revenues have declined precipitously, the Families First Coronavirus Response Act (FFCRA) authorized a 6.2 percentage point increase in the federal match rate (“FMAP”) (retroactive to January 1, 2020) available if states meet certain “maintenance of eligibility” (MOE) requirements. The health and economic consequences of the pandemic as well as the temporary FMAP increase were major drivers of Medicaid enrollment and spending trends as states finished state fiscal year (FY) 2020 and started FY 2021 (which for most states began on July 1).¹ 

This brief analyzes Medicaid enrollment and spending trends for FY 2020 and FY 2021 based on data provided by state Medicaid directors as part of the 20th annual survey of Medicaid directors in all 50 states and the District of Columbia. Overall, 43 states²  responded to the survey by mid-August 2020, although response rates for specific questions varied. The methodology used to calculate enrollment and spending growth as well as additional information about Medicaid financing can be found at the end of the brief. Key findings include the following:

• After relatively flat enrollment growth in FY 2020 (0.04%), states responding to the survey expect Medicaid enrollment to jump in FY 2021 (8.2%) attributed to the FFCRA’s MOE requirements and to the economic downturn that started late in FY 2020.
• Across all reporting states, states were anticipating that total Medicaid spending growth would accelerate to 8.4% in FY 2021 compared to growth of 6.3% in FY 2020. Enrollment was the primary factor identified as putting upward pressure on expenditure growth in FY 2021.
• While expected state spending on Medicaid is crucial to state budgets, the projections in this year’s survey do not provide a clear picture because enhanced federal funding is now slated to expire at the end of March 2021 based on the recent renewal of the Public Health Emergency (PHE), later than states had generally assumed. At the time of the survey, states estimated that state Medicaid spending would decline in FY 2020 (-0.5%) and then sharply increase in FY 2021 (12.2%) with most states assuming that the enhanced matching funds would expire by December 2020.
• Looking ahead, states are faced with many layers of uncertainty about the trajectory of the pandemic and economic downturn as well as the duration of the enhanced FMAP and the outcome of the elections in November.

Context

Medicaid (together with CHIP) provided coverage to about one in five Americans, or about 73.5 million people, as of May 2020. Total Medicaid spending was nearly $604 billion in FY 2019 with 64.4% paid by the federal government and 35.6% financed by states. Medicaid accounts for one in six dollars spent in the health care system and more than half of spending on long-term services and supports.³ 

Prior to the pandemic, state fiscal conditions were strong in FY 2020. Unemployment was low, states expected revenues to grow for the 10th consecutive year, and state general fund spending was on track to grow by 5.8%. In this context, Governors had developed budget proposals for FY 2021 that included projections for continued revenue and spending growth. Governors’ budgets are generally released early in the calendar year.

The pandemic resulted in a dramatic reversal in state fiscal conditions. Early estimates indicate that states are facing large shortfalls, with some estimates showing state budget shortfalls of up to $110 billion for FY 2020 and up to $290 billion for FY 2021. Other early reports from states similarly show state revenue declines of up to 15% in FY 2020 and up to 30% for FY 2021 compared to pre-pandemic state estimates of state revenue totaling $913 billion for FY 2020 and $944 billion in FY 2021. Faced with continued uncertainty regarding ongoing revenue collections and the possibility of additional federal fiscal relief, several states adopted temporary budgets or continuing resolutions to begin FY 2021 while some other states with previously enacted FY 2021 budgets planned to convene special sessions to adjust appropriation levels.⁴  Unlike the federal government, states must meet balanced budget requirements. In the face of major revenue shortfalls due to the economic effects of the pandemic, states can use reserves or cut spending if additional federal support is not available. During the Great Recession, states imposed layoffs or furloughs for state workers, reduced funding for state governments, made across the board spending cuts and program cuts to education, higher education, and Medicaid. However, major cuts to state services and workforce can be harmful to state residents facing increased demands for services and can also weaken economic recovery efforts. To reduce Medicaid spending during economic downturns, states typically turn to provider rate and benefit restrictions, however, with providers facing revenue shortfalls and enrollees facing increased health risks due to the pandemic, these methods to control costs may not be as viable.

While the FMAP increase included in the FFCRA supports Medicaid and provides broad fiscal relief to states, it is unlikely to fully offset state revenue declines and fully address state budget shortfalls. In the past, federal fiscal relief provided through increases in the Medicaid FMAP—or the share of Medicaid costs paid by the federal government— during significant economic downturns has helped to both support Medicaid and provide efficient, effective, and timely fiscal relief to states. The Families First Coronavirus Response Act (FFCRA) uses this model as well by providing a temporary 6.2 percentage point increase in the Medicaid FMAP from January 1, 2020 through the end of the quarter in which the public health emergency (PHE) ends. This FMAP increase does not apply to the ACA expansion group, for which the federal government already pays 90% of costs. To be eligible for the funds, states cannot implement more restrictive Medicaid eligibility standards or higher premiums than those in place as of January 1, 2020, must provide continuous eligibility for enrollees through the end of the month of the emergency period, and cannot impose cost sharing for COVID-19 related testing and treatment services including vaccines, specialized equipment, or therapies. States access the enhanced funds by submitting claims for federal reimbursement for Medicaid expenditures.

While all states are experiencing fiscal stress tied to the pandemic, the experience varies across states. For example, while the national unemployment rate in August 2020 was 8.4% (a decline from its initial peak of 14.7% in April 2020 at the start of the pandemic), there was considerable state variation in unemployment with state rates ranging from 4.0% (Nebraska) to 13.2% (Nevada). California, Hawaii, New York, Rhode Island and Nevada reported the highest state unemployment rates, exceeding the national rate by three percentage points or more. Similarly, projected revenue shortfalls vary across states, with states reporting revenue declines ranging from 1% to 15% in FY 2020 and from 1% to 30% for FY 2021.

Key Findings

Trends in Enrollment Growth FY 2020 and FY 2021

After declines in FY 2018 and 2019 followed by relatively flat enrollment growth in FY 2020, states expect Medicaid enrollment to jump in FY 2021 (Figure 1). Medicaid enrollment growth peaked in FY 2015 due to the implementation of the ACA and has tapered each year since. Enrollment declined in FY 2018 (-2.1%) and FY 2019 (-1.7%) and was relatively flat in FY 2020 (0.04%). However, for FY 2021, reporting states project a sharp increase in enrollment to 8.2%. A few states noted that the projections were completed prior to the pandemic and did not account for the economic downturn so were likely to change. Others noted uncertainty regarding when the PHE and related maintenance of effort (MOE) requirements would end, which would allow redeterminations and eligibility terminations to resume for beneficiaries who no longer meet eligibility standards (although fewer enrollees are likely to see income increase due to the economic downturn). A few states that recently adopted or implemented the Medicaid expansion anticipated larger increases in enrollment.

States largely attributed projected enrollment increases in FY 2021 to the FFCRA’s MOE requirements and to the economic downturn. All reporting states responded that the MOE was an upward or significant upward pressure on enrollment and nearly all reporting states noted that the economy was an upward or significant upward pressure on enrollment. The two factors (the MOE and the economy) are likely linked. Outside of the MOE, individuals may lose Medicaid coverage because they have a change in circumstance (such as an increase in income), because they fail to complete renewal processes or paperwork even when they remain eligible, or because they age out of a time- or age-limited eligibility category (e.g., pregnant women or former foster care youth). Due to the economic downturn, fewer enrollees are likely to see income increase, meaning they would remain eligible for Medicaid irrespective of the MOE. States anticipate that groups more sensitive to changes in economic conditions (e.g., children, parents, and other expansion adults) will grow faster than the elderly and people with disabilities; however, an aging state population was also identified as a key factor driving enrollment in almost half for reporting states. In last year’s survey, states tied declines in enrollment growth prior to the pandemic to a more robust economy, but also to process and systems changes including changes to renewal processes, upgraded eligibility systems, and enhanced data matching efforts to verify eligibility.

Trends in Spending Growth FY 2020 and FY 2021

Among reporting states, growth in total Medicaid spending was 6.3% in FY 2020, but is expected to jump to 8.4% in FY 2021 (Figure 1). High rates of enrollment growth, tied first to the Great Recession and later to the implementation of the ACA, were the primary drivers of total Medicaid spending growth over the last decade. Similarly, declining enrollment driven by a strong economy was the primary driver identified by states for slow total Medicaid spending growth in FY 2019. Even though enrollment growth was nearly flat in FY 2020, spending was in line with median spending growth over the last two decades. In last year’s survey, Medicaid officials indicated growth in total Medicaid expenditures for FY 2020 was largely tied to increasing costs for prescription drugs (particularly for specialty drugs), rate increases (most often for managed care organizations, hospitals, and nursing facilities), overall medical inflation, pressures from an aging state population, and a higher acuity case-mix.

For FY 2021, nearly all states expect enrollment increases to put upward pressure on total Medicaid expenditure growth, with additional upward pressure coming from spending on long-term services and supports and provider rate changes. Further, about three-quarters of states noted that utilization was a factor for Medicaid spending: slightly more than half of these states identified utilization as an upward pressure on projected spending while the remaining states indicated utilization was expected to be a downward pressure (likely due to pandemic-related utilization reductions). Overall, while many reporting states were uncertain or thought that the chance of a Medicaid budget shortfall was “50-50,” more states anticipated that a budget shortfall was “likely” or “almost certain” compared to “unlikely”; so, it is possible that current expenditure growth projections could be lower than what states actually experience.

Estimates that state Medicaid spending would decline in FY 2020 (-0.5%) and then sharply increase in FY 2021 (12.2%) were made prior to the most recent renewal of the PHE that extends the enhanced FMAP through March 2021 (Figure 2). The enhanced FMAP under FFCRA was retroactive to January 1, 2020 (halfway through most state fiscal years). The fiscal relief expires at the end of the quarter in which the Public Health Emergency (PHE) ends. On October 2, 2020 the PHE was extended from October 23, 2020 to January 21, 2021, leaving the enhanced FMAP in place through March 2021. However, states adopted budgets for FY 2021 prior to the most recent extension of the PHE, with most states anticipating that the enhanced FMAP would end by December 2020 or before. The anticipated expiration of the enhanced FMAP in 2020 along with overall increases in base Medicaid spending expected in FY 2021 resulted in a spike in projected state spending.

Nearly all reporting states indicated that federal fiscal relief is being used to support costs related to increased Medicaid enrollment and to help address Medicaid or general budget shortfalls. About two-thirds of reporting states said the fiscal relief is also being used to mitigate provider rate and/or benefit cuts. The state share of Medicaid spending typically grows at a similar rate as total Medicaid spending growth, unless there is a change in the federal matching rate. During the Great Recession, state spending for Medicaid declined in FY 2009 and FY 2010 due to fiscal relief from a temporary increase in the federal match rate provided in the American Recovery and Reinvestment Act (ARRA). State spending increased sharply when that fiscal relief ended. In other economic downturns (including the Great Recession), states typically turn to provider rate and benefit restrictions to reduce Medicaid spending, however, with providers facing revenue shortfalls and enrollees facing increased health risks due to the pandemic, these methods to control costs may not be as viable.

Conclusion and Looking Ahead

States are faced with many layers of uncertainty about the trajectory of the pandemic and economic downturn. Several states had adopted temporary budgets or continuing resolutions to start FY 2021, while other states noted FY 2021 state budgets had not yet been enacted. Some states planned to convene special sessions to make budget adjustments and noted further FY 2021 budget reductions were planned or likely. Unlike the federal government, states must meet balanced budget requirements. In the face of major revenue shortfalls due to the economic effects of the pandemic, states can use reserves or cut spending if additional federal support is not available. To reduce spending during economic downturns, states typically turn to provider rate and benefit restrictions, however, with providers facing revenue shortfalls and enrollees facing increasing health risks due to the pandemic, these methods to control costs may not be as viable. For now, states cannot restrict enrollment and must provide continuous coverage for current enrollees to access the enhanced Medicaid match rate in the FFCRA.

Looking ahead, states are also unsure about the duration of the PHE and the enhanced FMAP, whether Congress will consider additional fiscal relief, and the outcome of the elections. It is unclear if the PHE will be extended beyond the January 21, 2021. States have called for and the House passed legislation to increase the amount and duration of this federal fiscal relief, but to date the Senate has not considered these provisions. In addition, the US presidential election in November could have major implications for Medicaid, with a sharp contrast in goals for Medicaid and the ACA between President Trump and former Vice President Biden. Beyond the presidential election, the outcome of state elections (both governors and the make-up of state legislatures) will be important to watch.

Appendix

Medicaid Financing Structure. The federal government jointly funds the Medicaid program with states by matching qualifying state Medicaid expenditures. The federal match rate (known as the Federal Medical Assistance percentage, or FMAP) is calculated annually for each state using a statutory formula based on a state’s average personal income relative to the national average which results in higher FMAP rates for poorer states. The FMAP formula relies on three years of lagged personal income data, so data for federal fiscal years (FFYs) 2017 to 2019 was used to calculate FFY 2021 FMAP rates, which range from a floor of 50% (applicable to 13 states) to a high of 78% (for Mississippi). Because of the federal matching structure, Medicaid is both a state budget expenditure item and a source of federal revenue for states. In FY 2018 (the latest year of actual data), Medicaid accounted for 29.2% of total state spending, but 16.7% of state funds (general fund plus other state funds), a far second to spending on K-12 education (25.1% of state funds). Medicaid is the largest single source of federal funds for states, accounting for over half (57.9%) of all federal funds received by states (Figure 3).

Medicaid and the Economy. Medicaid is a countercyclical program. During economic downturns, more people qualify and enroll in Medicaid, increasing program spending at the same time that state tax revenues may be stagnating or falling. Prior to the current pandemic, to mitigate these budget pressures, Congress had twice passed temporary FMAP increases to help support states during economic downturns, most recently in 2009 as part of the American Recovery and Reinvestment Act (ARRA). The ARRA-enhanced FMAP rates provided states over $100 billion in additional federal funds over 11 quarters, ending in June 2011.⁵ 

Medicaid and the ACA. Effective January 1, 2014, the ACA expanded Medicaid eligibility to millions of non-elderly adults with income at or below 138% of the federal poverty level (FPL) –$17,609 per year for an individual in 2020.⁶  The law also provided 100% federal funding for expansion adults through 2016, phasing down to 90% in 2020 and future years. The June 2012 Supreme Court ruling on the ACA effectively made the Medicaid expansion optional for states; as of October 2020, 39 states (including DC) had adopted the expansion, including Missouri and Oklahoma, which have adopted the expansion through ballot measures and plan to implement in state fiscal year 2022.

1. State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and District of Columbia on October 1. ↩︎
2. The eight states that did not respond by mid-August 2020 are: Delaware, District of Columbia, Illinois, Ohio, New Mexico, New York, Rhode Island, and Utah. ↩︎
3. U.S. Centers for Medicare & Medicaid Services (CMS). National Health Expenditure Data Fact Sheet: Table 4, National Health Expenditures by Source of Funds and Type of Expenditure: Calendar Years 2011-2018 (CMS, March 2020), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html. ↩︎
4. National Association of State Budget Officer, States Work to Finalize Fiscal 2021 Budgets, Budget Blog, Updated August 4, 2020, http://budgetblog.nasbo.org/budgetblogs/blogs/brian-sigritz/2020/06/26/states-work-to-finalize-fiscal-2021-budgets-update. ↩︎
5. To be eligible for ARRA funds, states could not restrict eligibility or tighten enrollment procedures in Medicaid or CHIP. Vic Miller, Impact of the Medicaid Fiscal Relief Provisions in the American Recovery and Reinvestment Act (ARRA) (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2011), http://kff.org/medicaid/issue-brief/impact-of-the-medicaid-fiscal-relief-provisions/. ↩︎
6. U.S. Department of Health & Human Services, Office of the Assistant Secretary for Planning and Evaluation. U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs (January 2020), https://aspe.hhs.gov/poverty-guidelines ↩︎

The coronavirus pandemic has generated both a public health crisis and an economic crisis, with major implications for Medicaid, a countercyclical program. During economic downturns, more people enroll in Medicaid, increasing program spending at the same time state tax revenues may be falling. As demand increases and state revenues decline, states face difficult budget decisions to meet balanced budget requirements. To help both support Medicaid and provide broad fiscal relief, the Families First Coronavirus Response Act (FFCRA)¹  authorized a 6.2 percentage point increase in the federal match rate (“FMAP”)²  (retroactive to January 1, 2020) available if states meet certain “maintenance of eligibility” (MOE) requirements.³  The fiscal relief is in place until the end of the quarter in which the Public Health Emergency (PHE) ends. The current PHE is in effect through January 21, 2021 which means the enhanced FMAP is slated to expire at the end of March 2021 unless the PHE is renewed.⁴ 

States ended state fiscal year (FY) 2020 and adopted budgets and policies for FY 2021, which began on July 1 for most states⁵ , while faced with uncertainty about the pandemic, the economy, and the duration of the PHE. This report examines Medicaid policy trends with a focus on planned changes for FY 2021 based on data provided by state Medicaid directors as part of the 20th annual survey of Medicaid directors in all 50 states and the District of Columbia. Unlike previous years, the survey instrument was modified to primarily collect information about policy changes planned for FY 2021, especially policies related to responding to the pandemic. Overall, 43 states⁶  responded to the survey by mid-August 2020, although response rates for specific questions varied. Key findings suggest that most policy changes and issues identified for FY 2021 were related to responding to the COVID-19 PHE (Figure 1).

Eligibility and Enrollment

As part of the federal response to the COVID-19 pandemic, states meeting certain “maintenance of eligibility” (MOE) conditions can access enhanced federal Medicaid funding.⁷  In addition to meeting the MOE requirements,⁸  some states are utilizing Medicaid emergency authorities to adopt an array of actions to help people obtain and maintain coverage.⁹  While many states remained undecided, five states reported plans to continue COVID-19 related changes to eligibility and enrollment policies after the PHE ends, such as allowing self-attestation of certain eligibility criteria. States reported a variety of outreach efforts to publicize COVID-19 related eligibility and enrollment changes, and 10 states reported expanding enrollment assistance or member call center capacity during the PHE. At the time of survey submission, thirteen states had an approved State Plan Amendment (SPA) in place for the new Uninsured Coronavirus Testing group;¹⁰  however, this option that allows states to access a 100% federal match rate for coronavirus diagnostic testing expires at the end of the PHE.

Non-emergency eligibility changes were limited, except for plans to implement the Medicaid expansion. To date, 39 states (including DC) have adopted the ACA Medicaid expansion.¹¹  Of these, 37 states have implemented expansion coverage (including Idaho and Utah, which both implemented the expansion on January 1, 2020, and Nebraska, which implemented the expansion as of October 1, 2020). Two additional states, Missouri and Oklahoma, will implement the expansion in FY 2022 as a result of successful Medicaid expansion ballot initiatives. Six states reported plans to implement more narrow eligibility expansions. Only a few states reported planned eligibility restrictions or plans to simplify enrollment processes in FY 2021.

Provider Rates and Taxes

The COVID-19 pandemic has resulted in financial strain for Medicaid providers, so unlike in prior economic downturns more states are implementing policies to provide targeted support to providers rather than rate cuts. At the time of the survey, more responding states implemented or were planning fee-for-service (FFS) rate increases relative to rate restrictions in both FY 2020 and FY 2021. More than half of responding states indicated that one or more payment changes made in FY 2020 or FY 2021 were related in whole or in part to COVID-19. Many states adopted FFS payment changes in FY 2020 and/or planned to make changes in FY 2021 to provide additional relief to providers in response to the PHE. Still, three states have cut provider rates across all or nearly all provider categories and other states have indicated rate freezes or reductions were likely. Historically, states tend to increase or impose new provider taxes during economic downturns; however, only one state reported the addition of a new provider tax in FY 2021 and few states reported making significant changes to their provider tax structure in FY 2021. Impacts of COVID-19 on provider tax collections and provider rates are still emerging.

Nearly half of states reported that federal provider relief funds were not adequate for Medicaid providers, while other states did not know at the time of the survey. The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act provide $175 billion in provider relief funds to reimburse eligible health care providers for health care related expenses or lost revenues that are attributable to the pandemic.¹²  Almost half of states responding to the survey reported that relief funds under the CARES Act have not been adequate to address the negative impact of COVID-19 faced by providers serving a high share of Medicaid and low-income patients.

Delivery Systems

Since nearly seven in ten Medicaid enrollees nationwide receive comprehensive acute care services (i.e., most hospital and physician services) through capitated managed care organizations (MCOs), these plans have played a critical role in responding to the COVID-19 pandemic.¹³  Twelve MCO states (of 31 responding) indicated plans to make adjustments to FY 2021 MCO contracts or rates in response to both COVID-related depressed utilization and unanticipated treatment costs. Fourteen MCO states (of 32 responding) reported implementing directed payments to selected provider types in response to the COVID-19 pandemic. MCO states reported a variety of programs, initiatives, or “value-added” services newly offered by MCOs in response to the PHE. Beyond addressing pandemic-related issues, twelve states in FY 2020 and seven in FY 2021 reported notable changes in the benefits and services covered under their MCO contracts.

The pandemic has elevated the importance of addressing social determinants of health (SDOH)¹⁴  to improve health and reduce longstanding disparities in health and health care. Nearly two-thirds of responding states reported implementation, expansion, or reform of a program or initiative to address Medicaid enrollees’ SDOH in response to COVID-19 (27 states).

Long-Term Services and Supports

The majority of responding states reported concerns about the pandemic’s impact on the long-term services and supports (LTSS) direct care workforce supply as well as concerns about access to personal protective equipment (PPE), access to COVID-19 testing, and risk of COVID-19 infections for LTSS direct care workers. Medicaid is the nation’s primary payer for LTSS.¹⁵  As the pandemic continues, states have taken a number of Medicaid policy actions to address the impact on seniors and people with disabilities who rely on LTSS to meet daily self-care and independent living needs.¹⁶  States noted plans to retain a variety of LTSS policy changes adopted in response to COVID-19 after the PHE period ends, most commonly citing the continuation of HCBS telehealth expansions.

Benefits, Cost-Sharing, and Telehealth

The majority of states added or expanded telehealth access in response to the pandemic, and many states plan to extend these and/or other benefit and cost-sharing changes beyond the PHE period. The majority of responding states report currently covering a range of FFS services delivered via telehealth when the originating site is the beneficiary’s home, most of which newly added or expanded this coverage in response to the COVID-19 pandemic. Most states reported that services delivered via telehealth from the beneficiary’s home have payment parity as compared to services delivered face-to-face, and just over half of states planned to extend newly added/expanded FFS telehealth coverage beyond the PHE period, at least in part and at least for some services. Approximately one-third of responding states noted plans to extend other benefit and cost-sharing changes adopted during the PHE period (15 states); most of these are pharmacy changes. Prior to the COVID-19 pandemic, state changes to Medicaid benefits most commonly pertained to enhanced mental health and substance use disorder (SUD) services.¹⁷  Less than one-third of responding states reported plans to make benefit or cost-sharing changes that are not related to the PHE in FY 2021 (13 states).

Prescription Drugs

States continued to adopt pharmacy program cost containment strategies despite the COVID-19 emergency and other competing priorities. Managing the Medicaid prescription drug benefit and pharmacy expenditures remains a policy priority for state Medicaid programs, and state policymakers remain concerned about Medicaid prescription drug spending growth. Thirty-three responding states reported plans to newly implement or expand upon at least one initiative to contain prescription drug costs in FY 2021.

Challenges and Priorities

Nearly all states reported significant adverse economic and state budgetary impacts driven by the pandemic, as well as uncertainty about the future. In the face of the COVID-19 pandemic, states continue to encounter challenges to provide Medicaid coverage and access for a growing number of Americans, while also facing plummeting revenues and deepening state budget gaps. State Medicaid officials highlighted swift and effective state responses to the pandemic, such as the rapid expansion of telehealth, as well as ongoing efforts to advance delivery system reforms and to address health disparities and other public health challenges. In these ways, the pandemic has demonstrated how Medicaid can quickly evolve to address the nation’s most pressing health care challenges. However, the ability of states to sustain policies adopted in response to the pandemic (including through emergency authorities) may be tied to the duration of the PHE as well as the availability of additional federal fiscal relief and support. Looking ahead, great uncertainty remains regarding the future course of the pandemic, the scope and length of federal fiscal relief efforts, and what the “new normal” will be in terms of service provision and demand. Results of the November 2020 elections could also have significant implications for the direction of federal Medicaid policy in the years ahead.

Like all other aspects of the American health landscape, the COVID-19 pandemic and subsequent public health emergency (PHE) declaration¹⁸  have dramatically impacted state Medicaid programs, requiring states to rapidly adapt to meet the changing needs of their Medicaid beneficiaries and providers. Nationwide, Medicaid provides health insurance coverage to about one in five Americans¹⁹  and accounts for nearly one-sixth of all U.S. health care expenditures.²⁰  Prior to the pandemic, the Medicaid program had a history of constantly evolving to react to changes in federal and state policies, the economy, and other state budget and policy priorities. The current pandemic, however, has generated both a public health crisis and an economic crisis with increased unemployment, which contributes to growth in Medicaid enrollment and spending at the same time state tax revenues may be falling.

In response to the pandemic, Congress has authorized changes to Medicaid through the Families First Coronavirus Response Act (FFCRA)²¹  and Coronavirus Aid, Relief, and Economic Security (CARES) Act,²²  including a 6.2 percentage point increase in federal Medicaid matching funds (FMAP) (retroactive to January 1, 2020) available to states that meet five “maintenance of eligibility” (MOE) conditions that ensure continued coverage for current enrollees as well as coverage of coronavirus testing and treatment.²³  This fiscal relief is in place until the end of the quarter in which the PHE ends, which means it is currently slated to expire at the end of March 2021. Beginning early in the pandemic, states have adopted Medicaid policies to respond to COVID-19 through a variety of emergency authorities (Disaster-Relief State Plan Amendments (SPAs), traditional SPAs, other administrative authorities, HCBS waiver Appendix K, Section 1115 demonstration waivers, and Section 1135 waivers).²⁴  The beginning and end dates for these actions vary by authority and many are tied to the PHE.²⁵ 

This report draws upon findings from the 20th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by KFF and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). (Previous reports are archived here.²⁶ ) This year’s survey instrument was modified to focus on policy changes planned for FY 2021 and policies adopted in response to the pandemic, and was sent to each state Medicaid director in June 2020. Overall, 43 states²⁷  responded by mid-August 2020, although response rates for specific questions varied. 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.

This report highlights policy changes in place or planned for FY 2021 (which began for most states on July 1, 2020).²⁸  Key findings, along with state-by-state tables, are included in the following sections:

• Eligibility and Enrollment
• Provider Rates and Taxes
• Delivery Systems
• Long-Term Services and Supports
• Benefits, Cost-Sharing, and Telehealth
• Pharmacy Cost Containment Actions
• Challenges and Priorities in FY 2021 and Beyond Reported by Medicaid Directors

As part of the federal response to the COVID-19 pandemic, states meeting certain “maintenance of eligibility” (MOE) conditions can access enhanced federal Medicaid funding. The Families First Coronavirus Response Act,²⁹  amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act,³⁰  authorizes a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”)³¹  (retroactive to January 1, 2020) through the end of the quarter in which the public health emergency ends. To qualify for the enhanced funds, states must ensure continued coverage for current enrollees and are prohibited from increasing premiums or making eligibility standards, methodologies, or procedures more restrictive than those in effect on January 1, 2020, among other requirements.³² 

The MOE requirements³³  contribute to enrollment increases³⁴  by eliminating the usual enrollment churn that occurs when some individuals lose eligibility and are dis-enrolled from Medicaid each month. In the past, some eligibility churn occurred when otherwise eligible individuals lost coverage because they encountered barriers preventing them from timely documenting continued eligibility during the eligibility renewal process or when states conducted periodic data matches between renewals.³⁵  Prior to the pandemic, these types of barriers were potentially depressing overall Medicaid enrollment levels.³⁶ 

In addition to the MOE requirements, some states are utilizing Medicaid emergency authorities to take other actions to help people obtain and maintain coverage. These include actions to expand eligibility and make it easier to apply such as allowing for self-attestation of eligibility criteria; eliminating premiums; expanding the use of presumptive eligibility; and otherwise simplifying application processes.³⁷  The beginning and ending dates of these policies vary by authority³⁸  and many will expire with the end of the public health emergency (PHE) declaration (currently set for January 21, 2020).³⁹ 

Survey Findings

We asked states to report any non-emergency eligibility changes planned for FY 2021, including eligibility expansions, eligibility restrictions, and changes to enrollment processes. We also asked about changes to eligibility policies made in response to the COVID-19 pandemic and, specifically, whether states planned to adopt these changes on a more permanent basis. Finally, we asked states to report on outreach efforts to publicize COVID-19 related eligibility changes and/or the availability of Medicaid coverage following the economic downturn.

Non-Emergency Eligibility Changes

Seven states reported non-emergency plans to expand eligibility in FY 2021. As of October 2020, 39 states (including DC) have adopted the ACA Medicaid expansion (Figure 1).⁴⁰  Of these, 37 states to date have implemented expansion coverage to 138% FPL ($17,609 per year for an individual in 2020),⁴¹ ) including Idaho and Utah, which both implemented the expansion on January 1, 2020 (FY 2020), and Nebraska, which implemented on October 1, 2020 (FY 2021). Two additional states, Oklahoma and Missouri, will implement the expansion in FY 2022 as a result of successful Medicaid expansion ballot initiatives.

• Nebraska implemented the expansion on October 1, 2020 (FY 2021) pursuant to a ballot measure passed in November 2018. The state is currently seeking a Section 1115 waiver to implement its expansion with program elements that differ from what is allowed under federal law.
• Oklahoma voters approved a ballot measure on June 30, 2020 which adds Medicaid expansion to the state’s constitution and requires coverage to begin no later than July 1, 2021. The ballot measure language also prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population. The Oklahoma Health Care Authority intended to submit the necessary State Plan Amendments (SPAs) for expansion by September 30, 2020 with an effective date of July 1, 2021 (FY 2022).⁴² 
• Missouri voters similarly approved a ballot measure on August 4, 2020 which adds the expansion to the state’s constitution with coverage to begin July 1, 2021 (FY 2022). Like Oklahoma’s, Missouri’s approved ballot measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.

Six states reported plans to implement the following more narrow eligibility expansions in FY 2021. These other expansions include the following:

• Expanding coverage for parent/caretaker relatives and other low-income adults. One non-expansion state (South Carolina) has an approved Section 1115 waiver and plans to increase the income limit for parent/caretaker relative enrollees from 67% to 100% FPL and also to provide coverage with an enrollment cap for a new Targeted Adult group. Both expansions of eligibility are contingent on compliance with a work requirement. As a result of both the pandemic and litigation,⁴³  no states are currently implementing approved work requirements.⁴⁴ 
• Expanding coverage for postpartum women. Two states are expanding coverage for postpartum women beyond the 60 days provided under federal rules: Pending waiver approval, Georgia and New Jersey are extending to six months.⁴⁵  (Additionally, Indiana reported plans to extend postpartum coverage to one year beginning in FY 2022.)
• Expanding coverage for certain older adults and people with disabilities. California is expanding income eligibility for the optional aged, blind, and disabled (ABD) population from 100% to 138% FPL and also creating a new ABD income disregard in the amount of the individual’s Medicare Part B premium (which is paid by Medicaid). The new disregard in California is expected to allow individuals to retain eligibility in the ABD pathway and reduce churn between the ABD and medically needy with share of costs pathways and administrative burden. New Hampshire reported plans to implement its “Medicaid for Employed Older Adults with Disabilities” program, which will expand Medicaid buy-in coverage for working people with disabilities to include those ages 65 and older with incomes up to 250% FPL. (New Hampshire already covers working people with disabilities ages 18 to 64 up to 250% FPL.) Louisiana is expanding HCBS waiver coverage for children with significant disabilities without regard to household income and assets for children who live at home but would otherwise qualify for institutional placement in a hospital, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities.

Only two states reported a planned eligibility restriction in FY 2021 after the expiration of the PHE. Missouri reported that scheduled premium increases would go forward after the PHE ended and Montana reported plans to implement a community engagement/work requirement and premium changes for expansion adults pending CMS approval of the state’s Section 1115 waiver renewal.

Although not counted as an eligibility expansion or a restriction for purposes of this survey, Texas reported that it would implement changes (including applying modified adjusted gross income (MAGI) financial eligibility methodologies to individuals eligible for family planning-only services) to its Healthy Texas Women (HTW) Section 1115 waiver program as required under the waiver’s January 2020 approval from CMS.⁴⁶  The approved HTW waiver extended eligibility for family planning services to women age 18-44 up to 200% FPL not otherwise eligible for Medicaid and allowed Texas to waive non-emergency medical transportation (NEMT); retroactive eligibility; early and periodic screening, diagnostic, and treatment (EPSDT) coverage; and freedom of choice of provider for family planning services.

Two states reported non-emergency plans to simplify enrollment processes in FY 2021. Montana reported plans to implement an auto-renewal process for non-MAGI eligibility groups and Virginia reported plans to expand ex parte auto-renewals when individuals experience changes such as reaching the end of their postpartum coverage period or attaining an age requiring evaluation in other covered groups. While Virginia did not characterize this change as the extension of an emergency authority, the state did note that the proposed changes are intended to reduce caseworker caseloads when the PHE period ends.

Eligibility Changes in Response to COVID-19

Only five states⁴⁷  reported plans to continue COVID-19 emergency changes related to eligibility and enrollment policies beyond the PHE period. One state (Vermont) noted that a variety of certain emergency flexibilities would likely extend beyond the PHE period due to the time required to re-implement prior policies. A few states reported specific plans for the continuation of policies to simplify/expedite enrollment processes:

• Massachusetts intends to continue allowing self-attestation of all eligibility criteria except for citizenship and immigration status.
• Washington is working to adopt self-attestation of income and resources for aged, blind, and disabled (ABD) populations. Washington also reported working to adopt hospital presumptive eligibility for ABD populations and post-enrollment verification of assets for ABD populations.
• Arizona indicated that it would continue allowing electronic signatures on eligibility documents for its long-term care program (institutional and HCBS).
• Virginia intends to continue allowing applicants and enrollees to verbally appoint/authorize assisters, advocates, and other individuals.

Another 12 states reported that the continuation of emergency eligibility and enrollment policies remained undetermined. Indiana and Louisiana reported that more time could be needed to re-implement their prior policies; Missouri indicated that it may continue to allow self-attestation of most eligibility factors for ABD and MAGI populations; and a few states (West Virginia, Kansas, and Missouri) reported potential plans to further extend renewal timelines.⁴⁸ 

At the time of survey completion, thirteen states had approved State Plan Amendments (SPAs) in place for the new Uninsured Coronavirus Testing group at the time of survey submission. This new optional eligibility pathway provides 100% federal matching funds for states to cover coronavirus testing and testing-related services for uninsured individuals through the end of the PHE. ⁴⁹  In addition to this option, providers can alternatively obtain reimbursement for coronavirus testing and treatment provided to uninsured individuals from additional federal funds through the Health Resources and Services Administration.⁵⁰  One state (California) reported covering a significant number of persons under its Uninsured Coronavirus Testing group as of June 30, 2020 (6,390). All other states reported more modest enrollments: Colorado, Louisiana, and Minnesota reported covering between 50 and 450 individuals and Maine reported covering approximately 850 individuals. Other states that had adopted the option (including Alabama, Iowa, Montana, Nevada, New Hampshire, South Carolina, and West Virginia) reported between zero and 50 persons covered and Washington has an approved SPA for this group but did not report the number of individuals covered. Since the time of survey submission, two additional responding states (Connecticut and North Carolina) have received SPA approvals for this group.⁵¹ 

States reported a variety of outreach efforts to publicize COVID-19 related eligibility and enrollment changes, and ten states reported expanding enrollment assistance or member call center capacity during the PHE. Most states reported using their websites and social media platforms to provide COVID-19 related enrollment information. Many states also cited working with provider groups and advocacy organizations to disseminate information in addition to direct mailings to members and applicants and provider notices and alerts. A few states also commented on their managed care organizations’ (MCO) outreach efforts. Additionally, ten states (California, Florida, Indiana, Kentucky, Maryland, Missouri, Nebraska, South Carolina, Texas, and Virginia) reported expanding enrollment assistance or member call center capacity. Very few states reported experiencing application processing delays due to COVID-19 at the time of survey completion.

The coronavirus pandemic has resulted in financial strain for Medicaid providers. In prior economic downturns, states have typically resorted to provider rate reductions as well as cuts to optional benefits, restoring those rates and benefits when economic conditions improved.⁵²  Provider rate cuts may be harder to implement during the current downturn, however, due to the fiscal strain the pandemic has placed on many providers, particularly those serving Medicaid enrollees. While some providers are dealing with both increased utilization and costs related to COVID-19 testing and treatment, others have experienced substantial revenue losses as utilization has declined for non-urgent care. Providers that predominantly serve Medicaid enrollees and/or deliver services primarily financed by Medicaid, such as behavioral health or long-term care providers, may face disproportionate risks to their continued financial viability as their pre-pandemic operating margins were already modest due to lower Medicaid reimbursement levels relative to costs. To address the current fiscal challenges faced by providers, states have implemented various options to support providers⁵³  directly or by directing plans to do so. ^54 ,55 

The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act provide $175 billion in provider relief funds to reimburse eligible health care providers for health care related expenses or lost revenues attributable to coronavirus.⁵⁶  Specifically, funds are available for building or constructing temporary structures, leasing properties, medical supplies and equipment including personal protective equipment (PPE) and testing supplies, increased workforce and trainings, emergency operation centers, retrofitting facilities, and surge capacity. In June 2020, CMS announced the allocation of $15 billion in provider relief funds specifically for Medicaid/CHIP providers that were not funded in a prior distribution to Medicare fee-for-service providers, addressing concerns that Medicaid providers had been disadvantaged in prior distributions, both in the amount and timing of funding received.⁵⁷ 

States can use provider taxes and intergovernmental transfers (IGTs) to help finance the state share of Medicaid.⁵⁸  Over time, states have increased their reliance on provider taxes, especially during economic downturns.⁵⁹  States also have some flexibility to use funding from local governments to help finance the state share of Medicaid. All states (except Alaska) have at least one provider tax in place and many states have more than three.⁶⁰  On September 14, 2020, CMS withdrew the proposed Medicaid Fiscal Accountability Regulation, providing at least some stability for states with one or more provider taxes at risk under the proposed rule.

Survey Findings

Provider Rates

This survey examines rate changes across major provider categories: inpatient hospitals, outpatient hospitals, nursing facilities, primary care physicians, specialists, obstetricians and gynecologists (OB/GYNs), dentists, and home and community-based services (HCBS) providers. States were asked to report aggregate rate changes for each provider category in their fee-for-service (FFS) programs and whether these or other payment changes (e.g., retainer payments, interim payments) were adopted in response to the COVID-19 emergency. States were also asked to describe whether provider relief funds made available under the CARES Act were adequate.

At the time of the survey, more responding states implemented or were planning FFS rate increases relative to rate restrictions in both FY 2020 and FY 2021 (Tables 1 and 2). Out of the 43 states responding to this year’s survey, 41 states reported implementing rate increases for at least one category of provider in FY 2020 and 17 states reported implementing rate restrictions in FY 2020. In FY 2021, fewer states reported at least one planned rate increase (35 states) and the number of states planning to restrict rates increased (21 states). Most of the rate restrictions are freezes in rates for inpatient hospitals and nursing facilities that are counted as restrictions. Three states (Colorado, Nevada, and Wyoming) reported rate reductions across all or nearly all provider categories. These reductions were related to the states’ budget shortfalls for FY 2021. Six of the responding states did not report payment changes planned for FY 2021 in one or more categories of providers, but two of these states identified that rate freezes or reductions were likely pending final budget negotiations.

More than half of the responding states indicated that one or more payment changes made in FY 2020 or FY 2021 are related in whole or in part to COVID-19. Twenty-four out of the 43 responding states indicated that one or more provider rate changes implemented in FY 2020 and/or FY 2021 were related to COVID-19 at least in part. COVID-19 related payment changes were most commonly associated with nursing facilities (20 states) and HCBS providers (18 states) followed by inpatient hospital services (11 states).

At the time of the survey, many states adopted FFS payment changes in FY 2020 and/or are planning to make changes in FY 2021 to provide additional relief to providers in response to the COVID-19 emergency. These changes include increasing payment rates (per diem or percentage rate increases) and providing retainer payments, directed payments, or interim payments to certain provider types. Additional payments in some states are associated with facilities, services, or patients with a COVID-19 diagnosis (California, Florida, Indiana, Louisiana, Kentucky, Massachusetts, and Michigan).

At least 16 states have instituted retainer payments for HCBS providers⁶¹  and 19 states are providing rate increases, interim payments, or add-on payments to nursing facilities and other long-term care facilities.⁶²  A few states did not specifically update long-term care facility rates in response to COVID-19 but describe that their cost-based reimbursement systems improve payment due to inflation or COVID-19 related expenses. Other examples of COVID-19 related payment changes across state Medicaid programs include:

• Alaska adjusted its pharmacy reimbursement methodology and professional dispensing fees to address drug shortages, social distancing and increases in prescription drug deliveries.
• California and Louisiana are reimbursing COVID-19 related lab services at 100% of the Medicare payment rate.
• Oklahoma waived hospital penalties related to potential preventable readmissions and is allowing additional therapeutic leave days for certain long-term care facilities.
• Indiana and Washington increased payment rates for emergency medical service providers (EMS) and ambulance providers for transporting COVID-19 positive patients.
• Kentucky and West Virginia increased inpatient reimbursement for Diagnosis Related Groups (DRGs) with a COVID-19 diagnosis by 20%.
• Michigan increased the FFS rate for personal care services by $2/hour.

Almost half of states responding to the survey reported that relief funds under the CARES Act have not been adequate to address the negative impact of COVID-19 faced by providers serving a high share of Medicaid and low-income patients while others were uncertain. About half of states reported that the provider relief funds were inadequate, while the other half of states reported they did not know. In the states that did not believe funding was adequate, dental providers, long-term care facilities, HCBS providers, primary care providers, behavioral health providers, and non-emergency transportation were the most often cited provider types needing relief or additional funding. Many of these provider types are dependent on Medicaid reimbursement. States also explained that providers faced challenges in understanding whether they qualified for funding, resulting in missed opportunities for qualified providers. A few states noted that the funding methodology potentially disadvantaged Medicaid providers who did not serve a large Medicare patient population and that limiting relief to the 2% of net patient revenue may not be sufficient for some providers or to offset losses.

Provider Taxes

States were asked to report any provider tax changes in FY 2021. States were also asked to report any impacts related to COVID-19 on tax collections.

Only one state reported the addition of a new provider tax in FY 2021. Arizona added a new hospital tax on outpatient services in FY 2021 to raise additional money for its Medicaid program. However, two states (Hawaii and Wyoming) reported that they are investigating opportunities to add new provider taxes, or increase existing provider taxes, to address expected shortfalls related to COVID-19’s negative impact on the economy and available state general funds.

Few states reported making significant changes to the provider tax structure in FY 2021. Nine states reported planned increases to one or more provider taxes (Alabama, California, Colorado, Georgia, Hawaii, Idaho, Louisiana, Missouri, and New Jersey) in FY 2021, while four states reported provider tax decreases (Maryland, North Carolina, Oklahoma, and Pennsylvania). Montana reports that it is eliminating its provider tax for intermediate care facilities for individuals with intellectual disabilities (ICF-IDs) in FY 2021.

Impacts of COVID-19 on provider tax collections are still emerging. States were asked to describe any COVID-19 related impacts on provider tax collections anticipated in FY 2021. Some states anticipated no material impact, while a few states identified that the impact was yet to be determined. For states that reported a change in provider tax collections related to COVID-19, the impact was mixed and varied by the type of provider tax and the state. For example, Washington noted that the number of nursing facility bed days was on the decline, resulting in reduced revenue attributed to its Safety Net Assessment fee, while California observed an increase in nursing facility and ICF-ID provider tax collections due to corresponding rate increases for these providers. States noted that COVID-19 impacted provider tax collections in other ways, with providers in some states receiving partial refunds (Oklahoma) or deferring payments (Connecticut). Vermont reported a decrease in provider tax revenue collection and delays in payment and is working with providers to develop repayment plans. At least one state increased its hospital provider tax to generate additional revenue and protect providers from further rate cuts (Colorado).

TABLE 1: PROVIDER RATE CHANGES IN ALL 50 STATES AND DC*, FY 2020

TABLE 2: PROVIDER RATE CHANGES IN ALL 50 STATES AND DC*, FY 2021

Managed Care

Capitated managed care remains the predominant delivery system for Medicaid in most states. As of July 2019, 40 states were contracting with comprehensive risk-based managed care organizations (MCOs).⁶³  MCOs provide comprehensive acute care (i.e., most physician and hospital services) and in some cases long-term services and supports (LTSS) to Medicaid beneficiaries. Among the 40 states with MCOs, 33 states reported that 75% or more of their Medicaid beneficiaries were enrolled in MCOs. As of July 1, 2019, 28 states were contracting with one or more limited benefit prepaid health plans (PHPs) to provide Medicaid benefits including behavioral health care, dental care, vision care, non-emergency medical transportation (NEMT), or LTSS. Twelve states reported operating a primary care case management (PCCM) program. PCCM is a managed fee-for-service (FFS) based system in which beneficiaries are enrolled with a primary care provider who is paid a small monthly fee to provide case management services in addition to primary care.

With 69% of Medicaid beneficiaries enrolled in MCOs nationally, MCOs play a critical role in responding to the COVID-19 pandemic and its fiscal implications for states.⁶⁴  Given unanticipated costs related to COVID-19 testing and treatment, as well as depressed utilization affecting the financial stability of many Medicaid providers, many states are currently evaluating options to adjust current MCO payment rates and/or risk sharing mechanisms.⁶⁵  CMS has outlined state options to modify managed care contracts and rates in response to COVID-19 including risk mitigation strategies, adjusting capitation rates, covering COVID-19 costs on a non-risk basis, and carving out costs related to COVID-19 from MCO contracts.⁶⁶  States can also direct that managed care plans make payments to their network providers (known as “state directed payments”) using methodologies approved by CMS to further state goals and priorities, including COVID-19 response.⁶⁷  States can therefore impose state directed payment requirements on MCOs to help mitigate the impacts of the PHE on providers that are experiencing decreased utilization and reimbursement while non-urgent services are suspended or patients are hesitant to seek care.

Survey Findings

On this year’s survey, states were asked to identify any acute care MCO policy changes in FY 2020 or planned for FY 2021, including changes to increase enrollment in MCOs or changes to the benefits or services carved-in or out of MCO contracts. States were also asked to describe any other managed care changes (e.g., implementing, expanding, reducing, or terminating a PCCM program or limited-benefit prepaid health plan (PHP)) made in FY 2020 or planned for FY 2021.

In response to the COVID-19 pandemic, states were also asked whether adjustments to FY 2021 MCO contracts or rates have been made or are planned in response to unanticipated COVID-19 related testing and treatment costs or depressed utilization and whether they have imposed or plan to impose new provider payment requirements on MCOs. Finally, states were asked to describe any other COVID-19 related MCO policy changes made in response to the pandemic and to identify any COVID-19 related initiatives newly offered by MCOs.

Non-Emergency Acute Care MCO Policy Changes

Reflecting nearly full MCO saturation in most MCO states, only three states reported changes to expand comprehensive managed care as a delivery system in FY 2020 or FY2021. In FY 2020, Pennsylvania implemented the third phase of Community HealthChoices (a program covering both acute care and LTSS for full benefit dual eligible beneficiaries and individuals receiving LTSS), to new geographic areas of the state, while West Virginia began mandatorily enrolling foster care youth into MCOs. In FY 2021, Nebraska reported plans to enroll all expansion adults into MCOs upon the implementation of its ACA Medicaid expansion in October 2020. North Carolina reported delays to its MCO implementation plans noting its new managed care contracts will be effective in FY 2022.

Although MCOs provide comprehensive services to beneficiaries, states may carve specific services out of MCO contracts to FFS systems or limited-benefit plans. Services frequently carved out include behavioral health, pharmacy, dental, and LTSS. However, there has been significant movement across states in recent years to carve these services in to MCOs.

Twelve states in FY 2020 and seven in FY 2021 reported notable changes in the benefits and services covered under their MCO contracts (Exhibit 1).

• Pharmacy drugs. The most frequently reported changes were to carve in or carve out one or more pharmacy drug products (especially high cost/specialty drugs). Two states reported carve-outs of the entire pharmacy benefit (North Dakota in FY 2020 and California in FY 2021) and Missouri reported plans to carve out outpatient hospital drugs in FY 2021 (in addition to other covered outpatient drugs which were already carved out and covered on a FFS basis). (See Pharmacy Cost Containment Actions section for more information on pharmacy changes.)
• Behavioral health services. Four states reported changes related to behavioral health services. In FY 2020, New Jersey added autism benefits; Washington carved in high intensity behavioral health benefits in three geographic regions, but also carved out out-of-state inpatient psychiatric services for children; Wisconsin added sub-acute psychiatric services as an in-lieu of benefit for the BadgerCare Plus population; and West Virginia added services authorized under its Substance Use Disorder (SUD) and Children with Serious Emotional Disorder (SED) waivers. In FY 2021, Oregon is adding care coordination for persons with severe and persistent mental illness (SPMI), children with SED, and individuals with SUD receiving medication assisted treatment (MAT).

Other Non-Emergency Managed Care Changes – PCCM & PHP

Four states reported making changes to their PCCM programs or limited benefit PHP programs. In FY 2020, Alabama replaced its previous PCCM program (Patient 1st) and Maternity PHP program with a new PCCM entity program (the Alabama Coordinated Health Network) that covers care coordination services for most of the traditional Medicaid population including maternity, family planning, behavioral, and physical health care coordination services. In FY 2020, Washington reported eliminating its remaining three regional behavioral health PHP contracts, which had been providing non-integrated behavioral health benefits. As a result, Washington MCOs now provide integrated physical health and behavioral health statewide. In FY 2021, Texas will expand from two to three dental MCOs and Louisiana will move from one to two. Also, Texas will eliminate its NEMT PHP while adding NEMT services to its MCO contracts.

COVID-19 Related MCO Policy Changes & MCO Initiatives

Twelve MCO states (of 31 responding) indicated plans to make payment adjustments to FY 2021 MCO contracts or rates in response to both COVID-19 related depressed utilization and unanticipated treatment costs (Exhibit 2). Sixteen states reported plans to make payment adjustments to FY 2021 MCO contracts or rates in response to COVID-19 related depressed utilization while 14 states reported plans to make payment adjustments in response to unanticipated COVID-19 related testing and treatment costs. Many states remained undetermined about adjustments to FY 2021 MCO contracts at the time of survey completion. COVID-19 related payment adjustments could include risk corridors, capitation rate adjustments (upward or downward), carve-outs, or covering costs on a non-risk basis.⁷⁰  States planning to make payment adjustments to FY 2021 MCO contracts were asked to describe the contract and/or rate adjustments planned. A majority of states described plans to implement or tighten risk corridors, often specifying two-sided risk corridors which aim to mitigate risk to both MCOs and states. In addition to adjustments planned for FY 2021 MCO contracts, several states also reported implementing retroactive risk mitigation and/or rate adjustment strategies for FY 2020 MCO contracts.⁷¹ 

Fourteen MCO states (of 32 responding) reported implementing directed payments to selected provider types in response to the COVID-19 pandemic. Under certain circumstances, federal regulations permit states to direct MCOs to make specific provider payments (“state directed payments”).⁷²  In response to the COVID-19 pandemic, 12 states in FY 2020 and three in FY 2021 reported implementing state directed payments (usually noted as temporary) for selected provided types (Exhibit 3). The most frequently identified provider type was for certain home and community-based services (HCBS) (8 states) followed by nursing facilities (5 states). Six of the eight states noting HCBS-related directed payments (Arizona, Florida, Iowa, Kansas, Massachusetts, and Tennessee) reported requiring MCOs to make retainer payments to allow certain HCBS providers to continue to bill for individuals when circumstances prevent these individuals from receiving these services.

MCO states reported a variety of other MCO policy changes implemented to respond to the COVID-19 pandemic. In many cases, MCO states reported that emergency authorities obtained by the states were applied to MCOs (see Introduction for more information on Medicaid emergency authorities). These include requirements to lift prior authorization requirements, waive cost sharing requirements, and relax certain provider credentialing requirements. Many MCO states also reported requiring MCOs to expand telehealth access, consistent with changes adopted for the FFS delivery system (see Benefits, Cost-Sharing, and Telehealth section for more information). Additional contract changes reported include:

• restructuring of provider incentive arrangements or suspension of provider performance penalties;
• changes to required MCO quality metric reporting and incentive programs;
• relaxation of certain reporting requirements;
• suspension of capitation withholds; and
• adjustments to the minimum medical loss ratio (MLR) requirement from a three-year standard to a one-year standard.

Massachusetts also directed its MCOs to contract with Community Support Program providers working in emergency overnight shelters that were expanded as a result of the pandemic.⁷³ 

MCO states reported a variety of programs, initiatives, or value-added services newly offered by MCOs in response to the COVID-19 emergency. Although federal reimbursement rules prohibit expenditures for most non-medical services, plans may use administrative savings or state funds to provide these services. “Value-added” services are extra services outside of covered contract services and do not qualify as a covered service for the purposes of capitation rate setting. The most frequently mentioned offerings and initiatives were food assistance and home delivered meals (11 states) and enhanced MCO care management and outreach efforts often targeting persons at high risk for COVID-19 infection or complications or persons testing positive for COVID-19 (8 states). Other examples include states reporting MCO provision of personal protective equipment (4 states), expanded MCO telehealth and remote supports (3 states), expanded pharmacy home deliveries (3 states), and MCO-provided gift cards for members to purchase food and other goods (2 states).⁷⁴  Texas, a state with a uniform preferred drug list (PDL) across FFS and its MCOs, reported coordinating with its MCOs to identify drug shortages to enable the state to adjust its formulary and uniform PDL accordingly.

Social Determinants of Health

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health.⁷⁵  Addressing SDOH is important for improving health and reducing longstanding disparities in health and health care. SDOH include but are not limited to housing, food, education, employment, healthy behaviors, transportation, and personal safety. Within the health care system, there are multi-payer federal and state initiatives as well as Medicaid-specific initiatives focused on addressing social needs. Although federal Medicaid reimbursement rules prohibit expenditures for most non-medical services,⁷⁶  states have been developing strategies to identify and address enrollee social needs both within and outside of managed care. Medicaid MCOs may use administrative savings or state funds to provide some of these services.⁷⁷ 

The pandemic has exacerbated the challenges for state Medicaid programs related to health care access and other SDOH and has shined a light on persistent health inequities and disparities due to the disparate impact of COVID-19 on people of color.⁷⁸  Access to food, for example, is one area of growing need as many people have lost jobs and income and many children have lost access to school-provided meals due to school closures. At the same time, community food resources are facing higher service demands. Among Medicaid adults, 23% reported food insufficiency in the week ending July 21, 2020.⁷⁹ 

SURVEY FINDINGS

Nearly two-thirds of responding states reported implementation, expansion, or reform of a program or initiative to address Medicaid enrollees’ SDOH in response to COVID-19 (27 states).⁸⁰  States were asked whether the COVID-19 emergency caused their state to implement, expand, or reform a program or initiative to address enrollees’ SDOH, particularly related to housing and/or food insecurity. States reported a variety of initiatives, including many initiatives which are broader than Medicaid but may help Medicaid enrollees. Sixteen states reported efforts to address food insecurity and nine states reported efforts to address housing insecurity and homelessness. Four states implemented or enhanced technology platforms and phone call-in lines that support assistance identifying community resources to address SDOH (Exhibit 4).

Examples of new initiatives or policies states reported related to SDOH implemented during the public health emergency (PHE) include:

• Food Insecurity. Arizona expanded home-delivered meals to people with intellectual and developmental disabilities (I/DD). Minnesota created the Food Security Work Group, an interagency governmental structure to strategize, share information and leverage funds. This group will work to support food banks; to support and expand access to SNAP and school meals; and to increase access to food for seniors, individuals in homeless shelters, and Native American Indians.⁸¹  Montana, through the state’s Senior and Long-Term Care Division, sends frozen meals to very isolated individuals on the Northern Cheyenne and Crow reservations.
• Housing/Homelessness. Michigan put an eviction and foreclosure ban in place through July 15, 2020 and set up an eviction diversion program for households up to 100 percent of Area Median Income (AMI)⁸²  facing eviction after the ban expired. California implemented Project RoomKey to fund hotel and motel rooms around the state that provide non-congregate shelter options for the sick and medically vulnerable who lack stable housing.⁸³ 
• Social Services Referrals. North Carolina fast-tracked⁸⁴  the rollout of NCCARE360, the country’s first statewide technology platform connecting health care and human services. This platform makes it easier for providers, insurers, and community-based organizations to connect residents with the community resources they need during the COVID-19 pandemic. Pennsylvania added requirements to Medicaid MCO agreements that MCOs must work with community-based organizations to address key SDOH, with their reimbursement tied to moderate and high-risk value-based payment arrangements which will increase over time. Virginia’s Medicaid MCOs have created a grant program for community- and faith-based organizations to support outreach programs related to SDOH.

Managed Long-Term Services and Supports

About half of the states have a capitated managed long-term services and supports (MLTSS) program in place. As of July 1, 2019, 27 states reported having an MLTSS program.⁸⁵  Two states (Alabama and Washington) reported having a managed fee-for-service MLTSS model while the remaining 25 states covered LTSS through one or more of the following types of capitated managed care arrangements: Medicaid MCO covering Medicaid acute care and LTSS; PHP covering only Medicaid LTSS; MCO arrangement for dual eligible beneficiaries covering Medicaid and Medicare acute care and Medicaid LTSS services in a single, financially aligned contract under the federal Financial Alignment Initiative (FAI).

SURVEY FINDINGS

Non-Emergency MLTSS Policy Changes

States were asked to identify MLTSS policy changes in FY 2020 or planned for FY 2021 including changes to increase enrollment in capitated MLTSS contracts or to carve benefits/services in or out of MLTSS contracts.

Six states reported changes to their MLTSS programs in FY 2020 or FY 2021 (Exhibit 5). No states reported implementation of capitated MLTSS contracts or making enrollment mandatory for an additional population for the first time in FY 2020 or in FY 2021.

• Geographic expansions. Two states (Idaho and Pennsylvania) reported MLTSS expansion into new geographic regions in FY 2020 while one state (Massachusetts) reported geographic expansion in FY 2020 and planned geographic expansion in FY 2021. Idaho expanded IMPlus to an additional 13 counties in April 2020, while Pennsylvania completed the third phase of implementation of its MCO-based MLTSS program, Community HealthChoices, on January 1, 2020. One Care, Massachusetts’ MCO-based capitated FAI,⁸⁶  expanded to an additional county in FY 2020 and proposed to fully expand to another two counties in FY 2021.
• Benefit/service changes. Three states (Arizona, Massachusetts, and New Jersey) carved in additional benefits/services to MLTSS contracts in FY 2020 while one state (Wisconsin) carved out benefits in FY 2020. Massachusetts added services to One Care (transitional living program, high intensity residential services, enhanced residential rehabilitation services to ensure member medical, mental health, and addiction needs are addressed, and recovery coaching). Arizona integrated behavioral health services into contracts with the Arizona Department of Economic Security Division of Development Disabilities (DDD). Arizona DDD contracted with MCOs effective October 1, 2019 to offer eligible members physical and behavioral health services, children’s rehabilitative services, and limited LTSS.⁸⁷  New Jersey carved in autism services and some SUD services. In FY 2020, Wisconsin carved out most prescription outpatient drugs from Family Care Partnership, its integrated Medicare-Medicaid MLTSS program serving frail elderly and people with disabilities.⁸⁸ 

Medicaid is the nation’s primary payer for long-term services and supports (LTSS).⁸⁹  State Medicaid programs must cover LTSS in nursing homes, while most home and community-based services (HCBS) are optional, which results in considerable differences among states in HCBS eligibility, scope of benefits, and delivery systems.⁹⁰  The COVID-19 pandemic has greater implications for people who utilize LTSS, who may be at increased risk for adverse health outcomes if infected with coronavirus due to their older age, underlying health conditions, and/or residence in congregate settings. Members of the long-term care (LTC) workforce—which is predominantly female and low wage, and disproportionately Black—are also at elevated risk of coronavirus infection.⁹¹  LTC facilities have implemented many protocols to mitigate the spread of the virus, such as visitor restrictions and universal testing of residents and staff. These new measures have played an important role in reducing the number of new LTC cases and deaths in later months of the pandemic. ⁹²  However, given the close relationship between community transmission and LTC cases and deaths, there is still enormous state-level variation in patterns of new cases and deaths in LTC facilities. Notably, LTC cases and deaths continue to rise faster in “hotspot” states than “non-hotspot” states.⁹³  As of October 8, 2020, LTC facilities across the country had reported a total of over 500,000 cases of COVID-19 as well as nearly 85,000 deaths related to the virus.⁹⁴ 

As the pandemic continues, states have taken a number of Medicaid policy actions to address the impact on seniors and people with disabilities who rely on LTSS to meet daily self-care and independent living needs. These actions include expanding eligibility and streamlining enrollment, easing premium and/or cost-sharing requirements, enhancing benefits, increasing provider payment, modifying provider qualifications, and altering reporting requirements. Many of these policy changes have been adopted through temporary authorities that, according to CMS guidance,⁹⁵  will expire when the COVID-19 public health emergency (PHE) declaration ends or are otherwise time-limited. Prior to that time, policymakers will need to assess whether any changes can or should be retained and transitioned to other authorities.⁹⁶ 

Survey Findings

To better understand the impact of COVID-19 on the LTSS direct care workforce, we asked states to indicate whether they had a variety of concerns about the pandemic’s impact on HCBS and institutional direct care workers. We also asked states about whether COVID-19 has impacted institutional/HCBS rebalancing efforts and whether it has impacted access to non-home and residential HCBS settings. Finally, we asked states to identify the top three LTSS policy changes adopted in response to COVID-19 that they plan to retain after the PHE period.

The majority of responding states reported concerns about the pandemic’s impact on the LTSS direct care workforce, with similar issues across HCBS and institutional settings (Figure 2). Specifically, states reported the following concerns:

• More than three-quarters of states reported concerns about reductions in LTSS direct care workforce supply as a result of the pandemic. At least five states reported that the LTSS direct care workforce supply was an issue prior to COVID-19 but has become a greater issue during the pandemic; in general, LTSS direct care workforce supply was an issue for many states prior to the pandemic.⁹⁷  Using HCBS Appendix K emergency authority, some states are providing overtime and the use of legally responsible relatives (such as parents or spouses) as paid caregivers to address workforce supply issues.⁹⁸ 
• Nearly all states reported concerns about access to personal protective equipment (PPE) for LTSS direct care workers. A few states noted that they were prioritizing supply of PPE for workers in institutional or congregate settings.⁹⁹ 
• Nearly three-quarters of states reported concerns about access to COVID-19 tests for LTSS direct care workers. Several states reported the length of COVID-19 test processing times as a particular challenge.
• Over two-thirds of states reported concerns about COVID-19 infections among LTSS direct care workers. Several states noted that better access to PPE and testing would help mitigate concern about infections.

Some states noted some improvements since the beginning of the pandemic in workforce supply, access to PPE and testing, and ability to control infection rates, while a few states identified specific LTSS populations or geographic areas that presented particular issues or concerns. For example, a few states reported issues with workforce, testing, and infection rates specifically for the population with intellectual and developmental disabilities (I/DD). A small number of states noted that workforce issues, distribution of PPE, and testing (due to lack of transportation to testing sites) were of greater concern for rural areas.

State responses regarding COVID-19 implications on state institutional/HCBS rebalancing efforts were mixed. Most frequently, states did not expect the pandemic to have an impact on rebalancing efforts to support more people in community-based over institutional settings. Several states, however, indicated that the pandemic would halt or delay HCBS expansion and others reported that fewer nursing facility transitions to the community would occur. Fewer states indicated that the pandemic would likely drive further rebalancing. Several states reported that the potential impact was unknown and/or was under review. Finally, a few states specifically indicated that negative fiscal and budget impacts resulting from the pandemic may delay rebalancing. When asked about access to existing HCBS services, nearly all responding states reported reduced access to non-home HCBS settings such as adult day health and day habilitation as a result of the COVID-19 pandemic, while fewer states reported reduced access to residential HCBS settings. Although residential settings were less likely to be closed or eliminated in response to the pandemic, these settings were still impacted by the pandemic including by its effects on the direct care workforce (as described above).

States noted plans to retain a variety of LTSS policy changes adopted in response to COVID-19 after the PHE period ends, most commonly citing the continuation of telehealth expansions. As many LTSS emergency policy changes were adopted through time-limited temporary authorities (some of which will expire with the end of the PHE), states may need to assess how to retain changes and transition to other authorities.¹⁰⁰  Fourteen states reported they are still evaluating whether LTSS policy changes will be continued and three states reported that there are no plans to retain LTSS policy changes after the PHE declaration or other Medicaid emergency authority (such as HCBS waiver Appendix K) expires. The remaining states indicated plans to continue policy changes including:

• Telehealth expansions. The majority of responding states reported plans to retain telehealth or remote provision of HCBS services (21 states), far exceeding all other types of LTSS policy changes reported. For example, a few states mentioned plans to continue allowing personal care monitoring to be delivered via telehealth. (See Benefits, Cost-Sharing, and Telehealth section for more information on state expansions of telehealth for services including HCBS.)
• Streamlined processes for LTSS eligibility determinations and service authorizations. Six states cited continued remote delivery of assessments, reassessments, and case management (Connecticut, Minnesota, North Carolina, North Dakota, Oklahoma, and Oregon). A small number of states also mentioned continuing to allow verbal consent and electronic signatures, accepting self-attestation to verify Medicaid applications for aged, blind and disabled populations, and streamlining utilization review. (See Eligibility section for more information on changes to eligibility determination processes.)
• Changes to provider enrollment processes. Five states reported an intent to keep changes made to LTSS provider enrollment and training processes including simplification, modified qualifications, and recruitment techniques (Florida, New Hampshire, North Dakota, Oregon, and Washington). A couple of states also mentioned an intent to retain remote provider site inspections.
• Increased access to paid family caregiver services. Three states reported plans to continue allowing family members to provide certain services (Connecticut, Maine,¹⁰¹  and North Dakota).¹⁰² 
• Other LTSS policy changes. Other types of policies cited for retention by one or two states include modifications to provider payments (such as providing overtime or tying nursing facility reimbursement to quality and infection control), expansions of settings where HCBS may be delivered (such as acute hospital settings), and increased access to certain benefits (such as home delivered meals and assistive technology).

Prior to the COVID-19 pandemic, the most common state changes to Medicaid benefits were enhancements of mental health and substance use disorder (SUD) services. In recent years, the number of states reporting benefit expansions outpaced the number of states reporting benefit restrictions. For FY 2019 and FY 2020, more states reported policies to eliminate or reduce cost-sharing requirements than those that reported new or increased cost-sharing requirements.¹⁰³  The COVID-19 pandemic has shifted state priorities for Medicaid benefits and cost-sharing, with states utilizing Medicaid emergency authorities to adopt new benefits, adjust existing benefits, and/or waive prior authorization requirements.¹⁰⁴ 

In particular, states have focused on expanding telehealth access for Medicaid beneficiaries to increase health care accessibility and limit risk of exposure during the pandemic.¹⁰⁵  Prior to the pandemic, the use of telehealth in Medicaid was becoming more common and all states had some form of Medicaid coverage for services delivered via telehealth; however, the scope of this coverage varied widely across states and many included restrictions on allowable services, providers, and originating sites.¹⁰⁶  In response to COVID-19, states have utilized Medicaid emergency authorities to expand telehealth¹⁰⁷  as well as taken advantage of broad authority to further expand telehealth without the need for CMS approval. To guide states considering telehealth expansions, CMS released a State Medicaid & CHIP Telehealth Toolkit on April 23, 2020 which identified key areas of telehealth for state consideration, including what services can be delivered via telehealth; what kinds of sites can serve as originating sites (patient location); payment rates for services; technological modalities that can be used to deliver services; and whether Medicaid managed care organizations (MCOs) are required to cover all services that are available in fee-for-service (FFS) Medicaid.¹⁰⁸ 

Survey Findings

We asked states about non-emergency benefit and cost-sharing changes unrelated to COVID-19 planned for FY 2021. Further, to better understand the impact of COVID-19 on Medicaid benefit design and coverage policy, we asked about emergency benefit and cost-sharing changes made in response to the pandemic and, specifically, whether states planned to adopt the changes on a more permanent basis. Finally, we asked states about recent changes in FFS telehealth coverage policy and whether these changes were likely to continue past the public health emergency (PHE) period.

Non-Emergency Changes to Benefits and Cost-Sharing

Less than one-third of responding states plan to make benefit or cost-sharing changes that are not related to the COVID-19 pandemic in FY 2021 (12 states). Many states have not determined whether they will adopt any non-emergency benefit or cost-sharing changes (12 states), with at least one state noting that uncertainty regarding the length of the PHE period and its budgetary impact is a barrier to determining FY 2021 benefit and cost-sharing changes. Key reported changes for FY 2021, excluding telehealth coverage changes, include the following:

• Seven states are adding or expanding benefits (Alaska, California, Hawaii, Idaho, Montana, Texas, and Wisconsin). Reported benefit changes include expanded home and community-based (HCBS) services as well as behavioral health (BH) and SUD services, consistent with findings in prior years.¹⁰⁹ 
• Two states are eliminating or restricting benefits (Alaska and Wyoming). Alaska is adding prior authorization requirements for benefits that include non-preventive dental, vision, and therapies. Wyoming is removing its chiropractic benefit for all individuals, limiting some HCBS services, and reducing its adult vision and dental benefits.
• Four states (Colorado, Idaho, Michigan, and South Dakota) will be implementing new or expanded co-payments for a variety of services, or other cost-sharing. Idaho and Michigan report that these changes will apply to the Medicaid expansion population.
• Two states (California and Massachusetts) will be eliminating or reducing certain co-payments in FY 2021.

Benefit Changes in Response to COVID-19

Approximately one-third of responding states intend to extend other benefit and cost-sharing changes adopted during the PHE period (15 states); many of these are pharmacy changes. (See the Pharmacy Cost Containment Actions section of this report for more information on state pharmacy changes.) Similar numbers of states said they would not extend changes adopted in response to the PHE (15 states) or that they had not yet determined whether the changes would be extended (13 states). The benefit changes states were most likely to extend beyond the PHE period include covering a 90-day drug supply (five states), relaxing various documentation and other authorization or referral requirements to qualify for long-term care or HCBS (six states), and relaxing or waiving certain prior authorization requirements for some services (five states). A few states also indicated they would retain other pharmacy changes, including paying for prescription deliveries (two states), allowing pharmacists to administer medications and/or vaccines (two states), and covering additional types of medication (two states).

Telehealth Policy Changes in Response to COVID-19

The majority of responding states report covering a range of FFS services delivered via telehealth when the originating site is the beneficiary’s home; most of these states newly added or expanded this coverage in response to the COVID-19 pandemic (Figure 3). States most commonly reported adding or expanding telehealth delivery from the beneficiary’s home for occupational therapy (OT), physical therapy (PT), and speech therapy (35 states), followed by home and community-based services (HCBS) (33 states) and well/sick child visits (30 states). Several states noted they had utilized Section 1915 (c) Appendix K emergency authority to expand telehealth in their HCBS waivers.¹¹⁰ 

Most states reported that FFS services delivered via telehealth from the beneficiary’s home have payment parity as compared to services delivered face-to-face. Payment parity for telehealth increases access for patients by incentivizing providers to offer services delivered via telehealth.¹¹¹  Most states reported that reimbursement was the same for telehealth and in-person delivery of all FFS services asked about (well/sick child visits, mental health services, SUD services, prenatal care, contraceptive visits, HCBS, OT/PT/speech therapies, and dental services).

Just over half of responding states report plans to extend newly added/expanded FFS telehealth coverage when the beneficiary’s home is the originating site beyond the PHE period (Figure 4 and Table 3). Twenty-two states report that they will continue newly added/expanded telehealth coverage, at least in part and at least for some services. For most services with newly added/expanded coverage, however, the majority of states have not yet determined whether this coverage will continue beyond the PHE period. (See the Long-Term Services and Supports section for more information on state plans to retain telehealth or remote provision of long-term services and supports including HCBS after the end of the PHE).

States also reported other policies aimed at making telehealth widely accessible in response to COVID-19. Thirty-nine out of 42 responding states expanded available telehealth modalities in response to the pandemic, with telephone (or voice-only) most frequently reported. As one state noted, this expansion is important because beneficiaries may lack access to broadband internet. States also reported covering digital platforms, such as FaceTime, Zoom, and Skype. At least two states, Florida and Virginia, began allowing remote patient monitoring as a type of newly expanded telehealth service delivery. All responding states that contract with managed care organizations (MCOs) required MCOs to implement newly adopted FFS telehealth changes; three of these states required MCOs only to implement FFS telehealth changes in part. Tennessee, a state with 100% of its beneficiaries enrolled in managed care, indicated it worked closely with its MCOs to coordinate and increase use of telehealth.¹¹²  In Minnesota, some contracted MCOs cover virtual e-visits as an “in lieu of” services.¹¹³ 

TABLE 3: STATES PLANNING TO CONTINUE NEWLY ADDED OR EXPANDED COVERAGE OF FFS SERVICES DELIVERED VIA TELEHEALTH FROM THE BENEFICIARY’S HOME

Managing the Medicaid prescription drug benefit and pharmacy expenditures remains a policy priority for state Medicaid programs, and state policymakers remain concerned about Medicaid prescription drug spending growth. Because state Medicaid programs are required to cover all drugs from manufacturers that have entered into a federal rebate agreement (in both managed care and FFS settings), states cannot limit the scope of covered drugs to control drug costs. Instead, states use an array of payment strategies and utilization controls to manage pharmacy expenditures, including preferred drug lists (PDLs), multi-state purchasing pools, and managed care pharmacy carve-outs.¹¹⁴  States continue to update and refine their drug utilization controls to respond to changes, especially new product offerings, in the pharmaceutical marketplace.

Survey Findings

In this year’s survey, states were asked to describe any new or expanded pharmacy program cost containment strategies planned for FY 2021. States were asked to exclude routine updates to PDLs or state maximum allowable cost programs as these utilization management strategies are employed by states regularly and are not typically considered major new policy initiatives.

Thirty-three out of 43 responding states reported newly implementing or expanding upon at least one initiative to contain costs in the area of prescription drugs in FY 2021. Pharmacy cost containment actions included implementation of new policies (23 states) as well as expansion of policies adopted in prior years (19 states). Frequently reported pharmacy cost containment strategies include expanded PDLs (11 states), new or expanded value-based purchasing arrangements that link pharmacy reimbursement to patient outcomes (11 states), and targeted reforms to address transparency or other pharmacy benefit manager (PBM) concerns (7 states).¹¹⁵ 

Three states report adopting a uniform PDL in FY 2021 (Kentucky, Massachusetts, and Michigan) and North Carolina plans to use a uniform PDL for FFS and managed care when it implements managed care in FY 2022. In FY 2021, one state is carving the prescription drug benefit out of managed care organization (MCO) contracts (California) and three states report newly carving out certain high cost drugs (Iowa, Maryland, and South Carolina). North Dakota implemented a pharmacy carve out in FY 2020 and Nevada plans to carve out the prescription drug benefit effective in FY 2023, when MCO contracts are renewed. Both Michigan and Missouri will be partnering with other state agencies or initiatives to purchase drugs at lower costs, including Michigan’s Hepatitis C initiative aimed at reducing pharmacy and medical costs associated with the disease and working to eliminate Hepatitis C altogether.

Most state Medicaid officials remained heavily focused on their response to the COVID-19 public health emergency (PHE), taking action to assure health care access for a growing number of Medicaid beneficiaries while working to maintain the fiscal integrity of their programs. At the same time, many states also reported plans to move forward on other high priority initiatives.

Nearly all states reported significant adverse economic and state budgetary impacts driven by the pandemic, as well as uncertainty about the future. Many states commented on dramatic declines in state revenue collections leading to significant state budget shortfalls. While the full scope and extent of the economic downturn remains unknown, nine states indicated that its negative impacts were likely to exceed those of the Great Recession and nine states reported planning for or expecting future Medicaid budget reductions. At the same time, many states commented on the increased Medicaid enrollment expected to occur as a result of the economic downturn and high unemployment rates, placing added fiscal pressure on state Medicaid programs. Most responding states reported that dealing with state Medicaid budget and fiscal concerns was one of the biggest challenges facing the states in the coming year. Many states also commented on the great fiscal uncertainties that states currently face including how long the current enhanced FMAP will remain in place and how the course of the pandemic will continue to impact state economies and unemployment rates.

Many states reported the need for ongoing or greater fiscal relief as well as the need to strengthen the provider relief program for Medicaid-dependent providers to be able to continue to address the pandemic. Most states noted that state and federal responses to the pandemic were effective, but some states also identified needs related to improving or expanding federal communication efforts and guidance, further streamlining the emergency authority process, and receiving advance notice regarding when the PHE period will end. A few states were critical of the federal response regarding public health guidance (including mask wearing), the availability of personal protective equipment, and testing (e.g., supplies, distribution, inconsistent advice, and effectiveness of the tests).

At the time states responded to this survey in late July and early August, most indicated that the worst effects of the pandemic were likely still ahead or were unknown. Several states also commented on future challenges to treat the lingering impacts of COVID-19 infections as well as the population health impacts resulting from delayed health care utilization. A few states also expressed concern regarding the longer-term impact of the COVID-19 pandemic on the Medicaid provider network and access due, for example, to business closures. States also mentioned key priorities such as restoring utilization of preventive and routine care and transitioning from emergency authorities after the PHE ends.

Nearly half of responding states indicated that delivery system and payment reforms are a key priority. Efforts to better align payment with quality and improved health outcomes remain an important focus area for many states. States are pursuing these goals in part through managed care contract changes focused on value-based payment initiatives and the social determinants of health. States also mentioned efforts to integrate physical health and behavioral health, expand Health Homes¹¹⁶ , reform provider reimbursement methodologies, implement substance use disorder initiatives, and develop maternal health initiatives. Ten states also reported that assessing and/or expanding telehealth was a priority. Other priorities mentioned by multiple states include: implementation or pursuit of Section 1115 demonstration waivers, waiver amendments, or waiver renewals; technology projects (e.g., Medicaid Management Information System replacements and integrated eligibility and enrollment systems); improving quality metrics and eliminating health disparities and inequities; long-term services and supports reforms; and implementing or advocating for the ACA Medicaid expansion in states that have not adopted the expansion.

Conclusion

In the face of the COVID-19 pandemic, states continue to encounter challenges to provide Medicaid coverage and access for a growing number of Americans, while also facing plummeting revenues and deepening state budget gaps. State Medicaid officials highlighted swift and effective state responses to the pandemic, such as the rapid expansion of telehealth, as well as ongoing efforts to advance delivery system reforms and to address health disparities and other public health challenges. In these ways, the pandemic has demonstrated how Medicaid can quickly evolve to address the nation’s most pressing health care challenges. However, the ability of states to sustain policies adopted in response to the pandemic (including through emergency authorities) may be tied to the length of the public health emergency (PHE) as well as the availability of additional federal fiscal relief and support. Looking ahead, great uncertainty remains regarding the future course of the pandemic, the scope and length of federal fiscal relief efforts, and what the “new normal” will be in terms of service provision and demand. Results of the November 2020 elections could also have significant implications for the direction of federal Medicaid policy in the years ahead.

KFF commissioned Health Management Associates (HMA) to survey Medicaid directors in all 50 states and the District of Columbia to identify and track trends in Medicaid spending, enrollment, and policy making. This is the 20th annual survey, each conducted at the beginning of the state fiscal year from FY 2002 through FY 2021. Additionally, eight mid-fiscal year surveys were conducted during state fiscal years 2002-2004 and 2009-2013, when a large share of states were considering mid-year Medicaid policy changes due to state budget and revenue shortfalls. Findings from previous surveys are referenced in this report when they help to highlight current trends. Archived copies of past reports are available on the following page.¹¹⁷ 

The KFF/HMA Medicaid survey on which this report is based was conducted from June through August 2020. The survey instrument (in Appendix B) was designed to primarily document policy actions implemented or adopted for FY 2021 (which began for most states on July 1, 2020).¹¹⁸  The survey captures information consistent with previous surveys, particularly for eligibility, provider payment rates, benefits, long-term care, and managed care, to provide some trend information. Each year, questions are added or revised to address current issues. This year, in light of the ongoing COVID-19 pandemic, the survey was scaled back in length and scope and a number of questions were added or reframed to capture information regarding state actions taken or planned in response to the pandemic.

Medicaid directors and staff provided data for this report in response to a written survey and, in some cases, follow-up emails seeking additional information or clarifications. Unlike the surveys conducted in prior years, the project team did not conduct follow-up telephone interviews. The survey was sent to each Medicaid director in June 2020 and 43 states ¹¹⁹  provided responses by mid-August 2020.

The survey does not attempt to catalog all Medicaid policies in place for each state. This report highlights certain policies in place in state Medicaid programs in FY 2020 and policy changes implemented or planned for FY 2021. Experience has shown that adopted policies are sometimes delayed or not implemented for reasons related to legal, fiscal, administrative, systems, or political considerations, or due to delays in approval from CMS. Policy changes under consideration without a definite decision to implement are not included in the survey. Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis.

ABD – aged, blind, and disabled

ACA – Affordable Care Act

AMI – Area Median Income

BH – behavioral health

CARES – Coronavirus Aid, Relief, and Economic Security Act

CDC – The Centers for Disease Control and Prevention

CHIP – Children’s Health Insurance Program

CMS – The Centers for Medicare and Medicaid Services

DRG – Diagnosis Related Group

EMS – emergency medical services

EPSDT – Early and Periodic Screening, Diagnostic, and Treatment

FAI – Financial Alignment Initiative

FFCRA – Families First Coronavirus Response Act

FFS – fee-for-service

FMAP – Federal Medicaid Assistance Percentage

FPL – federal poverty level

FY – state fiscal year

HCBS – home and community-based services

HEDIS – Healthcare Effectiveness Data and Information Set

ICF-ID – intermediate care facility for individuals with intellectual disabilities

I/DD – intellectual and developmental disabilities

IGT – intergovernmental transfer

LTC – long-term care

LTSS – long-term services and supports

MAGI – modified adjusted gross income

MAT – medication assisted treatment

MCO – managed care organization

MLTSS – managed long-term services and supports

MLR – medical loss ratio

MOE – maintenance of eligibility

NEMT – non-emergency medical transportation

OB/GYN – obstetrician and gynecologist OT – occupational therapy

PBM – pharmacy benefit manager

PCCM – primary care case management

PCP – primary care physician

PDL – preferred drug list

PHE – public health emergency

PHP – prepaid health plan

PPE – personal protective equipment PT – physical therapy

SDOH – social determinants of health

SED – serious emotional disturbance

SNAP – Supplemental Nutrition Assistance Program

SPA – State Plan Amendment

SPMI – severe and persistent mental illness

SUD – substance use disorder

Download the Survey (.pdf)

1. Pub. L. 116-127 (March 18, 2020), https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf. ↩︎
2. FMAP = Federal Medicaid Assistance Percentage ↩︎
3. MaryBeth Musumeci, Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19 (Washington, DC: KFF, May 4, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/ ↩︎
4. US Department of Health and Human Services, Renewal of Determination That A Public Health Emergency Exists (October 2, 2020), https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx ↩︎
5. State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and DC on October 1. ↩︎
6. The eight states that did not respond by mid-August 2020 are: Delaware, District of Columbia, Illinois, Ohio, New Mexico, New York, Rhode Island, and Utah. ↩︎
7. MaryBeth Musumeci, Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19 (Washington, DC: KFF, May 4, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/ ↩︎
8. Rachel Dolan, Robin Rudowitz, and Samantha Artiga, Medicaid Maintenance of Eligibility (MOE) Requirements: Issues to Watch When They End (Washington, DC: KFF, September 22, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-requirements-issues-to-watch-when-they-end/ ↩︎
9. KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
10. Since the time of survey submission, two additional responding states (Connecticut and North Carolina) have received SPA approvals for this group. For an updated count of states with SPA approval to cover the new Uninsured Coronavirus Testing group, see: KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
11. KFF, “Status of State Medicaid Expansion Decisions”, last updated October 1, 2020, https://modern.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ ↩︎
12. Karyn Schwartz, Jennifer Tolbert, Karen Pollitz, and Tricia Neuman, Update on COVID-19 Funding for Hospitals and Other Providers (Washington, DC: KFF, April 24, 2020), https://modern.kff.org/policy-watch/update-on-covid-19-funding-for-hospitals-and-other-providers/ ↩︎
13. KFF, “Total Medicaid MCO Enrollment,” 2018, https://modern.kff.org/other/state-indicator/total-medicaid-mco-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D ↩︎
14. Samantha Artiga and Elizabeth Hinton, Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity (Washington, DC: KFF, May 10, 2018), https://modern.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/ ↩︎
15. Molly O’Malley Watts, MaryBeth Musumeci, and Priya Chidambaram, Medicaid Home and Community-Based Services Enrollment and Spending (Washington, DC: KFF, February 4, 2020), https://modern.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/ ↩︎
16. MaryBeth Musumeci, Rachel Dolan, and Madeline Guth, State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19 (Washington, DC: KFF, August 26, 2020), https://modern.kff.org/medicaid/issue-brief/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-covid-19/ ↩︎
17. Kathleen Gifford et al., “Benefits and Cost-Sharing,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-benefits-and-cost-sharing/ ↩︎
18. US Department of Health and Human Services, Renewal of Determination That A Public Health Emergency Exists (October 2, 2020), https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx ↩︎
19. KFF, “Health Insurance Coverage of the Total Population,” 2018, https://modern.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D ↩︎
20. U.S. Centers for Medicare & Medicaid Services (CMS). National Health Expenditure Data Fact Sheet: Table 4, National Health Expenditures by Source of Funds and Type of Expenditure: Calendar Years 2011-2018 (CMS, March 2020), https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html ↩︎
21. Pub. L. 116-127 (March 18, 2020), https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf. ↩︎
22. Pub. L. 116-136 (March 27, 2020), https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf. ↩︎
23. MaryBeth Musumeci, Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19 (Washington, DC: KFF, May 4, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/ ↩︎
24. KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
25. MaryBeth Musumeci, Rachel Dolan, and Madeline Guth, Appendix to State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19 (Washington, DC: KFF, August 26, 2020), https://modern.kff.org/report-section/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-covid-19-appendix/ ↩︎
26. KFF 50-State Medicaid Budget Survey Archives (Washington, DC: KFF, October 2020), https://modern.kff.org/medicaid/report/medicaid-budget-survey-archives/. ↩︎
27. The eight states that did not respond by mid-August 2020 are: Delaware, District of Columbia, Illinois, Ohio, New Mexico, New York, Rhode Island, and Utah. ↩︎
28. State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and DC on October 1. ↩︎
29. Pub. L. 116-127 (March 18, 2020), https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf. ↩︎
30. Pub. L. 116-136 (March 27, 2020), https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf. ↩︎
31. FMAP = Federal Medicaid Assistance Percentage ↩︎
32. MaryBeth Musumeci, Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19 (Washington, DC: KFF, May 4, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-increase-in-federal-medicaid-matching-funds-for-covid-19/ ↩︎
33. Rachel Dolan, Robin Rudowitz, and Samantha Artiga, Medicaid Maintenance of Eligibility (MOE) Requirements (Washington, DC: KFF, September 22, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-maintenance-of-eligibility-requirements-issues-to-watch-when-they-end/ ↩︎
34. Robin Rudowitz, Bradley Corallo, and Samantha Artiga, Analysis of Recent National Trends in Medicaid and CHIP Enrollment: Issues to Watch When They End (Washington, DC: KFF, August 24, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/ ↩︎
35. Tricia Brooks, Lauren Roygardner, Samantha Artiga, Olivia Pham, and Rachel Dolan, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey (Washington, DC: KFF, March 26, 2020), https://modern.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey/ ↩︎
36. Robin Rudowitz and Elizabeth Hinton, Early Look at Medicaid Spending and Enrollment Trends Amid COVID-19 (Washington, DC: KFF, May 15, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/early-look-at-medicaid-spending-and-enrollment-trends-amid-covid-19/ ↩︎
37. KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
38. MaryBeth Musumeci, Rachel Dolan, and Madeline Guth, Appendix to State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19 (Washington, DC: KFF, August 26, 2020), https://modern.kff.org/report-section/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-covid-19-appendix/ ↩︎
39. US Department of Health and Human Services, Renewal of Determination That A Public Health Emergency Exists (October 2, 2020), https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx ↩︎
40. KFF, “Status of State Medicaid Expansion Decisions”, last updated October 1, 2020, https://modern.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ ↩︎
41. Calculated based on the 2020 Federal Poverty Level (FPL) of $12,760 per year for an individual in 2020, in the 48 contiguous states and DC. See: U.S. Department of Health & Human Services, Office of the Assistant Secretary for Planning and Evaluation, U.S. Federal Poverty Guidelines Used to Determine Financial Eligibility for Certain Federal Programs (January 2020), https://aspe.hhs.gov/poverty-guidelines ↩︎
42. Oklahoma Healthcare Authority, Public Notice: Medicaid Adult Expansion, July 31, 2020, http://www.okhca.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=24995&libID=23981 ↩︎
43. MaryBeth Musumeci, 3 Key Questions About the Arkansas Medicaid Work and Reporting Requirements Case (Washington, DC: KFF, March 6, 2020), https://modern.kff.org/medicaid/issue-brief/3-key-questions-about-the-arkansas-medicaid-work-and-reporting-requirements-case/ ↩︎
44. For more information on South Carolina’s and other Section 1115 waivers, including the status of work requirements, see: KFF, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State”, last updated September 1, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/ ↩︎
45. Georgia is extending coverage for postpartum women to 6 months and New Jersey is extending this coverage to 180 days. ↩︎
46. Centers for Medicare and Medicaid Services, Letter to Stephanie Muth, Associate Commissioner, Medicaid/CHIP, Texas Health and Human Services Commission, from CMS Administrator, Seema Verma (January 22, 2020), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/tx/tx-healthy-women-ca.pdf. The HTW Program provides coverage of family planning services to low-income women who are not otherwise eligible for Medicaid coverage. ↩︎
47. New Hampshire also reported plans to continue coverage of COVID-19 diagnostic testing, testing-related services, and treatment services for the uninsured but is not counted here as authority for this coverage, created by the Families First Coronavirus Response Act, continues only through the end of the PHE period. ↩︎
48. Additionally, Nevada noted that eligibility for the new uninsured COVID-19 group may continue for up to 90 days after the end of the PHE period to allow for prior medical requests to cover testing and diagnostic services. Per the Families First Coronavirus Response Act, authority to cover the uninsured COVID-19 testing group will not extend past the end of the PHE. ↩︎
49. Marybeth Musumeci, Key Questions About the New Medicaid Eligibility Pathway for Uninsured Coronavirus Testing (Washington, DC: KFF, May 4, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-medicaid-eligibility-pathway-for-uninsured-coronavirus-testing/ ↩︎
50. U.S. Department of Health & Human Services, Health Resources & Services Administration, “COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured,” last updated May 2020, https://www.hrsa.gov/CovidUninsuredClaim ↩︎
51. For an updated count of states with SPA approval to cover the new Uninsured Coronavirus Testing group, see: KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
52. Laura Snyder and Robin Rudowitz, Trends in State Medicaid Programs: Looking Back and Looking Ahead (Washington, DC: KFF, June 21, 2016), https://modern.kff.org/medicaid/issue-brief/trends-in-state-medicaid-programs-looking-back-and-looking-ahead/ ↩︎
53. MaryBeth Musumeci, Robin Rudowitz, Elizabeth Hinton, Rachel Dolan, and Olivia Pham, Options to Support Medicaid Providers in Response to COVID-19 (Washington, DC: KFF, June 17, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/options-to-support-medicaid-providers-in-response-to-covid-19/ ↩︎
54. Elizabeth Hinton and MaryBeth Musumeci, Medicaid Managed Care Rates and Flexibilities: State Options to Respond to COVID-19 Pandemic (Washington, DC: KFF, September 9, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-managed-care-rates-and-flexibilities-state-options-to-respond-to-covid-19-pandemic/ ↩︎
55. CMS has described some of these options in the following two resources: Centers for Medicare and Medicaid (CMS), “COVID-19 Frequently Asked Questions (FAQs)”, last updated June 30, 2020, https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf Centers for Medicare and Medicaid (CMS), “Medicaid Managed Care Options in Responding to COVID-19,” last updated May 14, 2020, https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib051420.pdf ↩︎
56. Karyn Schwartz, Jennifer Tolbert, Karen Pollitz, and Tricia Neuman, Update on COVID-19 Funding for Hospitals and Other Providers (Washington, DC: KFF, April 24, 2020), https://modern.kff.org/policy-watch/update-on-covid-19-funding-for-hospitals-and-other-providers/ ↩︎
57. U.S. Department of Health & Human Services, “HHS Announces Enhanced Provider Portal, Relief Fund Payments for Safety Net Hospitals, Medicaid & CHIP Providers,” June 9, 2020, https://www.hhs.gov/about/news/2020/06/09/hhs-announces-enhanced-provider-portal-relief-fund-payments-for-safety-net-hospitals-medicaid-chip-providers.html ↩︎
58. Robin Rudowitz, Kendal Orgera, and Elizabeth Hinton, Medicaid Financing: The Basics (Washington, DC: KFF, March 21, 2019), https://modern.kff.org/report-section/medicaid-financing-the-basics-issue-brief/ ↩︎
59. Laura Snyder and Robin Rudowitz, Trends in State Medicaid Programs: Looking Back and Looking Ahead (Washington, DC: KFF, June 21, 2016), https://modern.kff.org/medicaid/issue-brief/trends-in-state-medicaid-programs-looking-back-and-looking-ahead/ ↩︎
60. Kathleen Gifford et al., A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/ ↩︎
61. These 16 states are: Arizona, California, Colorado, Florida, Georgia, Hawaii, Iowa, Kansas, Massachusetts, Montana, New Jersey, Pennsylvania, South Carolina, South Dakota, West Virginia, and Virginia. ↩︎
62. These 19 states are: California, Colorado, Connecticut, Florida, Georgia, Indiana, Iowa, Kentucky, Louisiana, Maine, Michigan, Montana, North Carolina, Oregon, South Carolina, Texas, Virginia, West Virginia, and Wyoming. ↩︎
63. Kathleen Gifford et al., “Delivery Systems,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-delivery-systems/ ↩︎
64. KFF, “Total Medicaid MCO Enrollment,” 2018, https://modern.kff.org/other/state-indicator/total-medicaid-mco-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D ↩︎
65. Elizabeth Hinton and MaryBeth Musumeci, Medicaid Managed Care Rates and Flexibilities: State Options to Respond to COVID-19 Pandemic (Washington, DC: KFF, September 9, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-managed-care-rates-and-flexibilities-state-options-to-respond-to-covid-19-pandemic/ ↩︎
66. Centers for Medicare and Medicaid (CMS), “COVID-19 Medicaid & CHIP All State Call,” April 10, 2020, https://www.cms.gov/files/zip/covid19allstatecall04102020.zip ↩︎
67. Centers for Medicare and Medicaid (CMS), “Medicaid Managed Care Options in Responding to COVID-19,” last updated May 14, 2020, https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib051420.pdf ↩︎
68. “Other” carve-ins reported include chiropractic, “treat-no transport” ambulance services, and diabetes prevention services (Missouri), doula services (New Jersey), and adult podiatry services (South Carolina). ↩︎
69. “Other” carve-outs reported were lens fabrications from selected plans (California) and elective C-sections (New Jersey). ↩︎
70. Elizabeth Hinton and MaryBeth Musumeci, Medicaid Managed Care Rates and Flexibilities: State Options to Respond to COVID-19 Pandemic (Washington, DC: KFF, September 9, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-managed-care-rates-and-flexibilities-state-options-to-respond-to-covid-19-pandemic/ ↩︎
71. The survey did not ask states to specify whether MCO contract or rate adjustments were made to FY 2020 MCO contracts so we are unable to report this information comprehensively. ↩︎
72. Elizabeth Hinton and MaryBeth Musumeci, Medicaid Managed Care Rates and Flexibilities: State Options to Respond to COVID-19 Pandemic (Washington, DC: KFF, September 9, 2020), https://modern.kff.org/medicaid/issue-brief/medicaid-managed-care-rates-and-flexibilities-state-options-to-respond-to-covid-19-pandemic/ ↩︎
73. MassHealth Managed Care Entity Bulletin 36, “Community Support Program for Homeless Individuals Residing in Department of Housing and Community Development-Funded New Temporary Shelters,” July 2020, https://www.mass.gov/doc/managed-care-entity-bulletin-36-community-support-program-for-homeless-individuals-residing-0/download ↩︎
74. The 11 MCO states that reported food assistance or home delivered meal initiatives are: Hawaii, Indiana, Kansas, Massachusetts, Michigan, Missouri, Nebraska, New Jersey, South Carolina, Virginia, and Wisconsin. The eight MCO states that reported enhanced MCO care management and outreach efforts often targeting persons at high risk for COVID-19 are: California, Colorado, Indiana, Kentucky, Missouri, Nebraska, Pennsylvania, and West Virginia. The four MCO states that reported provisions of PPE are: Arizona, Kansas, Kentucky, and Pennsylvania. The three MCO states that expanded telehealth and remote support are: Nebraska, Wisconsin, and West Virginia. The three MCO states that reported expanded pharmacy home deliveries are: Kansas, Nebraska, and West Virginia. The two MCO states that reported MCO-provided gift cards are: Kentucky and Virginia. ↩︎
75. Samantha Artiga and Elizabeth Hinton, Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity (Washington, DC: KFF, May 10, 2018), https://modern.kff.org/racial-equity-and-health-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/ ↩︎
76. In June 2015, CMS issued an Informational Bulletin to clarify when and how Medicaid reimburses for certain housing-related activities, including individual housing transition services, individual housing and tenancy sustaining services, and state-level housing related collaborative activities. In January 2018, CMS issued a State Medicaid Director Letter providing guidance on state Section 1115 waiver proposals to condition Medicaid on meeting a work requirement. CMS explicitly stated the demonstration opportunity does not provide states with the authority to use Medicaid funding to finance employment support services. Predating this guidance, a few states implemented voluntary work referral programs. Federal Medicaid funds also cannot be used to finance work referral programs. Centers for Medicare and Medicaid (CMS), “Coverage of Housing-Related Activities and Services for Individuals with Disabilities,” June 26, 2015, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf Centers for Medicare and Medicaid (CMS), “RE: Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries,” January 11, 2018,, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf ↩︎
77. Under federal Medicaid managed care rules, Medicaid MCOs may have flexibility to pay for non-medical services through “in-lieu-of” authority and/or “value-added” services. “In-lieu-of” services are a substitute for covered services and may qualify as a covered service for the purposes of capitation rate setting. “Value-added” services are extra services outside of covered contract services and do not qualify as a covered service for the purposes of capitation rate setting. ↩︎
78. Samantha Artiga, Bradley Corallo, and Olivia Pham, Racial Disparities in COVID-19: Key Findings from Available Data and Analysis (Washington, DC: KFF, August 17, 2020), https://modern.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-covid-19-key-findings-available-data-analysis/ ↩︎
79. Cornelia Hall, Samantha Artiga, Kendal Orgera, and Rachel Garfield, Food Insecurity and Health: Addressing Food Needs for Medicaid Enrollees as Part of COVID-19 Response Efforts (Washington, DC: KFF, August 14, 2020), https://modern.kff.org/report-section/food-insecurity-and-health-addressing-food-needs-for-medicaid-enrollees-as-part-of-covid-19-response-efforts-issue-brief/ ↩︎
80. Oklahoma and Missouri responded that “yes” the COVID-19 emergency caused the state to implement, expand, or reform a program or initiative to address enrollees’ social determinants of health but did not describe specific related actions and are therefore not included in Exhibit 4, but are included in count of 27 states. ↩︎
81. Minnesota Governor Walz directed more the 75 billion dollars in Coronavirus Relief funding toward food security. ↩︎
82. The area median income (AMI) is the household income for the median, or middle, household in a region and is calculated annually by the Department of Housing and Urban Development for every metropolitan region in the country. See: Brian McCabe, “The Area Medium Income (AMI), Explained,” (Washington, DC: Greater Greater Washington: September 1, 2016), https://ggwash.org/view/42671/the-area-median-income-ami-explained ↩︎
83. California Department of Social Services, “Project Roomkey: Emergency Housing for Immediate Protection Fact Sheet,” https://www.cdss.ca.gov/Portals/9/FEMA/Project-Roomkey-Fact-Sheet.pdf ↩︎
84. North Carolina implemented NCCARE360 six months ahead of schedule. ↩︎
85. Kathleen Gifford et al., “Long-Term Services and Supports,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-long-term-services-and-supports/ ↩︎
86. Centers for Medicare and Medicaid (CMS), “Financial Alignment Initiative (FAI),” last updated September 28, 2020, https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination ↩︎
87. Arizona Department of Economic Security, “DDD Health Plans,” website, https://des.az.gov/services/disabilities/developmental-disabilities/new-ddd-health-plans ↩︎
88. Wisconsin Department of Health services, “Family Care Partnership Program,” last updated January 28, 2020, https://www.dhs.wisconsin.gov/familycare/fcp-index.htm ↩︎
89. Molly O’Malley Watts, MaryBeth Musumeci, and Priya Chidambaram, Medicaid Home and Community-Based Services Enrollment and Spending (Washington, DC: KFF, February 4, 2020), https://modern.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/ ↩︎
90. MaryBeth Musumeci, Molly O’Malley Watts, and Priya Chidambaram, Key State Policy Choices About Medicaid Home and Community-Based Services (Washington, DC: KFF, February 4, 2020), https://modern.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/ ↩︎
91. Sarah True et al., COVID-19 and Workers at Risk: Examining the Long-Term Care Workforce (Washington, DC: KFF, April 23, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/covid-19-and-workers-at-risk-examining-the-long-term-care-workforce/ ↩︎
92. Priya Chidambaram, Key Questions About the Impact of Coronavirus on Long-Term Care Facilities Over Time (Washington, DC: KFF, September 1, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-impact-of-coronavirus-on-long-term-care-facilities-over-time/ ↩︎
93. Priya Chidambaram, Rising Cases in Long-term Care Facilities Are Cause for Concern (Washington, DC: KFF, July 21, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/rising-cases-in-long-term-care-facilities-are-cause-for-concern/ ↩︎
94. KFF, COVID-19: Long-Term Care Facilities from “State Data and Policy Actions to Address Coronavirus,” last updated October 8, 2020, https://modern.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-actions-to-address-coronavirus/ ↩︎
95. Centers for Medicare and Medicaid (CMS), “COVID-19 Frequently Asked Questions (FAQs)”, last updated June 30, 2020, https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf ↩︎
96. MaryBeth Musumeci, Rachel Dolan, and Madeline Guth, State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19 (Washington, DC: KFF, August 26, 2020), https://modern.kff.org/medicaid/issue-brief/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-covid-19/ ↩︎
97. Kathleen Gifford et al., “Long-Term Services and Supports,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-long-term-services-and-supports/ ↩︎
98. For updated counts of states taking this action using Medicaid emergency authorities, see: KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
99. Examples of congregate settings include assisted living facilities for seniors and group homes for individuals with disabilities. ↩︎
100. MaryBeth Musumeci, Rachel Dolan, and Madeline Guth, State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19 (Washington, DC: KFF, August 26, 2020), https://modern.kff.org/medicaid/issue-brief/state-actions-to-sustain-medicaid-long-term-services-and-supports-during-covid-19/ ↩︎
101. Maine reported plans to increase access to its shared living model, in which a family member can serve as a live-in paid caretaker. ↩︎
102. A number of states allowed legally responsible relatives to be paid providers prior to the COVID-19 pandemic. For more on this and other pre-pandemic HCBS policies, see: MaryBeth Musumeci, Molly O’Malley Watts, and Priya Chidambaram, Key State Policy Choices About Medicaid Home and Community-Based Services (Washington, DC: KFF, February 4, 2020), https://modern.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/ ↩︎
103. Kathleen Gifford et al., “Benefits and Cost-Sharing,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-benefits-and-cost-sharing/ ↩︎
104. KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
105. Madeline Guth and Elizabeth Hinton, State Efforts to Expand Medicaid Coverage & Access to Telehealth in Response to COVID-19 (Washington, DC: KFF, June 22, 2020), https://modern.kff.org/coronavirus-covid-19/issue-brief/state-efforts-to-expand-medicaid-coverage-access-to-telehealth-in-response-to-covid-19/ ↩︎
106. State Telehealth Laws & Reimbursement Policies (Center for Connected Health Policy, Spring 2020), https://www.cchpca.org/sites/default/files/2020-05/CCHP_%2050_STATE_REPORT_SPRING_2020_FINAL.pdf ↩︎
107. KFF, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
108. Centers for Medicare and Medicaid (CMS), “State Medicaid & CHIP Telehealth Toolkit,” last updated April 23, 2020, https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf ↩︎
109. Kathleen Gifford et al., “Benefits and Cost-Sharing,” A View from the States: Key Medicaid Policy Changes (Washington, DC: KFF, October 18, 2019), https://modern.kff.org/report-section/a-view-from-the-states-key-medicaid-policy-changes-benefits-and-cost-sharing/ ↩︎
110. For more information on this emergency authority, see KFF, Table: Approved Section 1915 (c) Waiver Appendix K Strategies to Address COVID-19 from “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” last updated October 7, 2020, https://modern.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/ ↩︎
111. Gabriela Weigel et al., Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond (Washington, DC: KFF, May 11, 2020), https://modern.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/ ↩︎
112. Because 100% of Tennessee’s Medicaid beneficiaries are enrolled in managed care, the state has no fee-for-service telehealth policies and thus is not included elsewhere in this write-up of emergency telehealth policies. ↩︎
113. For more information on how states can implement or update Medicaid managed care telehealth policies, see: Centers for Medicare and Medicaid (CMS), “COVID-19 Frequently Asked Questions (FAQs)”, question V.A.1, last updated June 30, 2020, https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf ↩︎
114. Kathleen Gifford et al., How State Medicaid Programs are Managing Prescription Drug Costs (Washington, DC: KFF, April 29, 2020), https://modern.kff.org/report-section/how-state-medicaid-programs-are-managing-prescription-drug-costs-introduction/ ↩︎
115. The 11 states that expanded PDLs are: Alaska, California, Colorado, Connecticut, Louisiana, Massachusetts, Missouri, Mississippi, Nebraska, New Hampshire, and Washington. The 11 states that had new or expanded value-based purchasing arrangements are: Alaska, Arizona, Colorado, Indiana, Massachusetts, Michigan, Nevada, North Carolina, Texas, Virginia, and Vermont. The seven states that had targeted reforms to address transparency and other PBM concerns are: Arizona, Kentucky, Maryland, Massachusetts, Mississippi, South Carolina, and Virginia. ↩︎
116. Health Homes (created under Section 2703 of the ACA) target beneficiaries who have at least two chronic conditions (or one and risk of a second, or a serious and persistent mental health condition), and provide a person-centered system of care that facilitates access to and coordination of the full array of primary and acute physical health services, behavioral health care, and social and long-term services and supports. ↩︎
117. KFF, 50-State Medicaid Budget Survey Archives, (Washington, DC: KFF, October 2020), https://modern.kff.org/medicaid/report/medicaid-budget-survey-archives/. ↩︎
118. State fiscal years begin on July 1 except for these states: New York on April 1; Texas on September 1; Alabama, Michigan, and DC on October 1. ↩︎
119. The eight states that did not respond by mid-August 2020 are: Delaware, District of Columbia, Illinois, Ohio, New Mexico, New York, Rhode Island, and Utah. ↩︎

The Survey on Race and Health, a joint project between KFF and ESPN’s The Undefeated, explores the public’s views and experiences on the topics of health care, racial discrimination, and the coronavirus pandemic, with a special focus on Black adults, a group that has borne a disproportionate burden of COVID-19 cases and deaths. This survey of 1,769 U.S. adults includes an oversample of 777 Black Americans to allow for in-depth reporting among this group, as well as comparison groups of White and Hispanic adults. This project focuses on African Americans’ views and experiences of being Black in America, including views of unconscious bias and structural racism; experiences of discrimination within and outside of health care settings; trust in the health care system; the social and economic impacts of the pandemic; and views of a potential coronavirus vaccine.

Read The Undefeated’s reporting:

New poll shows Black Americans see a racist health care system setting the stage for pandemic’s impact

Half of Black adults say they won’t take a coronavirus vaccine

New poll shows Black Americans put far less trust in doctors and hospitals than white people

New poll shows how the pandemic has devastated Black families

COVID-19 unveils an America that always sees itself in Black and white

Black Americans overwhelmingly say unconscious bias is a major barrier in their lives

Introduction

Racial disparities in health and health care have been longstanding and persistent in the United States. Even before the coronavirus pandemic, African Americans were experiencing lower rates of health insurance coverage, increased barriers to accessing health care, and worse health outcomes compared to their White counterparts. Black adults in the U.S. also face social and economic inequities, including higher rates of unemployment, that play a major role in shaping health. Beyond these factors, research shows that historic abuse and mistreatment of communities of color by the medical system and ongoing racism and discrimination drive disparities in health, contributing to lower quality of care, distrust of the health care system, and stress and trauma. Reflecting these experiences, KFF surveys dating back to 1999 have documented a gap in trust of health care providers between Black and White Americans.

The COVID-19 pandemic has drawn new attention to and compounded these existing disparities in health and health care. Since the pandemic hit the U.S. in early 2020, a growing body of research has consistently shown that people of color have borne a disproportionate burden of COVID-19, including being at increased risk for exposure and experiencing higher rates of infection, hospitalization, and death. Data also show that people of color are taking a harder hit financially from the economic downturn associated with the pandemic, experiencing higher rates of increases in unemployment and difficulty paying for basic needs. In addition, the deaths of Black men and women including George Floyd and Breonna Taylor at the hands of police, and ensuing protests around the country and the world, have shined a spotlight on inequities in the criminal justice system, and the threat of violence that feels like an all-too-common occurrence for many Black Americans.

In light of these facts, KFF partnered with ESPN’s The Undefeated to conduct a survey exploring African Americans’ views and experiences of being Black in America, focusing on experiences with racism and discrimination, including within the health care system; the impacts of the pandemic; and views of a potential coronavirus vaccine. The survey of over 1,700 U.S. adults includes an oversample of nearly 800 Black Americans to allow for in-depth reporting among this group by age, gender, education, and income, as well as comparison groups of White and Hispanic adults. Other groups, including Asian, American Indian and Alaska Native, and Native Hawaiian and Pacific Islander people are included in the total in proportion to their population, but the sample size is not sufficient to break their responses out separately.

This work builds on KFF’s long history of documenting racial and ethnic disparities in health and health care, as well as our history of using surveys to document the views and experiences of African Americans on broader issues of race, culture, and discrimination in partnership with media organizations like CNN and The Washington Post.

(back to top)

Executive Summary

• The share of Black adults who believe it is a good time to be Black in America has plummeted in recent years, but most believe the current protest movement will lead to meaningful change that will improve Black people’s lives. Just a quarter of Black men now say it is a good time to be a Black man in America, down from 60% in 2006, and just a third of Black women (34%) now say it’s a good time to be a Black woman, down from 73% in 2011. Yet almost six in ten Black adults (57%) believe the current protest movement and fight for racial equality will lead to meaningful change that will improve the lives of Black people in the United States.
• Black Americans – and Black parents in particular – have been especially hard-hit by the coronavirus pandemic, both financially and emotionally. Half of Black adults (compared to 42% of White adults) say someone in their household has lost a job or had their income reduced as a result of the pandemic, and one-third (compared to 17% of White adults) say it has had a major negative impact on their ability to afford basic needs like housing, utilities, and food. Among Black parents, the share reporting income loss rises to two-thirds, and almost half (46%) of Black parents report a major problem affording necessities. Black parents are also more likely than White parents to say the pandemic has had a major impact on their relationships with family members and their ability to care for their children. Overall, Black adults are more likely than their White counterparts to say they that know someone who has died from COVID-19, that they are worried about contracting the virus at work, and that the pandemic has caused a major decline in their mental health. Two-thirds of Black adults think that the federal government would be taking stronger action to fight the pandemic if White people were getting sick and dying at higher rates than people of color.
• About half of Black adults say they would not want to get a coronavirus vaccine if it was deemed safe by scientists and freely available, with safety concerns and distrust cited as the top reasons. By contrast, most White adults say they would get vaccinated, and those who wouldn’t get a vaccine are more likely to say they don’t think they need it. Majorities of Black adults also lack confidence that the vaccine development process is taking the needs of Black people into account, and that when a vaccine becomes available it will have been properly tested and will be distributed fairly.
• Seven in ten Black adults believe race-based discrimination in health care happens at least somewhat often, and one in five say they have personally experienced it in the past year. Black adults are also more likely than those who are White to report some specific negative experiences with health care providers, including providers not believing they were telling the truth or refusing to provide pain medication or other treatments they thought they needed. Two-thirds of Black adults – across income and education levels – say it is difficult to find a health care provider who shares their background and experiences, and one-quarter say they have never received care from a Black doctor. Reflecting these experiences, Black adults are less likely than their White counterparts to say they trust doctors, local hospitals, and the health care system to do what is right for their communities.
• Black women – particularly mothers – report experiencing even higher rates of discrimination in health care settings. Among Black women who have a child under the age of 18, 37% say they have been treated unfairly based on their race while getting health care for themselves or a family member in the past year, and 41% say there was a time in the past three years when a health care provider talked down to them or didn’t treat them with respect. (Among Black men these shares are 15% and 17%, respectively). Black women overall are also more likely than Black men to report feeling that a health care provider didn’t believe they were telling the truth, assumed something without asking, or suggested they were personally to blame for their health problems. 

(back to top)

The Big Picture: Being Black in America Today

Majorities of Black men and women, regardless of age, income, and education, say it is a bad time to be Black in America. The survey finds that Black men and women largely agree that it is a difficult time to be Black in America, a finding that is perhaps not surprising given the disproportionate impact of the coronavirus pandemic on Black families and the national attention drawn to police violence against Black Americans, along with broader issues of systemic racism, over the summer of 2020. Among Black men, just one quarter say now is a good time to be a Black man in America, down 35 percentage points from 60% in a 2006 survey conducted by KFF and The Washington Post. Similarly, the share of Black women who say it’s a good time to be a Black woman in America dropped by more than half, from 73% in a 2011 KFF/Washington Post survey to 34% in 2020. Now, majorities of both groups say it is a bad time to be a Black man (65%) or a Black woman (59%), a finding that holds true across Black men and women regardless of age, income, and education.

When asked to say in their own words the biggest concerns facing them and their families right now, 36% of Black adults cite financial issues and a similar share (34%) cite concerns related to the COVID-19 pandemic. These are also the top two concerns mentioned by White and Hispanic adults, though Black adults are 10 percentage points more likely than White adults to name financial challenges among their top concerns (36% vs. 26%). Conversely, White adults are more likely than Black or Hispanic adults to cite concerns about government and politics, such as the upcoming presidential election (15% of White vs. 7% of Black and 5% of Hispanic). Notably, six percent of Black adults cite issues related to racism as being among their top concerns, and three percent cite worries about police violence.

Most Black adults report experiencing race-based discrimination in the past year. The survey finds that nearly six in ten (58%) Black adults say they were treated unfairly while shopping, working, getting health care, or interacting with police in the past 12 months because of their race or ethnic background. Four in ten Hispanic adults also report experiencing such unfair treatment, compared with just 16% of White adults.

Black adults identify multiple structural and systemic barriers as major obstacles to achieving equal outcomes with White people, as well as individual acts of racism and unconscious bias. When asked about obstacles to Black people achieving equal outcomes with White people in the U.S., larger shares of Black adults compared to White adults view various things as “major obstacles.” At least three-quarters of Black adults see structural or systemic racism (79%) and historic wealth gaps (76%) as major barriers, and about seven in ten say the same about individual acts of racism and discrimination (73%), unconscious bias (71%), limited opportunities for career advancement (70%), and limited access to quality housing (69%). Two-thirds of Black adults see limited access to quality education as a “major obstacle.” The share of White adults viewing each of these things as a major obstacle to Black people achieving equal outcomes with White people is at least 20 percentage points lower than the share of Black adults giving the same answer.

Most Black adults report that unconscious bias, racism and discrimination, and structural and system barriers have been personal obstacles in their lives. When Black adults were asked whether this same list of items had been an obstacle in their own life, the list was similar, but unconscious bias was at the top (71% say this has been an obstacle), followed by about two-thirds who named individual acts of racism and discrimination (65%), structural or systemic racism (65%), and historic wealth gaps (63%). Nearly as many (57%) say that limited opportunities for career advancement has been a personal barrier. Fewer Black adults – about four in ten – see limited access to quality housing (44%) or quality education (41%) as obstacles in their own lives.

Although unconscious bias ranks at the top of the list of personal obstacles, most Black adults who report experiencing discrimination in the past 12 months (58% of all Black adults) say that when people treat them unfairly based on their race, they are usually discriminating on purpose (70%), rather than being unaware they are being unfair (27%).

Despite these challenges, Black Americans are not without hope, with most believing the current protest movement will lead to meaningful change that will improve their lives. A majority (57%) of Black adults say they believe that “the current protest movement and fight for racial equality will lead to meaningful change that will improve the lives of Black people,” while a slight majority (53%) of White adults say they do not think the movement will lead to meaningful change. Hispanic adults respond similarly to Black adults, with 56% saying protests will lead to meaningful change. These racial differences at least partially reflect differing partisanship; 72% of Democrats (including 65% of Black Democrats and 75% of white Democrats) expect the protest movement to lead to meaningful change, while eight in ten Republicans (the large majority of whom are White) expect no meaningful change.

(back to top)

The Disproportionate Impact of the COVID-19 Pandemic

Beyond its stark impacts on health and mortality, the coronavirus pandemic is also having significant economic impacts and taking a toll on individuals’ mental and emotional health. Similar to the disproportionate rates of infection, serious illness, and death people of color are experiencing from the virus, the survey findings show that they also are bearing a disproportionate burden of negative consequences on their financial and emotional well-being.

Black and Hispanic adults are more likely to report employment disruptions and financial hardships associated with the pandemic compared to their White counterparts. With unemployment rising to record levels, about half of all U.S. adults, including higher shares of those who are Black (51%) or Hispanic (57%) compared to 42% of White adults, say that they or someone in their household has lost a job, been placed on furlough, or had their hours or income reduced as a result of the pandemic. The shares are even higher among Black parents with children under age 18 living at home, two-thirds (66%) of whom report a pandemic-related disruption in employment or income.

For many, these employment disruptions are leading to significant financial struggles. About three in ten of those who are Black (32%) or Hispanic (28%) say the pandemic has had a “major negative impact” on their ability to pay for basic necessities like housing, utilities, and food, compared with 17% of White adults. Again, Black parents have been hit particularly hard, with nearly half (46% of Black parents overall, 48% of Black mothers) saying the pandemic has had a major negative impact on their ability to pay the bills.

Black parents also report disproportionate impacts on their ability to care for their children and their family relationships. Larger shares of Black parents than White parents say the coronavirus pandemic has had a “major negative impact” on their ability to care for their children (32% vs. 13%) and on their relationships with family members (25% vs. 12%). Majorities of both Black parents (60%) and White parents (59%) say the pandemic has had a major negative impact on their children’s education.

Black and Hispanic adults are more likely to report the pandemic has had a major negative impact on their mental health and to say they know someone who has died from coronavirus compared to those who are White. The coronavirus pandemic is taking an emotional toll on many Americans, including people of color. While more than half of adults across racial and ethnic groups say the pandemic has had a negative impact on their mental health, the share saying it has had a “major negative impact” is higher among Black and Hispanic adults (28% each) compared to White adults (19%). In addition, four in ten Black adults (39%) and a third of Hispanic adults say they know someone who has died from coronavirus, compared with 24% of those who are White.

Black adults who work outside their homes are also disproportionately worried about contracting the virus while at work. Among those who work outside of their home, six in ten Black adults are worried about getting sick from coronavirus while at work (including 34% who are “very worried”), compared with just under half of White adults who are worried (11% “very worried”). Worry rises to seven in ten among Black women who work outside the home (69%) and among working Black adults who live in a household where someone has a serious health condition (71%).

Two-thirds of Black adults think that the federal government would be taking stronger action to fight the pandemic if White people were getting sick and dying from coronavirus at higher rates than people of color. In contrast, 72% of White people believe the government’s response would not be different. Attitudes among Hispanic adults are more mixed: 42% say the government’s response would be stronger and 47% say it would not be different. These attitudes are also highly partisan, with six in ten Democrats believing the government response would be stronger if more White people were dying and the vast majority (90%) of Republicans saying the response would be no different.

(back to top)

Views Of A Potential COVID-19 Vaccine

With planning beginning for an eventual COVID-19 vaccine, one important consideration is making sure that distribution processes and outreach and communication strategies reach people of color. Vaccination among people of color will be particularly important because they are bearing a heavy, disproportionate burden of the disease, and population immunity is not likely to be reached without high vaccination rates across all communities. However, achieving a high vaccination rate will require public health officials and providers to overcome a range of barriers to vaccination among people of color, many of which are rooted in a historic legacy of abuse and mistreatment by the medical system and ongoing racism and discrimination today. The survey findings provide greater insight into these barriers.

The survey finds that Black adults are less likely than other groups to say they would get a coronavirus vaccine if it was free and determined safe by scientists. Half of Black adults say if a coronavirus vaccine was determined to be safe by scientists and available for free to everyone who wanted it, they would “definitely” or “probably” get vaccinated, compared to six in 10 Hispanic adults and 65% of White adults. In fact, just 17% of Black adults say they would “definitely” get the vaccine, 20 percentage points lower than the share of both Hispanic and White adults (37% each).

The racial differences in willingness to obtain a vaccine widen when partisan differences are taken into account. About three-quarters of Democrats (77%) say they would “definitely” or “probably” get a coronavirus vaccine if it was free and safe, compared to about two-thirds of independents (67%) and just under half of Republicans (47%). Considering both race and partisanship together, the racial divide in vaccine hesitancy among Democrats and independents is stark. Two-thirds (65%) of White Democrats say they would “definitely” get vaccinated, compared with just 23% of Black Democrats. Similarly, among independents, those who are White are more than 3 times as likely to say they would definitely get a vaccine as those who are Black (41% vs. 12%).

Risk factors appear to play a small role in Black adults’ willingness to obtain the vaccine. Six in ten Black adults ages 65 and over – who are at higher risk for serious illness if they contract coronavirus– say they would probably or definitely get vaccinated if a safe vaccine was available for free, slightly higher than among those under age 65. But, Black adults who live in a household where someone has a serious health condition or works in a health care setting – two other groups at disproportionate risk for serious illness or exposure – are not significantly more likely than their counterparts to say they would be willing to take a vaccine.

The racial difference in willingness to take a coronavirus vaccine may at least partially reflect a difference in attitudes towards vaccines in general. Black adults are less likely than their White counterparts to say they usually get a flu vaccine each year (49% vs. 60%). Still, this doesn’t explain the difference entirely, as Black adults who normally get a flu vaccine are 18 percentage points less likely than White adults who normally get a flu vaccine to say they would get a vaccine for coronavirus if it was determined to be safe and freely available (66% vs. 84%).

The primary reasons Black adults cite for saying they definitely or probably would not get a coronavirus vaccine are safety concerns and distrust of the health care system. When asked to say in their own words why they would not get a coronavirus vaccine, four in ten Black adults (39%) cite safety concerns, as do three in ten White adults. Thirty-five percent of Black adults who say they won’t get vaccinated cite distrust in either the health care system, the government, or vaccines in general as a reason, higher than the share of White adults who say the same (23%). By contrast, White adults who say they won’t get vaccinated are more likely than Black adults to say they don’t want or need a vaccine or don’t think they’re at risk of getting sick from coronavirus (39% vs. 21%). Six percent of both Black and White adults who say they would not get vaccinated cite concerns about the vaccine development process.

Overall, a majority of Black adults express concerns about whether an eventual vaccine will have been properly tested for safety and effectiveness and whether it will be distributed fairly. Nearly two-thirds (65%) of Black adults are “not at all confident” or “not too confident” that the development of the vaccine is taking the needs of Black people into account. Moreover, six in ten Black adults (61%) say they are “not too confident” or “not at all confident” that an eventual vaccine will have been properly tested for safety and effectiveness, and 66% are not confident that it will be distributed in a way that is fair. By contrast, about half of Hispanic adults and about six in ten White adults say they are at least somewhat confident that a vaccine will be properly tested and that it will be distributed fairly.

(back to top)

Trust And Experiences In The Health Care System

The longstanding and persistent racial disparities in health reflect a variety of factors both within and beyond the health care system, including differences in health insurance coverage, health care access, and social and economic factors that influence health. Moreover, research shows that racial disparities in health persist after controlling for these factors, suggesting that other factors, including historic and ongoing racism and discrimination, play a role in driving these differences. The survey findings provide greater insight into how racism and discrimination shape Black adults’ experiences with the health care system.

Trust of Providers and Hospitals

Reflecting their experiences with discrimination and systemic racism, Black people express lower levels of trust in a variety of organizations and institutions compared to those who are White. The gulf is widest when asked how often they can trust the police to do what is right for them and their community – just 30% of Black adults say they can trust the police “almost all of the time” or “most of the time,” compared with 72% of White adults. A little over half of Hispanic adults (56%) say they can trust the police.

While Black and Hispanic adults are generally more trusting of doctors and hospitals than they are of the police, courts, and schools, there is a racial gap in trust when it comes to health care as well. Compared to White adults, Black adults are 19 percentage points less likely to trust doctors (59% vs. 78%), 14 percentage points less likely to trust local hospitals (56% vs. 70%), and 11 percentage points less likely to trust “the health care system” (44% vs. 55%) to do what is right for them and their communities. On each of these items, the responses for Hispanic adults fall in between those of Black and White adults.

There is an age gap in trust as well, with younger Black adults less likely than their older counterparts to say they trust doctors and the health care system to do what is right for them and their communities. For example, roughly half of Black adults under age 50 say they can trust doctors almost all or most of the time, compared with about 7 in 10 Black adults ages 50 and over.

Perceptions of Unfair Treatment in Health Care

Most Black adults feel the health care system treats people unfairly based on their race or ethnic background, and this share has increased over time. Fully seven in ten Black adults say that “our health care system treats people unfairly based on their race or ethnic background” very often or somewhat often, compared to 41% of White adults and 43% of Hispanic adults.

The share of Black adults who believe race-based discrimination in health care happens very or somewhat often has increased over the past 20 years (from 56% in 1999 to 70% now), while the shares among Hispanic and White adults have remained statistically similar to what they were in 1999.

Black adults identify a range of reasons why Black people have worse average health outcomes compared to White people. When asked about potential reasons why Black people in the U.S. have worse outcomes on average compared to White people, Black adults are much more likely than White adults to view various factors as major reasons, including disparities in access to health care and insurance (72% vs. 49%), environmental exposures (70% vs. 40%), and disparities in the level of care provided to Black vs. white patients (54% vs. 26%). Black adults are also somewhat more likely than their White counterparts to blame lack of healthy behaviors (38% vs. 24%) and genetic differences (26% vs. 14%) for racial disparities in health outcomes. The perception of the role of genetic differences stands in contrast to research disproving biologic differences as a driver of racial disparities in health; moreover, there is growing recognition that individual health behaviors are influenced by policies, systems, and environments.

Experiences With and Access to Health Care Providers

A significant and longstanding body of research suggests that provider and institutional bias and discrimination are drivers of racial disparities in health, contributing to racial differences in diagnosis, prognosis, and treatment decisions. Research further points to the role of communication and interactions between providers and patients and suggests that enhancing providers’ ability to provide culturally and linguistically appropriate care as well as increasing diversity of the health care workforce may help address disparities in health. Reflecting these factors, studies show, for example, that people of color receive lower quality of care, receive less adequate treatment for acute and chronic pain, and report higher rates of mistreatment during the course of their pregnancy. Pointing to the importance of culturally competent care, one recent study found that there were significant improvements in mortality for Black newborns who were cared for by Black physicians. Beyond these factors, people of color may face increased difficulty accessing care due to cost or lack of easily accessible providers, among other factors. The survey findings provide greater insight into individuals experiences with health care providers and their ability to access providers, including those with a shared background and experience.

One in five Black and Hispanic adults report they were personally treated unfairly because of their race and ethnicity while getting health care in the past year, with higher shares among younger Black adults and women, particularly mothers. Twenty percent of Black adults and 19% of Hispanic adults say they were personally treated unfairly because of their race or ethnicity when getting health care for themselves or a family member in the past 12 months, while just 5% of White adults say this has happened to them. Younger Black adults (23% of those ages 18-29 and 28% of those ages 30-49) and Black women (25%) are more likely than older Black adults to report being treated unfairly when receiving care. Among Black mothers of children under age 18, nearly four in ten (37%) say they have been treated unfairly in the past 12 months while getting health care for themselves or a family member. Familiarity with the medical community also does not appear to shield Black adults from discrimination in health care settings; 34% of those who work in a health care delivery setting or live with someone who does say they’ve experienced race-based discrimination while getting health care in the past year.

In addition to reporting being treated unfairly, an even larger share of Black adults – 36% – say there was a time in the past few years when they think they would have gotten better medical care if they belonged to a different race or ethnic group. Mirroring age patterns of reported discrimination, Black adults under age 50 are more likely than those ages 50 and over to feel they would have gotten better care if they were a different race.

Across racial and ethnic groups, many adults report having some specific negative experiences with health care providers. Overall, about a quarter of adults say that in the past 3 years, a doctor or other health care provider has assumed something about them without asking (24%) or talked down to them or treated them without respect (23%). Just under one in five say there was a time in the past 3 years when a provider didn’t believe they were telling the truth (19%) or suggested they were personally to blame for a health problem (17%). About one in seven say a doctor refused to order a test or treatment (14%) or pain medication (13%) they thought they needed.

Black adults are more likely than White adults to report some negative experiences with health care providers. These differences include feeling that a provider didn’t believe they were telling the truth (22% of Black adults vs. 17% of White adults say this happened to them in the past 3 years), being refused a test or treatment they thought they needed (19% vs. 12%), and being refused pain medication (18% vs. 13%). Other negative experiences were reported at similar rates among Black and White adults, including health care providers suggesting they were personally to blame for a health problem, assuming things without asking, and treating them with a lack of respect. About half of Black adults (49%), a similar share of White adults (45%), and four in ten Hispanic adults (39%) report experiencing at least one of these things in the past 3 years. Together, these findings suggest that across groups, patients encounter negative experiences obtaining care, but Black people are more likely to report negative experiences in some specific instances.

Interestingly, most Black adults who experienced at least one form of mistreatment do not believe their race was a factor. About four in ten (38%) of those who had at least one negative experience (19% of all Black adults) think it happened specifically because of their race, while the majority (27% of all Black adults) say it was for some other reason.

In addition to differences by race, there are also gender differences in the treatment people report receiving from health care providers. Black women are more likely than Black men to report feeling that a health care provider didn’t believe they were telling the truth (27% vs. 16%), assumed something without asking (32% vs. 22%), talked down or treated them without respect (27% vs. 17%), or suggested they were personally to blame for their health problems (24% vs. 15%). Among Black women with children, the share who say a health care provider talked down to them or treated them with disrespect rises to 41%.

In most cases, there are similar gender gaps between the experiences of White women and men as well, though when it comes to being personally blamed for their health problems, the opposite pattern is true, with White men more likely than White women to report this experience.

Black and Hispanic adults are more likely than their White counterparts to say it’s difficult to find a doctor who shares their background and experiences and one who treats them with dignity and respect. About two-thirds (65%) of Black adults and over half (54%) of Hispanic adults say it is very or somewhat difficult for them to find a doctor who shares their background and experiences, while most White adults (53%) say this is easy. Similarly, about one in five adults who are Black (21%) or Hispanic (22%) say it is difficult to find a doctor who treats them with dignity and respect, compared to a smaller share of those who are White (14%).

Among White adults, those with college degrees are much more likely than those without a degree to say it’s easy to find a doctor who shares their background and experience. However, this education advantage does not exist among Black adults. Nearly two-thirds (64%) of Black adults with a college degree say it’s difficult to find a doctor who shares their background and experience, about two and a half times the rate among college-educated White adults (27%). The pattern is similar across income groups – higher-income White adults are more likely than those with lower incomes to say it is easy to find a provider who shares their background and experiences, while about two-thirds of Black adults across income groups say it is difficult.

For Black and Hispanic Americans, finding a doctor who shares their background and experience may or may not mean seeing a doctor of the same race or ethnicity. In fact, about one quarter (24%) of Black adults say they would prefer to see a Black doctor, while most say it doesn’t make much difference. Still, 24% of Black adults say they’ve never received care from a Black doctor, including 35% of those ages 18-29 and 28% of those who say they would prefer to see a doctor who is Black. A similar 28% of Hispanic adults say they’ve never received care from a doctor who is Hispanic or Latino.

Black and Hispanic adults are more likely than White adults to report financial and accessibility barriers to obtaining health care. About half of Black (48%) and Hispanic (49%) adults say it is very or somewhat difficult to find health care they can afford, compared to a somewhat smaller share of White adults (39%). Similarly, about a quarter (24%) of Black adults and three in ten Hispanic adults say it is difficult to find health care at a location that is easy for them to get to, compared to 18% of White adults.

The differences between Black and White adults on these questions are largely driven by income differences. That is, those with lower incomes generally report more difficulty finding accessible and affordable care than those with higher incomes, and Black and White adults at similar income levels report similar levels of difficulty on both these measures.

(back to top)

Conclusion

These survey findings highlight some of the many challenges facing Black individuals and families in 2020. Black people in the U.S. are bearing a heavy burden of the health and economic consequences of the COVID-19 pandemic, and the survey shows the pandemic is taking an unequal toll on their financial stability, their ability to care for their children, and their emotional well-being. The findings further illustrate that, once a COVID-19 vaccine becomes available, accomplishing a high vaccination rate will require addressing multiple barriers to vaccination among the Black community, including building public trust and willingness to obtain the vaccine by addressing distrust and safety concerns.

In addition, despite longstanding research documenting racial health disparities, the survey shows that racism and discrimination still play a major role in shaping people’s perceptions and experiences with obtaining health care. Most Black adults believe that race-based discrimination in health care happens at least somewhat often, and they are more likely compared to White adults to report experiencing specific negative experiences with health care providers. Many of these experiences are even more common among Black women, particularly those with children. Black adults also face difficulties finding providers who share their background and experiences and treat them with dignity and respect, as well as challenges finding health care they can afford and easily access – challenges shared by Hispanic adults. These findings point to the importance of continuing to prioritize equity in health care, and, in particular, efforts to address individual and institutional bias and discrimination and social and economic inequities that increase barriers to health.

(back to top)

The KFF/The Undefeated Survey on Race and Health is based on interviews conducted in English and Spanish with a nationally representative sample of 1,769 U.S. adults ages 18 and older, including an oversample of Black adults. Specifically, the survey oversampled mothers, people younger than 30, and college-educated respondents who identify as Black or African American. The survey was conducted August 20-September 14, 2020, using a hybrid design that combined a stratified, dual-frame (landline and cell phone) random digit dial (RDD) telephone sample (N=1,303) with a probability-based web/phone panel (N=466). Sampling, data collection, weighting, and tabulation were managed by SSRS of Glen Mills, PA, in close collaboration with Kaiser Family Foundation researchers. Teams from KFF and The Undefeated worked together to develop the questionnaire and analyze the data, and both organizations contributed financing for the survey. Each organization is solely responsible for its content.

For the RDD sample, computer-assisted telephone interviews were conducted with respondents reached by cell phone and landline. To efficiently obtain a sample of Black respondents, the RDD sample was stratified to oversample areas with a high population share of Black adults. The telephone sample also included 226 respondents reached by calling back Black respondents (predominantly those who previously indicated they were college graduates or under age 30) who had previously completed an interview on the SSRS Omnibus poll, a weekly dual-frame RDD telephone survey. Both the RDD landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone.

Panel interviews were conducted using the SSRS Opinion Panel, a representative probability-based panel of adults ages 18 and over living in the United States, recruited using the SSRS Omnibus poll and through address-based sampling (ABS). Panel members who do not have internet access complete surveys via telephone, and internet users complete surveys via the web (for the current study, 38 panel respondents completed via phone and 428 completed via web). A total of 233 Black panelists were included, targeting those who previously indicated they were mothers of children under age 18, college graduates, or under the age of 30. In addition, 233 non-Black panel members were included so that any differences in the mode of data collection would not impact the Black sample alone. In total (including the RDD sample and phone interviews from the panel sample), 283 interviews were completed via landline and 1,058 via cell phone (including 749 who could not be reached via landline); 428 interviews were completed via web.

The combined landline, cell phone, and web sample was weighted to match the sample demographics to estimates for the national population. A multi-stage weighting process was used to adjust for the fact that not all survey respondents were selected with the same probabilities and to account for systematic non-response. In the first weighting stage, adjustments were made to 1) correct for the oversampling of different groups; 2) account for the fact that respondents with both a landline and cell phone have a higher probability of selection in the RDD sample; 3) adjust for likelihood of non-response for the re-contacted sample; 4) match estimates of the population (Black and non-Black) that do not use the internet based on estimates from the Pew Research Center; and 5) match current patterns of telephone use (Black and non-Black) according to the June-December 2019 National Health Interview Survey. In the second weighting stage, the sample was weighted (separately for Black and non-Black respondents) to match demographics of the adult U.S. population using data from the Census Bureau’s 2018 American Community Survey (ACS) on age by gender, education, race and Hispanic origin (for non-the non-Black sample), parent status (by gender), metropolitan status, and Census region. Weights were then trimmed separately for the Black and non-Black samples, and in the final stage, the samples were combined and adjusted to ensure the proportion of Black respondents in the total sample would equal their share of the adult population. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

U.S. Supreme Court decisions shape health policy in important ways. The nomination of Judge Amy Coney Barrett, if confirmed, is expected to establish a solid 6:3 conservative majority that could affect case outcomes in several areas. This issue brief considers the potential implications of a reconfigured Court for health policy issues, including those already on the Court’s docket for the coming term and those that the Court may choose to consider in this term or in the future:

• The future of the ACA: The Court will decide California v. Texas, a case that could determine whether the entire Affordable Care Act can continue, with significant implications for the U.S. health care system and virtually every American. Oral argument is scheduled for November 10, 2020.
• Cases requesting Supreme Court review:
  • Abortion: The Court may decide to consider one or more cases that could overturn the precedent of Roe v. Wade, alter the standard to evaluate whether abortion regulations are constitutional, or decide that abortion providers cannot sue to challenge abortion regulations.
  • Title X: The Court is likely to want to resolve conflicting appeals court decisions about whether the Trump Administration Title X Federal Family Planning regulations that prohibit federal funding to clinics that offer or refer for abortion are permissible under federal law.
  • Medicaid enrollees’ free choice of provider: The Court will decide whether to hear a case about whether Medicaid enrollees can sue to challenge a state’s refusal to allow Planned Parenthood to offer Medicaid services if that provider also separately offers abortion services (which are not covered by Medicaid). Federal appeals courts are split on this issue. The case has implications for enrollees’ ability to bring lawsuits challenging state violations of federal Medicaid law as well as enrollees’ free access to providers.
  • Medicaid work requirements: The Court will decide whether to hear cases about whether the HHS Secretary can approve Section 1115 waivers that condition Medicaid eligibility on meeting work and reporting requirements, which have led to over 18,000 people losing coverage in Arkansas.
• Cases that could reach the Supreme Court:
  • Payment of ACA cost-sharing reductions to insurers: The Court could be asked to hear cases brought by Marketplace insurers seeking unpaid cost-sharing reductions (CSRs) from the Trump Administration. Restoring CSR payments could lower Marketplace premiums and federal costs and improve affordability for individuals who do not qualify for Marketplace premium tax credits.
  • Nondiscrimination in health coverage and care: The Court could be asked to review cases challenging the Trump Administration’s rollback of regulations implementing ACA Section 1557, which bans discrimination in health programs and activities that receive federal funding. Issues include whether discrimination based on gender identity is prohibited and the extent to which individuals and entities are exempt from discrimination claims based on religious freedom.
  • Public charge rule: The Court could be asked to review cases challenging the Trump Administration’s regulations that prevent individuals from obtaining a green card or entering the U.S. if they are determined likely to use certain public programs, including Medicaid. The regulations are likely to lead to decreased participation in Medicaid by immigrant families and their primarily U.S. born children.
  • Hospital price transparency rule: The Court could be asked to hear a challenge to the Trump Administration’s regulations requiring hospitals to disclose their negotiated rates with insurers. The Administration argues that the regulations could lead to lower costs for consumers. However, if the Supreme Court accepts the argument, supported by the Trump Administration, that the entire ACA is invalid, Congress would need to pass new legislation before any price transparency regulations could be adopted.

Introduction

Along with legislation and administrative agency actions, U.S. Supreme Court decisions shape health policy issues in important ways. In the upcoming October 2020 term, the Court will hear a case involving the Affordable Care Act’s (ACA) survival. It also will decide whether to review cases involving abortion, Title X, Medicaid enrollees’ free choice of provider, and Medicaid work requirements. Other cases affecting health policy may reach the Court, such as payment of ACA cost-sharing reductions to Marketplace insurers, whether gender identity and sexual orientation are prohibited bases of discrimination in health care, issues affecting immigrants’ access to health coverage under the public charge rule, and regulations requiring hospital price transparency. With the exception of the abortion cases, all of these cases involve federal regulations and laws and could become moot if the administration and congressional majorities change. For example, if Congress raises the tax above zero dollars for failure to comply with the individual mandate, the question raised in the ACA case could become moot before the Supreme Court issues a decision.

Members of the Court, including Chief Justice John Roberts, reject the assertion that judicial decisions may be motived by particular political party’s ideology. Still, analysis of the justices’ voting patterns reveals a spectrum with those appointed by Democratic Presidents typically supporting positions characterized as liberal and those appointed by Republican Presidents typically supporting positions characterized as conservative. As with any generalization, there can be exceptions, as the issues before the Court and its composition evolve over time. Even so, the recent death of Justice Ruth Bader Ginsburg and the nomination of Judge Amy Coney Barrett, if confirmed, to fill the empty seat is expected to establish a solid 6:3 conservative majority that could affect case outcomes in a number of areas.¹  This issue brief considers the potential implications of a reconfigured Court for key health policy issues, including the ACA case, scheduled to be heard November 10, 2020, and cases the Court may choose to consider this term or in the future.

The Supreme Court Will Decide the Future of the ACA

The Court will once again consider the survival of the Affordable Care Act (ACA) in California v. Texas, a case with far-reaching consequences, affecting nearly every American in some way.²  Currently scheduled for oral argument on November 10, 2020, the case challenges the constitutionality of the ACA’s individual mandate and asks the Court to decide whether the entire law can continue. A group of Republican-led states and two individuals who have purchased Marketplace coverage argue that, because Congress reduced the payment for failure to comply with the individual mandate to zero dollars, the mandate is no longer a constitutional tax. They further argue that the rest of the law is not severable from the mandate, so the entire ACA must be invalidated as a result. Notably, the Trump Administration is not defending the ACA. Instead, the Administration is arguing that the entire ACA is invalid, though it is asking the Court to prohibit it from enforcing only the provisions that ultimately are found to harm the individual plaintiffs.

A decision by the Court invalidating all or even some of the ACA would have significant implications for the U.S. health care system and virtually every American. At stake are the ACA’s changes to the individual insurance market, including protections for people with pre-existing conditions, restrictions on premium surcharges based on health or gender, coverage of essential benefits, insurance marketplaces, and premium subsidies for people with low and modest incomes. Overturning the ACA could also roll back other changes throughout the health care system including expanding Medicaid eligibility for low-income adults; requiring private insurance, Medicare, and Medicaid expansion to cover preventive services with no patient cost sharing; phasing out the Medicare prescription drug doughnut hole coverage gap; reducing the growth of Medicare payments to health care providers and insurers; establishing new national initiatives to promote public health, care quality, and delivery system reforms; and authorizing a variety of tax increases to finance these changes.

Cases Requesting Supreme Court Review

There currently are cases in three key health policy cases requesting certiorari, for the Supreme Court to accept the case to review this term. Four justices must vote to accept a case.

Abortion

If the Court accepts a case involving abortion, the precedent of Roe v. Wade could be overturned or states could be granted more authority to restrict abortion access or doctors could lose the ability to sue to challenge abortion regulations.  Among the most contentious issues in the country right now is abortion. There are two abortion cases the Supreme Court is currently considering whether to hear.

The first case is Thomas E. Dobbs, State Health Officer of the Mississippi Department of Health  v. Jackson Women’s Health Organization. This case involves a Mississippi law, House Bill 1510, Gestational Age Act, banning all abortions over 15 weeks’ gestational age except in medical emergencies and in the case of severe fetal abnormality. The Court’s ruling could allow states to restrict abortions by directly overturning Roe v. Wade, establishing a new standard to evaluate state restrictions with more deference to state legislatures, or overturning the long held precedent that abortion doctors and clinics have the right to bring lawsuits to challenge abortion regulations on behalf of their patients (third-party standing). If the Court overturns Roe v. Wade, 15 states have laws in place that would immediately ban abortion. If the Court allows more deference to states on restricting abortions, patients may not be able to access abortion in many states. If the Court decides that doctors and clinics no longer have the right to challenge abortion regulations on behalf of their patients (third-party standing), abortion would remain a constitutional right, but many unconstitutional abortion regulations may go unchallenged. Women seeking abortions often must overcome numerous obstacles, including financial limitations, and concerns for privacy and personal safety, that would make it difficult for them to assert their constitutional rights and challenge an abortion restriction. This could have far-reaching implications for other cases where third-party standing has been recognized including physicians’ ability to challenge laws on behalf of their patients’ rights to privacy for contraception, and to obtain mental health services.

The second case at the Supreme Court is Food and Drug Administration v. American College of Obstetricians and Gynecologists. In this case, the FDA is requesting that the Court lift the national injunction issued by the United States District Court of Maryland preventing the FDA from enforcing the Risk Evaluation and Mitigation Strategies (REMS) requirements for mifepristone, the abortion medication, during the COVID-19 pandemic. The REMS only permit medical providers who have received special certification from the manufacturer to prescribe and dispense the drug which limits access to abortion during the emergency. On October 8, 2020, the Supreme Court directed the FDA to request that the district court to lift or modify the preliminary injunction before the Supreme Court rules on the issue. It is possible that this unusual order to not rule on the stay until the FDA requests the district court to reconsider the scope of the injunction may reflect a compromise when there are only eight justices. When the case comes back to the Supreme Court, there will likely be nine justices. While this case could be limited to the availability of mifepristone during the pandemic, the case could have broader implications because the Solicitor General is requesting that the Court accept this case in order to clarify the legal standard that should be applied to determine if abortion regulations are constitutional.

Title X Family Planning Regulations

To resolve a split between the 9th Circuit Court of Appeals and the 4^th Circuit Court of Appeals, the Court will likely consider a case challenging the Trump Administration’s Title X regulations. These regulations effectively block the availability of Title X grants to family planning clinics that offer abortion services with other non-federal funds, curtail counseling, ban Title X projects from making referrals to abortion services, and require all pregnant patients served by Title X clinics to be referred for prenatal services, regardless of their pregnancy intention.

The Court’s decision could uphold the regulations, which have resulted in 29% of the Title X family planning sites to leave the Title X Program and six states to completely withdraw from the program. This would likely affect the availability of affordable family planning services to low-income people in many parts of the country. Eight lawsuits challenging the regulations were filed in federal court. There is a split in decisions between the 4th Circuit Court of Appeals, which held that the regulations are arbitrary and capricious and contrary to law, and the 9th Circuit Court of Appeals, which allowed the regulations to go into effect. The regulations are currently blocked in Maryland, but in effect in the rest of the county. The American Medical Association, Oregon Medical Association, Planned Parenthood Federation of America, National Family Planning and Reproductive Health Association, and Essential Access Health, Inc. have petitioned the Court to review the case from the 9^th Circuit to resolve the circuit split. The Oregon Attorney General with 21 other Attorneys General separately petitioned the Court to review the case from the 9^th Circuit. HHS has also petitioned the Court to review the case from the 4^th Circuit. Many provisions in the Trump Administration’s regulation mirror those issued in 1988 by the Reagan Administration. In 1991, the Supreme Court upheld the Reagan regulations in the case, Rust v. Sullivan.

The petitioners asking for review from the 9^th Circuit argue that the applicable law has changed, and that Rust v. Sullivan is not controlling. The Court’s ruling about the future of the ACA may ultimately impact the decision for the Title X case. One of the key arguments for those challenging the regulations is based on the violation of Section 1554 of the ACA, which states that HHS shall not promulgate any regulations that create any unreasonable barriers to the ability of individuals to obtain appropriate medical care or restricts communications between a doctor and a patient. They contend that these Title X regulations create barriers to and restrict patient-doctor communication. However, HHS contends that Rust v. Sullivan is controlling and that the agency has the statutory authority to promulgate these regulations.

Medicaid Enrollees’ Free Choice of Provider

The Court will decide whether to hear Baker v. Edwards, a case about whether Medicaid enrollees can sue to challenge a state’s refusal to allow a provider to participate in Medicaid if that provider also separately offers abortion services (not covered by Medicaid). Federal law requires states to allow Medicaid enrollees to obtain covered services from any qualified willing provider. South Carolina’s Medicaid agency terminated Planned Parenthood as a Medicaid provider after the governor issued an executive order declaring that providers are “unqualified” to participate in Medicaid  if they also offer abortion. Planned Parenthood and one of its Medicaid patients sued to challenge this state action, and the lower court issued a preliminary injunction allowing Planned Parenthood to continue as a South Carolina Medicaid provider while the case is pending. The Fourth Circuit Court of Appeals found that a Medicaid enrollee has the right to sue in federal court to enforce Medicaid’s free choice of provider requirement. The Medicaid Act itself does not explicitly authorize third parties, like Medicaid enrollees, to sue to enforce its provisions. However, the Fourth Circuit Court of Appeals found that the enrollee can sue under federal civil rights law, Section 1983, which allows individuals to bring federal lawsuits to challenge state actions that deprive them of rights provided under federal law. The Fourth Circuit joins the Fifth, Sixth, Seventh, Ninth, and Tenth Circuit Courts of Appeals in upholding a Medicaid enrollee’s right to sue to enforce the free choice of  provider provision, while the Eighth Circuit Court of Appeals has ruled that Medicaid enrollees cannot bring these lawsuits.

If the Court rules that the enrollees cannot sue to enforce the free choice of provider provision, state rules restricting provider participation in Medicaid may go unchallenged. Medicaid enrollees have often sued as third parties to enforce the free choice of provider provision. Removing the ability of enrollees to sue also eliminates the availability of an injunction to allow providers to continue to participate in Medicaid while the merits of a case are decided. In an earlier case, former CMS administrators explained that the agency does not have the resources to investigate all potential violations of federal Medicaid law and relies on third parties like Medicaid enrollees to bring lawsuits to challenge state actions. If unchallenged, state actions restricting enrollees’ free choice of provider can limit enrollees’ access to covered services. Planned Parenthood in South Carolina provides Medicaid enrollees services including physical exams, cancer screening, contraception, pregnancy testing, and screening for chronic conditions such as diabetes, depression, anemia, cholesterol, thyroid disorder, and high blood pressure.

Medicaid Work Requirements

The Court will decide whether to hear Azar v. Gresham and Azar v. Philbrick, cases about whether the Health and Human Services Secretary can approve Section 1115 demonstration waivers authorizing Medicaid work requirements and other restrictive provisions.³  The Trump Administration is seeking review of a unanimous DC Circuit Court of Appeals decision which found that the Secretary’s waiver approval in Arkansas was unlawful because he failed to consider the impact on coverage as required by the statute.⁴  The Administration also is seeking review of a second appeals court decision in which the court concluded that the reasoning of its Arkansas decision required a similar outcome in a case challenging a New Hampshire waiver approval.

Court decisions about the bounds of the Secretary’s Section 1115 authority not only determine the legality of Medicaid work requirements in Arkansas and New Hampshire, but also could have implications for similar waivers in other states and the Secretary’s discretion in approving waivers more broadly. To date, Arkansas is the only state to have implemented a waiver that conditioned Medicaid eligibility on meeting a work and reporting requirement, with significant effects on enrollees. Before Arkansas’ waiver was set aside by a lower court, over 18,000 Medicaid enrollees lost coverage in that state. The Trump Administration has continued to expand the bounds of the Secretary’s Section 1115 authority, issuing guidance inviting states to apply for new waivers that would impose work requirements and other eligibility and benefit restrictions in exchange for a federal financing cap, and currently is considering a “modified block grant” proposal from Tennessee.

Cases That Could Reach the Court

Payment of ACA Cost-sharing Reductions to Insurers

The Court could be asked to hear appeals in the lawsuits brought by Marketplace insurers seeking unpaid cost-sharing reductions (CSRs), Community Health Choice v. U.S. The ACA requires CSR payments to compensate insurers for reducing out-of-pocket costs such as deductibles and copayments to Marketplace enrollees with income from 100-250% of the federal poverty level. In October 2017, the Trump Administration stopped making CSR payments, on the basis that Congress had not appropriated funds. The ACA still required insurers to offer plans with CSRs to enrollees, so insurers sued the federal government to recover their CSR costs. In August 2020, a three-judge panel of the Federal Circuit Court of Appeals ruled that the federal government must reimburse insurers for CSR costs. However, the appeals court limited the amount that insurers can recover, finding that payments must be reduced by the amount insurers received in higher premium tax credits due to “silver loading.” For example, many insurers increased premiums on silver level plans – which are the benchmarks for ACA premium subsidies — to account for unpaid CSRs. Consequently, the amount of CSR costs that any insurer may recover could vary based on the degree of premium loading each has adopted. Both insurers have asked the entire appeals court to rehear the case, and the federal government may join in this request.

The outcome of this case also has implications for the federal deficit and for individuals who do not qualify for premium tax credits and therefore pay full Marketplace plan premiums. Because the second-lowest cost silver level plan is used to determine the premium tax credit amount, higher silver level premiums result in higher premium tax credit costs for the federal government. In 2017, when the Trump Administration ended CSR payments to insurers, the Congressional Budget Office estimated that premium loading would increase the overall federal cost of Marketplace premium tax credits by about $10 billion per year. If CSR payments to insurers resume and premium loading stops, the overall cost of Marketplace premium tax credits could be reduced. Premium loading also can result in higher premiums for Marketplace enrollees with incomes above 400% of poverty who are ineligible for premium tax credits and must bear the entire premium cost. Resuming CSR payments to insurers could result in a downward adjustment of silver level Marketplace plan premiums, lowering costs for these enrollees.

Nondiscrimination in Health Coverage and Care

One or more of the pending lawsuits challenging the Trump Administration’s rollback of regulations implementing ACA Section 1557’s prohibition of discrimination in health programs and activities receiving federal financial assistance could reach the Court. The Trump Administration’s June 2020 final regulations eliminate the prior regulations’ nondiscrimination protections based on gender identity and specific health insurance coverage protections for transgender individuals issued by the Obama Administration; adopts blanket abortion and religious freedom exemptions for health care providers; reduces protections for those with limited English proficiency; and limits the activities and entities covered, among other provisions. It also eliminates prohibitions on discrimination based on gender identity and sexual orientation in ten other federal regulations outside Section 1557.

The Court could be asked to confirm that its recent decision finding that sex discrimination includes sexual orientation and gender identity in the employment context also applies to the health care context and to determine the parameters of religious freedom objections. Just after the Trump Administration published its final Section 1557 regulations, the Supreme Court decided Bostock v Clayton County, Georgia, finding that sex discrimination includes sexual orientation and gender identity in the employment context. In Bostock, the Court said that questions about the intersection of religious freedom and nondiscrimination protections “are questions for future cases.” Based on the Bostock decision, two federal courts issued nationwide preliminary injunctions blocking parts of the final Section 1557rule: NY and DC courts blocked provisions excluding sex stereotyping from the definition of sex discrimination, and the DC court also blocked the religious freedom exemption. The NY court is now considering whether to block other provisions of the rule, and other lawsuits are pending.

Public Charge Rule

The Court could be asked to review one or more of the pending lawsuits challenging the Trump Administration’s final rule changing public charge policy to prevent individuals from obtaining a green card or entry into the U.S. if they are determined likely to use certain public programs, including Medicaid. Longstanding policy allows the federal government to deny an individual entry into the U.S. or adjustment to legal permanent resident (LPR) status (i.e., a green card) if he or she is determined likely to become a public charge. Under the Trump Administration rule, officials will newly consider use of certain previously excluded programs, including non-emergency Medicaid for non-pregnant adults, the Supplemental Nutrition Assistance Program (SNAP), and several housing programs, in public charge determinations. As of September 11, 2020, a nationwide preliminary injunction blocking the rule was lifted, allowing the Administration to implement the rule while litigation continues.

The public charge changes will create new barriers to getting a green card or immigrating to the U.S. and likely lead to decreases in participation in Medicaid and other programs among immigrant families and their primarily U.S.-born children beyond those directly affected by the new policy. Nationwide, over 13.5 million Medicaid and Children’s Health Insurance Program (CHIP) enrollees, including 7.6 million children, live in a household with at least one noncitizen or are noncitizens themselves and may be at risk for decreased enrollment a result of fear and uncertainty surrounding the rule. Decreased participation in these programs would contribute to more uninsured individuals and negatively affect the health and financial stability of families and the growth and healthy development of their children. Growing fear and uncertainty among individuals in immigrant families may also lead to some individuals avoiding accessing services including health care and/or enrolling in public programs, including health coverage through Medicaid and CHIP, even if they are eligible for them.

Hospital Price Transparency

The Court could be asked to review a case challenging the Trump Administration’s regulations implementing the ACA’s hospital price transparency requirement, American Hospital Association v. Azar. The ACA requires each hospital to publicly disclose an annual “list of the hospital’s standard charges for items and services provided by the hospital.” Following President Trump’s Executive Order on improving price and quality transparency, in November 2019, HHS issued final regulations effective January 2021, requiring hospitals to disclose their negotiated rates with insurers and authorizing financial penalties for failure to comply. The new regulations would replace those issued by the Obama Administration, which interpreted the ACA as requiring disclosure only of hospitals’ list prices (or gross charges), absent any discounts. In December 2019, the American Hospital Association with other hospital and health system groups challenged the Trump Administration’s regulations, contending that the statute only allows the Administration to require disclosure of standard list prices, not “custom” negotiated prices. In June 2020, the DC federal district court ruled in favor of the Administration, finding that the new regulations are a reasonable interpretation of “standard charges,” and the ACA authorizes the imposition of penalties. The district court also found that the regulations do not violate the hospitals’ First Amendment right to free speech because the requirements are reasonably related to the government’s interests in “providing consumers with factual price information to facilitate more informed health care decisions” and “lowering healthcare [sic] costs.”  The plaintiffs appealed the case the D.C. Circuit Court of Appeals, which will hear oral argument on October 15, 2020.

If the Supreme Court accepts the argument in California v. Texas, supported by the Trump Administration, that the entire ACA is invalid, then Congress would need to pass new legislation before any hospital price transparency regulations could be adopted. The Trump Administration argues that these regulations are necessary to implement the ACA provision that requires hospitals to publicly disclose their standard charges; without the ACA, the Administration would have no legal authority to issue any price transparency regulations. The Trump Administration and organizations supporting the regulations contend that disclosure of negotiated prices is necessary to tackle rising hospital costs by enabling consumers to meaningfully compare prices and improving competition. The hospitals and organizations opposing the regulations maintain that disclosure will not lead to lower costs because the regulations are burdensome to implement and could create “confusion” among consumers between insurers’ reimbursement rates and consumers’ out-of-pocket costs.

Looking Ahead

The outcome of the election could impact the underlying laws and regulations related to some of the health policy cases before the Supreme Court, while the Court will remain the final arbiter in others. If former Vice President Biden wins the Presidential election, and the Democrats gain control of the Senate and maintain control of the House, the tax penalty associated with the ACA individual mandate and CSR payments could potentially be reinstated, essentially making these cases moot. Similarly, the regulations changing Title X, Section 1557, public charge policy, and hospital price transparency could be revised or withdrawn. However, the Supreme Court will maintain the final say about the constitutionality of abortions, the rights of states to restrict abortion access, and whether Medicaid enrollees can sue to enforce the free choice of provider provision regardless of the outcome of the 2020 election.

While it is impossible to predict a justice’s decision in a particular case with absolute certainty, the confirmation of Judge Barrett is expected to replace Justice Ginsburg’s vote as the leader of the Court’s liberal wing with votes reflecting a conservative judicial ideology. Judge Barrett is a member of the conservative Federalist Society and has said that she follows the same judicial philosophy as Justice Scalia, who is well-known for his conservative legal views and for whom Judge Barrett clerked. While not determinative of the current ACA challenge before the Court, Judge Barrett has criticized the Court’s NFIB v. Sebelius decision, writing that Chief Justice Roberts’ opinion upholding the mandate as a constitutional exercise of Congress’ taxing power “pushed the Affordable Care Act beyond its plausible meaning to save the statute.” While a professor at the University of Notre Dame, Judge Barrett signed a statement in a 2006 advertisement opposing “abortion on demand” published in the South Bend Tribune. On the 7^th Circuit, she dissented in two court decisions declining en banc hearings after the initial 3 judge panel struck down abortion regulations. She also dissented from a 7^th Circuit Court of Appeals decision in a case challenging the public charge rule, writing that she found the Trump Administration’s interpretation to be reasonable. Though her prior opinions cannot definitively predict how she would rule in future individual cases before the Court, it is expected that her confirmation would shift the Court’s ideological balance to a solid 6:3 conservative majority, with potential implications for case outcomes affecting a number of health policy issues for years to come.

1. Judge Barrett is President Trump’s third Supreme Court nominee, preceded by Justice Neil Gorsuch (replacing Justice Scalia in 2017) and Justice Brett Kavanagh (replacing Justice Kennedy in 2018). (After Justice Scalia’s death in February 2016, President Obama nominated Judge Merrick Garland to fill the open seat, but Senate Republicans refused to consider the nomination, arguing at that time that the vacancy occurred too close to the November Presidential election.) ↩︎
2. In an earlier challenge to the ACA’s constitutionality, National Federation of Independent Business (NFIB) v. Sebelius, a divided Court upheld the individual mandate as valid exercise of Congress’s taxing power. In reaching this decision, Chief Justice Roberts was joined by Justice Ginsburg, along with Justices Breyer, Kagan, and Sotomayor. The dissent, joined by Justices Alito, Kennedy, Scalia, and Thomas, concluded that the mandate was unconstitutional and consequently the entire ACA could no longer stand. The Court’s NFIB decision also found that Congress could not require states to adopt the ACA’s Medicaid expansion, effectively making expansion a state option; only Justices Ginsburg and Sotomayor dissented from that part of the opinion. In a subsequent case, King v. Burwell, Chief Justice Roberts was joined by Justice Ginsburg, along with Justices Kennedy, Breyer, Sotomayor, and Kagan, in upholding an IRS rule making ACA premium subsidies available to individuals purchasing coverage in states that have not established their own Marketplace but instead participate in a federally-run Marketplace. ↩︎
3. Medicaid waivers are popular, with 55 waivers approved across 43 states as of September 1, 2020. Some of these waivers are comprehensive, making broad changes in Medicaid eligibility, benefits and cost-sharing, and provider payments across their programs, while other waivers focus more narrowly on specific services or populations. ↩︎
4. Section 1115 of the Social Security Act allows the Secretary to waive state compliance with certain federal Medicaid requirements if the Secretary determines that the initiative is an “experimental, pilot, or demonstration project” that “is likely to assist in promoting the objectives of the program.” ↩︎