Safety-net hospitals have long played an important role in the US health care system in serving vulnerable populations, providing high cost services such as trauma and burn care and often in training medical and nursing students.  The Affordable Care Act (ACA) fundamentally changes the health care landscape and safety-net hospitals need to make major changes to compete.  New coverage from Medicaid expansions and new Marketplace coverage provide opportunities for safety-net hospitals.  However, these providers face challenges competing for newly insured patients and continuing to serve the remaining uninsured (including adults in states not expanding Medicaid and undocumented immigrants who remain ineligible for Medicaid or new ACA coverage).  Safety-net hospitals also face reductions in financing for uncompensated care.

Building off of a 2012 Health Affairs brief that looked at early ACA preparations by safety-net hospitals,¹  this brief examines four safety-net hospitals to learn how they were preparing for the full implementation of health reform, in order to gain additional insight into the strategies being used and challenges being faced among safety-net hospitals across the country.  The four hospitals are Cook County Health and Hospitals System (Cook County HHS) in Chicago, Illinois; Harris Health System (Harris Health) in Houston, Texas; Santa Clara Valley Medical Center (SCVMC) in San Jose, California; and University Medical Center of Southern Nevada (UMC) in Las Vegas, Nevada (see tables in the Appendix for additional hospital information).  The findings are based on information gathered from site visits and interviews between June and September 2013 with local health care stakeholders and key hospital management.  While hospitals were employing strategies with different intensity, key findings about adapting for changes from health reform include:

• Study hospitals were implementing an array of financial strategies focused on tapping Medicaid revenues (through early coverage expansion and delivery system reform waivers), improving patient billing, lowering cost structures to shore up revenues and using strategic contracting and purchasing arrangements.
• To reduce fragmentation and increase efficiency, study hospitals were adopting delivery system reforms particularly related to developing community-based partners and systems of care.
• Most study hospitals implemented changes in hospital leadership and management structure as well as efforts to better align physician incentives with hospitals and changing the culture of patient care to be more responsive to changing markets.
• Improving infrastructure and Health Information Technology (HIT) were being employed to make hospitals more attractive to consumers and to increase efficiency.

Even after full implementation of the ACA, the study hospitals, as well as other safety-net hospitals across the country, are expected to continue to serve a critical role in their communities. While safety-net hospitals must adopt new strategies to thrive under reform, policy makers at the federal, state, and local levels of government will need to monitor and evaluate how safety-net hospitals are faring as the ACA is implemented to ensure that the safety-net is sustainable for vulnerable populations and for broader community needs.

Safety-net hospitals have long played an essential role in the US health care system. They are a major source of care for the nation’s most medically vulnerable, including Medicaid beneficiaries and the uninsured, and provide services that other hospitals generally do not offer, such as trauma and burn care. In addition, many of these hospitals serve as training facilities for medical and nursing students. Safety-net hospitals face more challenges compared to other hospitals because of limited revenue streams, due to a reliance on uncompensated care financing pools and a poor payer mix, often complex governance and leadership structures, and high needs for infrastructure (IT) investments.

The ACA makes fundamental changes to the health care landscape primarily in terms of coverage and financing.  First, the ACA extends coverage to many uninsured through an expansion of Medicaid for low-income adults and through premium tax credits to help people purchase insurance through new Health Insurance Marketplaces for individuals with moderate incomes. With the June 2012 Supreme Court ruling on the ACA, the Medicaid expansion became optional for states. As of May 2014, 27 states, including the District of Columbia, are implementing the Medicaid expansion and 24 states are not moving forward at this time. In states not implementing the Medicaid expansion, many adults will remain uninsured. In terms of financing, new coverage through Medicaid and the Health Insurance Marketplaces could mean additional revenues for hospitals and other providers, but the ACA also significantly reduces Medicare and Medicaid disproportionate share hospital (DSH) payments, which often represent a major revenue source for safety-net hospitals. In addition, state and local funding sources for uncompensated care could decline with reform. Finally, the ACA emphasizes value-driven care, which will challenge all hospitals to deliver quality care in a cost-effective way.

As a result of changes under the ACA, safety-net hospitals will need to make major changes to the way they do business in order to compete. Under reform, increases in coverage will mean that safety-net hospitals will face increases in patient demand from those newly insured through Medicaid and the Health Insurance Marketplaces. At the same time, they will need to actively compete with private hospitals for those newly insured patients, a sea change for many safety-net hospitals’ organizational culture as historically they have focused on caring for the uninsured and underinsured. In states that are not implementing the Medicaid expansion, safety-net hospitals will continue to serve a high number of uninsured patients, but could also see reductions in financing for uncompensated care. This is particularly true for safety-net hospitals that serve large shares of undocumented immigrants who remain ineligible for Medicaid or tax credits to purchase coverage in the new Marketplaces.

Building on earlier work,²  this report examines four safety-net hospitals to learn how they were adapting to changes in the ACA and what major challenges the hospitals will likely face as they enter the post-reform world. The four hospitals are Cook County Health and Hospitals System (Cook County HHS) in Chicago, Illinois; Harris Health System (Harris Health) in Houston, Texas; Santa Clara Valley Medical Center (SCVMC) in San Jose, California; and University Medical Center of Southern Nevada (UMC) in Las Vegas, Nevada. Each of these hospitals exists within broader health systems, which often includes an extensive outpatient infrastructure. Using a semi-structured protocol, site visits and interviews were conducted between June and September 2013 with key hospital management, including the chief executive officers, chief technology officers, chief financial officers, and chief medical officers. We also interviewed local health care stakeholders.

In selecting the hospitals diversity was sought along several dimensions— geography, whether the hospital is located in a state implementing the ACA Medicaid expansion, and level of state Medicaid DSH payments prior to the ACA (Table 1).  Each of the hospitals is located in an area expected to have significant numbers of uninsured remaining after ACA implementation due to high shares of immigrants (both undocumented and documented immigrants who have been in the US for less than five years) who will not be eligible for coverage under the ACA coverage expansions. For hospitals in states not implementing the Medicaid expansion, the number of uninsured will remain higher because many adults will not have a new coverage option.

Each hospital was described as the principal provider of inpatient and outpatient care in its community for the low-income and uninsured populations. For Cook County HHS and Harris Health, 85 percent of hospital discharges are either uninsured or Medicaid beneficiaries, with SCVMC and UMC somewhat lower at 76 and 63 percent, respectively (Table 2).  These are substantially higher than the figure for the average US hospital (25 percent; data not shown), and higher than the average safety-net hospital (54 percent; data not shown).³ 

Characteristic of safety-net hospitals generally, the study hospitals rely heavily on revenues from Medicaid, Medicare, and state and local support (Table 2). They do differ, however, in their level of commercial revenue: Nearly 20 percent of SCVMC and UMC’s revenues come from commercial sources, whereas Cook County HHS and Harris Health have very little commercial revenue. Managed care plays a role to varying degrees across the four hospitals. For example, Medicaid managed care enrollment in 2010 accounted for 14 percent of total non-elderly Medicaid enrollment in Cook County; 46 percent in Santa Clara County; 76 percent in Clark County; and 82 percent in Harris County.⁴  Most individuals newly enrolled through ACA coverage initiatives in these states will receive care through managed care, providing yet another incentive for hospitals to cost-effectively coordinate and integrate care.

The study hospitals’ quality performance is comparable to national averages on some measures, including an “effective care” measure related to appropriate antibiotic use after outpatient surgery and 30-day mortality and readmission rates (Table 3). All four hospitals, however, scored lower on a measure of timely care based on the wait for an admission from the emergency department and on patient willingness to recommend the hospital. Nonetheless, UMC and SCVMC were categorized regionally as a top-ranked hospital in their respective metropolitan areas, according to US News and World Report’s ranking.⁵ 

The context in which the study hospitals are operating varies greatly, including state preparations and support for the ACA (Table 1). SCVMC and Cook County HHS have benefited from active state preparations for the ACA. California (where SCVMC is located) opted to expand Medicaid early across the state and Illinois (where Cook County HHS is located) has supported a Medicaid Section 1115 waiver that has expanded Medicaid early in Cook County (see below). While Nevada (where UMC is located) is taking up the Medicaid expansion, the state has been less active in ACA preparations and did not seek a Medicaid waiver to expand coverage early. In contrast, Texas (where Harris Health is located) has not participated in the ACA expansion of coverage, opting not to implement the Medicaid expansion and deferring to a Federally-Facilitated Marketplace. Since Texas had a pre-ACA uninsurance rate that was the highest in the nation, Harris Health, in particular, will continue to serve a large number of uninsured adults as the ACA moves forward.⁶ 

Leading up to implementation of the ACA, the study safety-net hospitals were employing reform strategies that fell into four broad and interrelated categories—financial strategies, delivery system reforms, organizational changes, and infrastructure improvements, with all of the changes focused on insuring the long-term financial viability of the hospital in a changing market.

Financial Strategies

Perhaps the most important area where the hospitals devoted a significant amount of effort to prepare for reform is shoring up their financial situation. Overall, leadership from each hospital described efforts to reduce cost and improve efficiencies that would help them be successful in the post-reform world. To varying degrees, each of the hospitals undertook strategies aimed at tapping Medicaid revenues, improving patient billing and using strategic contracting and purchasing arrangements as key financial strategies. For Cook County HHS, SCVMC, and UMC, financial strategies were often tied to the Medicaid expansion and the expected gains in revenue associated with increases in the share of patients with insurance coverage. Since Harris Health is located in a state that is not expanding Medicaid at this time, it focused on expanding revenues beyond those available through the Medicaid expansion.

Study hospitals are tapping Medicaid revenues as a key financial strategy. Medicaid Section 1115 waivers for early expansions of coverage and for delivery system reforms have been an important way for the hospitals to obtain new revenues. Since 2010, California, Illinois, and Texas have each received Section 1115 waiver that have provided significant funding to three of the study hospitals—SCVMC, Cook County HHS, and Harris Health, respectively. Illinois’s waiver allowed Cook County HHS to begin covering the ACA Medicaid expansion population early. Since this population was almost entirely uninsured, the early expansion allowed Cook County to access Medicaid patient revenues for this population. Similarly, under California’s waiver, Santa Clara County opted to expand Medicaid early so they too were able to access new Medicaid patient revenues for a population that had previously been uninsured.

Both California and Texas also have Delivery System Reform Incentive Payment or “DSRIP” waivers. While the features and requirements of each state’s DSRIP waiver is unique, these waivers provide significant amounts of federal Medicaid funding for hospitals (and other providers) that are tied to payment and delivery system reforms, including system redesign, infrastructure development, population health improvements, and quality care improvements. To receive waiver funding, the hospitals must meet specified quality and other milestones. Texas’s waiver, called the Transformation and Quality Improvement Program, has the potential to increase state revenues to $30 billion during the five-year waiver period (2011 – 2016).  Harris Health would be a major beneficiary of these increased funds.  The funding for the California DSRIP waiver is about $3.3 billion over the five year waiver period. Leadership at each of the hospitals readily acknowledged the importance of the funding they received from the waivers.

Although not participating in an 1115 waiver program, UMC recently availed itself to a new infusion of federal funds by expanding its use of Medicaid Upper Payment Limits (UPL) payments. This funding helped UMC underwrite its electronic health record (EHR) initiative, which was viewed by management as an essential part of preparing for the ACA. The funding also helped to fill a UMC revenue gap created by cuts in local county support during the recession, which hit Nevada quite hard.

Study hospitals are also implementing efforts to improve patient billing. Executives at each of the hospitals conceded that they left significant funds on the table because of inefficient or, in some cases, a complete lack of patient billing. Through revamping its billing processes, Harris Health, for example, now collects more than $300 million per year from patients, up from $240 million. Cook County HHS has also overhauled its billing process. Previously, billing was spread across three different billing and medical records offices, while now it is consolidated into a single office and system. Related to improving their billing practices, the hospitals have also been educating physicians and other hospital staff to record all services that they provide to each patient to support the billing process. Management explained that this sounds easier than it actually is because many hospital staff have never been required to do this and, in some cases, are philosophically opposed to billing poor people for health care. Due to increases in coverage under the ACA, these improvements in patient billing are critical to operations.

Reducing costs and improving cost-effectiveness were other financial strategies study hospitals employed. Leadership from each hospital also described a renewed focus on cost reductions and efficiencies that would help them be successful in the post-reform world. Management at three of the hospitals (Cook County HHS, SCVMC, and UMC) acknowledged that their cost structures are high, and that longer term, they needed to adjust their operating costs to be competitive. In contrast, Harris Health felt its costs are already competitive. Even so, Harris Health is also implementing efficiency strategies.

Strategic contracting and purchasing arrangements is a cost-saving strategy the hospitals have employed. Hospitals are also looking to develop partnerships with community providers, in part to better serve patients, but also to reduce costs. Harris Health and Cook County HHS were most explicit about these plans, which included subcontracting certain services to community-based centers, like FQHCs and outpatient surgery centers. One hospital executive emphasized the cost motivations underlying this strategy – “some services will have to be contracted out; we can’t do everything ourselves and, even if we could, it would be too expensive. The best strategy is to have community partners.” In a similar strategy, SCVMC is contracting with primary care providers outside their system to expand its network and to more effectively control expenses.

Delivery System Reforms

Another critical area of change among these hospitals was delivery system reforms, particularly related to developing community-based partners and systems of care.  These efforts are highly inter-related with some of the financing strategies described above.

Management at study hospitals view strategies to enhance community-based care systems as critical to reduce fragmentation and improve efficiency. Overall, the goal of each of the hospitals is to create a more cooperative community-based system that leverages the strengths of the hospital with other resources in its area to reduce fragmented care and eliminate duplication of effort. Cooperation and coordination, however, are new to the hospitals in some cases (e.g., Cook County HHS, Harris Health, and UMC) as well as to community providers.

SCVMC is the furthest along, among the study hospitals, in developing a community-based care system. The hospital has long-standing relationships with community providers, dating back to when Santa Clara County implemented Medicaid managed care in the mid-1990s. In preparations for reform, SCVMC has further expanded and enhanced these partnerships through various efforts, such as integrating community providers into the hospital’s IT systems and jointly sponsoring community clinics that offer primary and specialty care. These well-established relationships forged as part of Medicaid managed care provided a strong foundation for SCVMC to cultivate deeper relationships with local providers, particularly aligning community physicians and the hospital.

Both Harris Health and Cook County HHS’s efforts to coordinate with community providers are being driven to a great extent by their recent Medicaid Section 1115 waivers, which, among other things, incent both hospitals to move from a system focused on inpatient and acute care toward one focused on outpatient care and community-based providers. Under its waiver, Cook County HHS has contracted with community-based providers and other area hospitals to start a managed care plan so there are now more than 150 access points to its network. In addition to expanding risk-based managed care, Texas’s waiver also calls on local areas to improve care delivery. As part of those efforts, Harris Health has developed contractual relationships with “same day” clinics, ambulatory care surgery centers, and began taking referrals from local FQHCs. Harris Health is expanding beyond its relatively well-established local integrated care system toward a more regional model of care delivery with the goal of developing an Accountable Care Organization (ACO) that serves a broad geographic region in the state.

In contrast, UMC has engaged in only very preliminary efforts to identify potential partners. Interviewees attributed this lack of development of a community-based system of care, in large measure, to UMC operating in the highly competitive Las Vegas hospital market, one that is dominated by private, for-profit hospitals that are wary of coordinating care with their competitors and have little interest in working together or supporting a safety-net. In addition, UMC, with its long-standing financial challenges, was not viewed as having the resources to take on the major system change that would be needed to create broad collaborative models in Las Vegas. Even so, in early 2013, UMC began conversations with community providers about how they might begin to create a system of collaboration in the future.

Study hospitals were also focused on strengthening primary care and better integrating services. Central to strengthening primary care capacity was a push to certify primary clinics as patient-centered medical homes. Hospitals planned to enhance preventive services through medical home implementation, and coordinate care efficiently in order to reduce unnecessary spending. Study hospitals were at various points of achieving medical home recognition for their primary care facilities. Harris Health was leading the way with its primary care clinics having reached NCQA Level 3 Certification. Harris Health is also working to integrate services and build “one big medical home” across its hospitals and clinics.

SCVMC is working to better integrate its mental health and alcohol services, which have historically operated in siloes. In addition, SCVMC is currently trying to unify its two county-sponsored managed care plans, as well as, take on more risk and narrow provider networks in an effort to retain more of the public health dollars in its system. Through its new managed care plan Cook County HHS is establishing relationships with hospitals and clinics across the county.

Hospital Organizational Changes

Significant organizational overhauls have occurred at each of the hospitals, due both to the lingering effects of the recession and preparations for health reform. Key organizational changes include changing the hospitals’ leadership and management structure, as well as, aligning physician and hospital priorities.

In three out of the four study hospitals, changes in the hospitals’ leadership and management structure have been key to responding to the rapidly changing health care landscapes. Prior work has highlighted the important role that strong leadership plays in the ability of safety-net hospitals to respond to rapidly changing circumstances. The importance of leadership was echoed in the experiences of the four study hospitals. Three of the hospitals—Cook County HHS, SCVMC, and UMC – have had significant changes in management within the last few years, while leadership at Harris Health has remained relatively stable.

Perhaps most striking has been the leadership shift at Cook County HHS, which introduced a wholesale reorganization of the hospital’s management structure, from one that was very hierarchical to one that is flat, which is intended to facilitate more rapid decision-making. This leadership change took place at the system-level, affecting not only Cook County HHS, but also the system’s extensive ambulatory care network.  Respondents from both inside and outside of Cook County HHS also noted an important move away from the hospital’s traditional crisis management model to one of a shared vision for system change. These changes were seen as key factors in securing Illinois’s 2012 Medicaid Section 1115 waiver, that is playing a critical role in the transformation occurring at Cook County HHS.

In 2012, UMC also had a noteworthy management change, bringing on chief officers for finance, medicine, and operations, positions that had been vacant for several years. Prior leadership turmoil and serious financial problems, however, have compromised the new leadership’s ability to make significant preparations for reform. UMC instead remains very much in a crisis management model, with hospital leadership struggling to address day-to-day financial and operational challenges. The hospital’s prior governance structure, which required the hospital CEO to report directly to the Clark County Commission, further thwarted its efforts for change. However, in 2013 UMC received approval from the commission to move its governance from the county to an independent board. The expectation both inside and outside of UMC is that the new governance structure will support the hospital’s ability to make more effective and timely decisions. This change in governance for UMC also holds the promise of being the starting point for the hospital to institute fundamental organizational reforms.

Finally, related to management structure, one Cook County HHS executive observed that hospitals that operate in less unionized environments enjoy a higher level of “nimbleness” in staffing than their heavily unionized counterparts, which can allow for a quicker adaptation to new initiatives and demands.

To remain competitive as more residents gain coverage, study hospitals were working on strategies to change the culture of patient care. While the four study hospitals have extensive experience in providing core safety-net services to their communities, each hospital is preparing for increased competition from private hospitals for newly-insured patients under the ACA. To prevent losing insured patients to other providers, each hospital is implementing initiatives to change the culture of patient care within their system. This is a seismic shift in the way the hospitals have traditionally done business. Historically, these hospitals have served the patients who “have nowhere else to go”. Across the board, hospital management conceded that changing the culture of patient care and how they are perceived in the community is a heavy lift. One SCVMC executive observed that improving the patient experience is among the biggest organizational challenges that SCVMC faces. Despite the challenges, these hospitals have strong foundations to build off of because they already provide quality care and critical community health care services, have loyal patient bases, and have strong track records of providing health care services that are culturally and linguistically sensitive.

Initiatives to improve the patient experience include altering patient processes to reduce wait times and educating staff about having positive interactions with patients. The hospitals are also pushing to have a cleaner and more attractive physical environment. SCVMC, for example, is altering inpatient rooms by increasing the number of private rooms and Harris Health is moving from four-bed rooms to semi-private rooms. UMC, on the other hand, lacks the resources for such improvements and is the only hospital in Las Vegas without private rooms. However, UMC is also the only hospital in Nevada ranked by US News and World Report.⁷ 

The hospitals are also conducting outreach and education targeted to staff, patients, and the broader community. A major objective of these campaigns is to emphasize that the hospitals are providers to the entire community and not just standalone sources of care for the uninsured. These efforts were viewed as more important in Cook County HHS, SCVMC, and UMC, where significant shares of the uninsured are expected to gain coverage under the Medicaid expansion, than in Harris Health, where little change in insurance coverage is expected, given Texas’s decision not to expand Medicaid. While the hospitals plan to staff about their mission to serve the uninsured, it is also important that they understand that if insured patients go elsewhere, the hospital will cease to exist.

Study hospitals have sought to better align the incentives of their physicians with the hospital’s needs and goals to support more efficient care delivery. This has been less of an issue in SCVMC and Cook County HHS, where the hospitals’ physicians are county employees (Table 1). One Cook County HHS leader observed that having employed physicians “is a gigantic strength of our organization because we attract people who want to work here. They didn’t just get assigned here.”

In contrast, the majority of UMC’s physicians are based in the community and have limited ties to the hospital and Harris Health relies on contracts through two medical schools for its physicians. Respondents at both UMC and Harris Health acknowledge that the interests and motivation of the physicians are not necessarily consistent with the needs of the hospital. To help mitigate this, UMC is working to build a stronger relationship with the University of Nevada’s School of Medicine. Along the same lines, Harris Health is pushing against “fractionalization”—that is, where the medical schools fill a full-time position with multiple physicians rather than a single individual, compromising continuity of care. The goal of both UMC and Harris Health is to have a more limited group of physicians who have a stronger focus on prioritizing patient needs.

Infrastructure and Technology Investments

As the study hospitals prepare for the future, each has included infrastructure investments as part of their strategic plans. Improvements to their physical and information infrastructures, not only make the hospitals more attractive to consumers, including newly-insured consumers, but they also offer opportunities to improve efficiency, capacity, and can enable cost-savings over time to support the hospitals’ on-going financial viability. While some of the study hospitals had infrastructure projects underway before reform passed, the ACA provided additional incentives to undertake these investments. Local revenue as well as the priorities of each hospital’s governing boards also affected the hospitals’ ability to pursue infrastructure improvement projects.

Hospital strategic plans and governing board priorities played an important role in determining new infrastructure projects. As part of its strategic plan, Harris Health designed a capital building program, supported by its governing board that designated $370 million for the effort, made possible by an increase in Houston property values and a bond issue. Harris Health began capital construction in 2008, which was still ongoing as of late 2013. Meanwhile, lack of capital and support from its county commissioners have prevented UMC from making any investment in facility renovation, which executives fear may negatively affect the hospital’s competitiveness. UMC executives estimate that they would need an infusion of $50 million “to bring them up to where they should be” in terms of capital investment.

To better meet the needs of their patients and to control costs, both SCVMC and Harris Health have built new ambulatory care centers. Harris Health is also building nine new primary care and same-day clinic facilities, which are projected to enable an additional 30,000 primary care visits per year.

Health Information Technology (HIT) offers opportunity for increased efficiency, timelier patient information-sharing, and cost savings over time. The ACA has new billing collection and financial aid requirements that can be best met through the usage of EHRs, an area of significant infrastructure development for each of the hospitals. All four hospitals are working on modifying or improving their current HIT systems to better share patient health information among providers both within their own health system and throughout the community, as well as to enable patients to interact with doctors through the EHR.

Cook County HHS and Harris Health have had EHRs for several years, whereas UMC began installation of EHRs in late 2012 and SCVMC switched to EHRs at the beginning of 2013, with the goal of making the transition on an accelerated basis.

The new EHR frontier for the hospitals is improving communication among their hospitals, ambulatory, and urgent care centers, and with their partner clinics. Improving this type of communication was a priority for each of the study hospitals, but they were at different levels of integration. Cook County HHS, for example, uses a single EHR throughout its inpatient, outpatient and correctional care settings but it still has a limited ability to communicate and share information with its partnership clinics, and instead uses a separate web-based system. In contrast, SCVMC’s EHR linked the hospital and its associated ambulatory and specialty care centers, and plans to link to its community partners in the near future.

Looking Ahead

Leadership at the study hospitals thought the ACA provided them with opportunities and were optimistic that, in the long run, reform will have a positive impact on them. The opportunities for study hospitals were clearer at Cook County HHS, SCVMC, and UMC, because they operate in states that are moving forward with the Medicaid expansion, these hospitals have opportunities to reduce the number of uninsured patients and capture significant new Medicaid patient revenues. Some Harris Health hospital executives and local health care stakeholders believe that a “Texas Solution” for the ACA coverage expansion will eventually be executed, and that they could see an increase in Medicaid revenues for eligible but unenrolled individuals, in addition to those with new coverage purchased through the Health Insurance Marketplace.

At the same time hospital leaders were concerned about financial risks associated with the changes under the ACA. All were worried about the federal Medicare and Medicaid DSH cutbacks that have been key sources of financing for safety-net hospitals. This was a key issue in Texas where the numbers of uninsured are likely to remain significant despite reductions in DSH. Financial worries also stemmed from the potential decline in state or local funding. In California, for example, the governor has announced that because many individuals will gain Medicaid coverage with the ACA, the state is reducing funding that it had provided to counties to support health care services for the low-income. Similarly, UMC leadership noted that cutbacks in local indigent care funding will ensue once the ACA Medicaid expansion is implemented. While hospital leadership understand that new funds will be available to them under reform (particularly in states implementing the Medicaid expansion), given that each of the study hospitals is located in areas with high immigrant populations, many of whom will not qualify for coverage under the ACA, reductions in support for indigent care will be challenging.

For the three hospitals with 1115 waivers, management also expressed concern about the continued flow of revenue through this vehicle. While Harris Health hopes for another waiver, it acknowledges that the federal matching dollars provided through DSH, UPL payments, and the waiver are critical, they also need to consider strategies if the state cannot secure a second waiver.

Hospital executives also worry about being able to compete in a post-ACA health care market. Hospital leaders recognize the amount of work ahead in having the right patient culture and up-to-date infrastructure in place to compete for the expanded pool of insured patients and to operate in health care systems that are moving toward increasing levels of integration and coordination.

Another concern expressed by hospital leadership is whether they will effectively be able to compete for newly-insured patients and the revenue associated with those patients. Leadership at each hospital acknowledged that there is excess capacity in their local health care system, which will drive competition for the newly insured. Even with their preparations, management worried that the attitude and culture of their hospitals had not sufficiently shifted to keep their patients after they obtained insurance. As one Cook County HHS executive observed, when Medicaid shifted to managed care for pregnant women, the pregnant women often chose better facilities to get care. Now, Cook County HHS handles few deliveries. Harris Health’s experience was similar when Texas introduced managed care for pregnant women and children.

The ability to effectively broaden their mission was another major concern for management. While acknowledging that they “will always be the safety-net hospital,” they need to move beyond being “just” a safety-net provider and get their communities to view them differently. From their perspective, they need to be “a system of choice” or they will cease to exist. Making the transition from “the” safety-net hospital to the hospital for all of the community is a critical component of the hospitals’ plans to survive and hopefully thrive under health reform.

This study has reviewed the major opportunities and challenges four safety-net hospitals were facing in adapting to changes under the ACA, as well as strategies to be better positioned to meet these challenges. Reflecting the diversity of safety-net hospitals’ situations across the country, study hospitals varied in both the intensity of effort and their availability of resources to adapt for health reform. SCVMC has taken a robust approach to its ACA preparations, which have included employing financial strategies, undertaking significant organizational changes, forging new relationships with community-based providers, and moving ahead with infrastructure improvements. Leading up to ACA implementation, SCVMC, Cook County HHS, and Harris Health all benefit from Section 1115 waivers that are supporting system transformation. Constrained financial resources and a highly competitive market in Las Vegas that is resistant to collaborative efforts, have strained UMC’s health reform preparations. However, the challenges are greater for Harris Health, given that Texas is not moving forward with the Medicaid expansion.

Even after full implementation of the ACA, the study hospitals, as well as other safety-net hospitals across the country, are expected to continue to serve a critical role in their communities in caring for uninsured and underinsured populations including undocumented immigrants who are not eligible for Medicaid and other coverage options in the ACA. Safety-net hospitals are also important as providers of core services for the entire community that are not available elsewhere (e.g., trauma and burn care services). So while these and other safety-net hospitals must adopt new strategies to thrive under reform, policy makers at the federal, state and local levels of government will need to monitor and evaluate how safety-net hospitals are faring as the ACA is implemented to ensure that the safety-net is sustainable for vulnerable populations and for broader community needs. We will also continue to track safety-net hospitals across the country as health reform is fully implemented to identify successful strategies hospitals are using to adapt to the changing health coverage environment and to better understand how they and the populations they serve are faring in the post-reform world.

1. Theresa Coughlin, Sharon Long, Edward Sheen, and Jennifer Tolbert, “How Five Leading Safety-Net Hospitals Are Preparing for the Challenges and Opportunities of Health Reform,” Health Affairs vol. 31, issue no. 8 (August 2012): 1690 – 1697, doi: 10.1377/hlthaff.2012.0258. ↩︎
2. Theresa Coughlin, et al.  “How Five Leading Safety-Net Hospitals Are Preparing for the Challenges and Opportunities of Health Reform” (August 2012). ↩︎
3. Authors tabulations based on the 2010 NAPH Characteristics Report and the Healthcare Cost and Utilization Project [HCUP]. ↩︎
4. Authors’ tabulations based on the summary 2010 federal fiscal year Medicaid Statistical Information System data.  Figures cited represent the number of nonelderly enrolled in a comprehensive managed care plan as a percentage of the number of total nonelderly Medicaid enrollees in the given county. ↩︎
5. U.S. News and World Report, Best Hospitals (2013) http://health.usnews.com/best-hospitals/area/nv/university-medical-center-6880071. ↩︎
6. Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements). ↩︎
7. U.S. News and World Report, Best Hospitals (2013). ↩︎

Summary

Medicaid is the nation’s primary health insurance program for low-income and high-need Americans.  States administer Medicaid within broad federal rules and have a lot of flexibility to design their programs.  Medicaid is jointly financed by the states and the federal government.  The Affordable Care Act (ACA) expands Medicaid to a national eligibility floor of 138% of the federal poverty level (FPL) and provides significant federal funding for this new coverage.  The Supreme Court ruling on the ACA effectively made the Medicaid expansion a state choice.  Medicaid and the Children’s Health Insurance Program (CHIP) play an important role in providing health coverage for millions of children across the country.  Both programs are jointly financed by states and the federal government and largely administered by states within broad federal rules but differ in several key ways, including size and scope, financing, benefits and cost-sharing.¹ 

Generally once a year, the Congressional Budget Office (CBO) releases a detailed “baseline” for federal spending for Medicaid, CHIP and the ACA that serves as a neutral benchmark for Congress to measure the budgetary effect of proposed legislation and as a reference point for analysis of Medicaid enrollment and spending.  This baseline assumes current law remains in place, but adjusts for changes in the economy and other factors that will affect federal revenues and spending.  CBO does not provide state-by-state projections or estimates of the effects of legislation.  Key findings from the April 2014 CBO projections for federal Medicaid, CHIP and the ACA spending over the 2014-2024 period include the following:² 

• Compared to the CBO Medicaid baseline from March 2012, federal spending projected for 2020 in the April 2014 baseline is 14% lower due to a number of factors including the Supreme Court decision effectively making the ACA Medicaid expansion an option.
• Under the current baseline, federal Medicaid expenditures are expected to grow by an average annual rate of about 7% (including the effects of the ACA) with enrollment increasing by 2% on average.
• Primarily due to expansion of coverage for adults under the ACA, by 2024, children and adults will account for 8 in 10 enrollees and nearly half of all spending which are higher shares compared to today.
• Under current law CHIP funding expires in 2015.  The CBO baseline continues the budget authority levels set in the ACA for 2015.  As a way to reduce the costs for the ACA, budget authority for CHIP was reduced to $5.7 billion and the remaining funding was provided through a one-time appropriation.   As a result of lower spending level, CHIP enrollment is expected to decline over the projection period.
• Due to the ACA, the number of uninsured is expected to decline by 26 million by 2024.  Federal Medicaid and CHIP outlays are expected to increase by $792 billion over the 2015-2024 period and state spending for matching funds by $46 billion (a reduction from $70 billion in the February 2014 projections primarily due to lower than expected take-up of current eligible).

Introduction

What is Medicaid?

Medicaid is the nation’s primary health insurance program for low-income and high-need Americans.   CBO estimates show that Medicaid covered 72 million low-income Americans including children, pregnant women, parents, elderly and individuals with disabilities at some point in 2013.  Medicaid provides critical assistance to low-income Medicare beneficiaries and is the primary payer for long-term services and supports.  The program accounts for about one in six dollars spent on health care; is the largest source of funding for safety-net providers, and the largest insurer of births.  States administer Medicaid within broad federal rules and have significant of flexibility to design their programs.  Medicaid is jointly financed by the states and the federal government.  The federal share (FMAP) averages 57 percent and ranges from a floor of 50 percent to a high of 73 percent based on a formula that relies on state per capita income and is recalculated each year.³ 

The Affordable Care Act expands Medicaid to a national eligibility floor of 138% of the federal poverty level (FPL) which will primarily expand Medicaid coverage to adults.  In general, the ACA provides 100% federal financing for those newly eligible for Medicaid from 2014 to 2016 and then phases down the federal share to 90% by 2020 and beyond.  The Supreme Court upheld the ACA but limited the federal government’s ability to enforce the Medicaid expansion to low-income adults, effectively making implementation of the Medicaid expansion a state choice.

Medicaid is the third-largest domestic program in the federal budget following Medicare and Social Security.  In federal fiscal year 2014, spending from Medicaid will account of an estimated 8% of federal spending.  (Figure 1) 

What is the Role of the Congressional Budget Office?

The Congressional Budget Office (CBO) prepares reports and analyses with economic forecasts and budget projections that cover a 10 year period for all spending in the federal budget that is used in the Congressional budget process.  In addition, CBO prepares other reports for Congress including long-term budget projections, an analysis of the President’s budget, cost estimates, analysis of federal mandates, budget options, reports and estimates related to appropriations and other program specific reports affecting the federal budget like health care.  For legislation being considered by Congress, CBO provides cost estimates of the impact and offsets on the federal budget.  In this role, CBO is often referred to as the “scorekeeper.”  CBO provides aggregate estimates of the effects of legislative proposals on states, but CBO does not provide state-by-state Medicaid projections or estimates of the effects of legislation.

CBO regularly publishes projections of economic and budget outcomes which incorporate the assumption that current law regarding federal spending and revenues generally remains in place. Those baseline projections cover the 10-year period used in the Congressional budget process. Most of the reports on those projections also describe the differences between the current projections and previous ones; compare the economic forecast with those of other forecasters; and show the budgetary impact of some alternative policy assumptions.  The budget projections and economic forecast are generally issued each January and updated in August; the budget projections are also generally updated in March.⁴   The March (sometimes April or May) update includes more detailed “baseline” projections for federal spending for Medicaid, CHIP and the ACA which include estimates of federal spending by eligibility group and service as well as enrollment and spending by eligibility group.

What Are CBO’s Estimates for Medicaid?

Each year, CBO produces a fact sheet that provides more detail about federal Medicaid spending projections over the next decade.  The fact sheet shows federal Medicaid payments for benefits (acute and long-term care), disproportionate share hospital (DSH) payments, spending for the Vaccines For Children program and administrative expenses.  The fact sheet also shows estimates of federal benefit payments by eligibility category, enrollment by eligibility category and average federal spending on benefits per enrollee.  For the baseline released in April 2014, the projection period is for 2014-2024.  Given that the Affordable Care Act (ACA) was enacted and is now current law, the CBO baseline Medicaid projections include the effects of the ACA.  These projections also estimate the effect on federal spending of the Supreme Court decision that effectively gave states the option to implement the Medicaid expansion.

CBO generally reports on the legislative, economic and technical changes in the baseline from one projection period to the next; however, significant details about the underlying assumptions beyond what is included in the baseline fact sheet are not generally available.  Projections for Medicaid spending have declined from the CBO projections released in 2012 due to state decisions on whether to expand Medicaid, lower than anticipated year to date spending and other technical corrections.  Examining the components of the baseline fact sheet may help to better understand the overall projections.

Current Compared to Earlier CBO Medicaid Projections

For the year 2020, the CBO projections for federal Medicaid spending declined by 14% from the baseline issued in March 2012 to the baseline issued in April 2014.  (Figure 2)

• From March 2012 to August 2012, the primary reason for lower spending was primarily driven by the Supreme Court decision which effectively gave states the option to implement the Medicaid expansion.  The August 2012 baseline were the first projections to assume that some states will not expand their Medicaid programs at all or will not expand coverage to the full extent authorized by the ACA.
• From August 2012 to February 2013 the Medicaid baseline declined primarily due to lower anticipated enrollment (primarily tied to lower enrollment in the Supplemental Security Income program which is linked to Medicaid enrollment) and lower expected costs per person.
• More recent estimates have been more stable.  Changes from February 2014 to April 2014 reflect increases in enrollment as a result of updates to the size and demographic characteristics of the overall population as well as increases in the cost of incentive payments related to the adoption of health information technology.  These increases were partially offset by a continued downward revision to SSI enrollment and a decrease in the projected costs per-person for newly eligible adults under the ACA.

Spending

Over the next decade CBO expects federal Medicaid expenditures to grow from $299 billion in 2014 to $576 billion in 2024, an average annual rate of about 7 percent.  This growth rate includes higher federal Medicaid spending over the decade related to the implementation of the ACA.  The CBO baseline consists of four key parts: benefits, Disproportionate Share Hospital (DSH) payments, the Vaccines for Children Program and Administrative expenses.  More than 90 percent of federal Medicaid spending is on benefits (acute care, long-term care and payments for Medicare premiums for low-income Medicare beneficiaries).

Over the projection period, acute care spending (fee-for-service spending, payments to managed care and payments for Medicare premiums) accounts for about 75 percent of spending for Medicaid benefits.  Long-term care, which includes both institutional and community-based long-term care spending, accounts for the remaining 25 percent.  Fee-for-service and managed care spending both are projected to increase sharply in 2014 as the ACA expansion of Medicaid coverage become effective.  This translates to faster growth for these categories of spending over the 10 year period relative to long-term care spending.  (Figure 3)

Enrollment and Spending by Eligibility Group

CBO estimates that total Medicaid enrollment will grow from 72 million in 2013 to 93 million by 2024.  These figures are based on the total number of individuals enrolled in Medicaid at any point during the fiscal year.  Average monthly enrollment is expected to increase from 58 million in 2013 to 73 million in 2024.  CBO projects enrollment for four categories: the aged, disabled, children and adults.  Overall enrollment is expected to grow at an average annual rate of about 2 percent per year between 2014 and 2024.  Generally, enrollment growth accounts for underlying population growth trends, economic assumptions (i.e. unemployment rates) and assumptions about state or individual behavior that may affect participation.  Since Medicaid enrollment is based on income, projections about the economy and unemployment will affect Medicaid.

Over the projection period, growth for adults is expected to increase significantly (from 21 million in 2013 to 37 million in 2024) due to the Medicaid expansion; however, these estimates assume that not all states will implement the expansion and in states that implement the expansion not all of those newly eligible will participate.  By 2024, adults account for 4 in 10 enrollees.  (Figure 4)  Prior to the implementation of the ACA Medicaid expansion, children accounted for nearly half of all enrollees.

As the share of enrollment shifts over the projection period, the share of spending by eligibility group is expected to shift as well.  Prior to the ACA, the elderly and disabled had historically accounted for about two-thirds of spending on Medicaid.  By 2024, children and adults are expected to account for slightly under half of Medicaid spending and the aged and disabled categories are expected to account for just over half of spending on Medicaid benefits.  (Figure 4)

Spending Per Enrollee

Growth in spending per enrollee largely reflects inflation and expectations of the costs to purchase medical services in the health care market place.  By 2024, spending for an aged or disabled enrollee is projected to be about five times greater than spending for a child or adult enrollee.  (Figure 5)  The aged and disabled tend to use more complex acute care services as well as expensive long-term care services.  Over the 2014 to 2024 period, spending per enrollee is expected to increase at rates ranging from 4 percent for the aged to 6 percent for adults.  Historically, Medicaid spending has increased at rates faster than inflation, but slower than per person increases for private health care premiums.

What Are CBO’s Estimates for CHIP?

Under current law, CHIP was funded through FY 2015 as part of the ACA.  Generally, the CBO assumes that funding for an expiring program will be funded at a level equal to the last year it was financed in the law.  However, to reduce costs for the ACA in the CBO score, when CHIP financing was set in the ACA, the final year funding authority was reduced from $21.1 billion in FY 2015 to $5.7 billion in 2016.  (Figure 6)  The rest of the CHIP financing was provided through a one-time appropriation that is not assumed to continue in the baseline but would be required to maintain the program at current levels.  While this lowered the cost of the ACA, it increases the costs of extending CHIP beyond 2015 because these funds need to be paid for.  A similar financing mechanism was used during the CHIP Reauthorization Act (CHIPRA) in 2009.

Under the CBO baseline assumptions, CHIP enrollment is expected to decline due to limited financing.  By 2024, CHIP enrollment is expected to fall to 2.9 million over the course of the year or 2.1 million on an average monthly basis from a high of 10.2 ever-on and 7.3 average monthly enrollment in 2015.  (Figure 7)  CBO assumes that when states face federal CHIP funding shortfalls, children enrolled in CHIP-funded Medicaid coverage will be shifted to regular Medicaid (at the regular Medicaid matching rate). Other children will lose their CHIP coverage and shift to subsidized coverage in the marketplaces, and some children previously on CHIP will end up uninsured because coverage through ESI is unaffordable and they are not eligible for marketplace subsidies.  The affordability test in the law is based on whether the policy for a worker (not the family) is less than 9% of family income.

Medicaid, CHIP and the ACA

While the effects of the ACA are included in the current baseline projects for Medicaid, CBO also released updated estimates of the effects on the deficit and coverage related to the health insurance coverage provisions in the ACA.

Overall, the most recent estimates assume a reduction in the uninsured of 26 million (from 57 million to 31 million) by 2024 which is attributable to increases in coverage through the new marketplaces and Medicaid and CHIP.  The CBO estimates that 25 million will be newly covered in marketplaces and Medicaid and CHIP enrollment will increase by 13 million by 2024.  These estimates assume that not all states will implement the expansion.  The increase is a combination of those made newly eligible by the ACA as well as increased participation among those eligible but not enrolled prior to the ACA.  (Figure 8)

CBO estimates that on net the ACA is expected to reduce the federal deficit, but since the passage of the law, CBO has only continued to update the estimates for the coverage provisions of the ACA which are expected to result in increases in federal spending.  Overall, the coverage provisions in the ACA are expected to increase gross federal costs by $1.8 trillion over the 2015-2024 period.  Medicaid and CHIP outlays are expected to increase by $792 billion over the 2015 to 2024 period as a result of the ACA coverage provisions accounting for 43 percent of the total gross costs.

CBO estimates that state spending would increase by about $46 billion from 2015 to 2024 as a result of the ACA coverage provisions.  Compared to the February 2014 estimates, the federal cost estimates did not change but the estimate for state costs declined from $70 billion to $46 billion.  (Figure 9)  While CBO does not provide a direct explanation for this, the majority of this change is likely tied to reducing the estimate of those eligible for coverage without the ACA Medicaid expansion (reimbursed at the regular state match rate).  Since overall enrollment and federal costs are the same as February, the higher estimate of newly eligible enrollees appears to be offset by a lower estimate of cost per enrollee.

1. Robin Rudowitz, Samantha Artiga, and Rachel Arguello.  Children’s Health Coverage: Medicaid, CHIP and the ACA.  Kaiser Commission on Medicaid and the Uninsured, March, 2014.  https://modern.kff.org/health-reform/issue-brief/childrens-health-coverage-medicaid-chip-and-the-aca/ ↩︎
2. CBO Updated Projections 2014-2024.  Baseline Projections for Health (Children’s Health Insurance Program, Effects of the Affordable Care Act on Health Insurance Coverage, and Medicaid.  http://www.cbo.gov/publication/45229 ↩︎
3. The Medicaid Program at a Glance, Kaiser Commission on Medicaid and the Uninsured, March 2013.   ↩︎
4. From the CBO website, about our products.  http://www.cbo.gov/about/our-products     ↩︎

In December 2013, nearly 5.8 million children were enrolled in the Children’s Health Insurance Program (CHIP.) Enrollment in December 2013 increased on net by 175,020 or by 3.1 percent, compared to one year earlier. Since 2011, annual rates of growth have remained fairly steady, hovering around 3 percent. In contrast, during the height of the Recession, enrollment increased annually by 6.9 to 8.1 percent. (Figure 1, Appendix Tables 1 and 2)

CHIP, combined with Medicaid, provides a crucial safety net of coverage for low-income children. Both programs, aided by maintenance of eligibility (MOE) provisions maintained under the Affordable Care Act (ACA) helped to stave off increases in the number of uninsured children. Between 2007 and 2012, the uninsured rate for children dropped from 10.9% to 9.2%, despite a decline in the share of children with employer-sponsored coverage.¹  While the MOE provisions for adults ended in January 2014, the MOE provisions for children remain in effect until October 2019. However, the ACA only extended CHIP funding through October 2015; Congress would need to appropriate additional funds in order for allotments to be available after October 2015. This, combined with the advent of new coverage options available through the marketplaces, raises questions about the program’s future role.

This report focuses on changes in monthly CHIP enrollment between December 2012 and December 2013. This is a long standing report that collects monthly CHIP enrollment data for December (and June, not reported here) going back to 2000. The most recent data included in this report predate preliminary data released by CMS that show the early effects of full implementation of the ACA. While the data provided in this report are not directly comparable to the data released by CMS (see methodology for more details,) they provide context for the preliminary data released by CMS, illustrating historical trends in CHIP enrollment.

ACA Eligibility Changes for Children

The ACA requires that Medicaid cover children with incomes up to 133 percent of the federal poverty level (FPL) as of January 2014. Before this change, states were required to cover children under the age of six in families with income of at least 133 percent FPL and school-age children and teens with incomes up to 100 percent FPL in Medicaid. Many states already covered children with incomes up to 133 percent FPL in Medicaid, but due to the change in law, 21 states needed to transition some children, mostly school-age children with incomes between 100 and 133 (a.k.a. Stairstep children) from their CHIP state plans to their Medicaid state plans.²  (Figure 2) These children remain eligible for the Title XXI Federal CHIP match rate.

As of April 2014, more than half of the states (29, including DC) cover children in families with incomes at or above 250% FPL and 19, including DC, cover children in families with incomes at or above 300% FPL either through Medicaid or CHIP. Thirty-seven states continue to operate standalone CHIP programs, most in combination with CHIP Medicaid expansions, for higher income children.³ 

A few of the 21 states that covered “Stairstep” children under separate CHIP programs decided to move these children before the requirement was in place. New York and Colorado implemented an early transition of children from CHIP to Medicaid but are maintaining separate CHIP programs. Meanwhile, New Hampshire and most recently California transitioned all CHIP kids to Medicaid, not just these older children with incomes under 133 percent FPL. The remaining 17 states will transition an estimated 13 percent to 48 percent of their CHIP coverage to Medicaid.⁴ 

Continued improvement in economic conditions likely resulted in both some growth as children shifted from Medicaid to CHIP and some declines as family incomes continued to increase above CHIP eligibility levels. CHIP offers coverage to low-income children in families who do not have access to affordable coverage but whose incomes are above Medicaid eligibility levels. Therefore, economic pressures provide both upward and downward pressure on enrollment. As the economy continues to improve, as it did during 2013, family income rises, which results in some children shifting from Medicaid to CHIP coverage. However, economic conditions improving can also result in some children leaving the program as income increases above CHIP eligibility levels for higher income families.During the period from December 2012 to December 2013, there were a number of factors likely influencing CHIP enrollment in different directions, most notably:

Successful outreach and enrollment efforts for new Marketplaces likely pushed enrollment up in some states.  Implementation of the major coverage provisions of the ACA had begun but had not been completed. Broad outreach efforts to encourage individuals to apply for coverage (through CHIP, Medicaid, or the Marketplaces) were well underway; such efforts in the past have been noted to apply upward pressure on CHIP enrollment. CHIP programs also face the same ACA requirements in terms of enrollment simplifications, coordination with Medicaid and the new Marketplaces, as well as the use of Modified Adjust Gross Income beginning in 2014. The full effect of these changes would occur just after this data collection period.

Problems implementing new enrollment systems for the Federally Facilitated Marketplace (FFM) and State Based Marketplaces (SBM) likely put downward pressure on CHIP enrollment growth. States and the Federal Government faced IT systems challenges, particularly early on in the open enrollment period, which may have applied some downward pressure on CHIP enrollment during this period.  States that relied on FFMs had significant problems with “account transfers” from the FFM to agencies handling CHIP enrollment. Many children were assessed or determined eligible for CHIP through the FFMs, but because of system problems, accounts could not be easily transferred to effectuate enrollment. There were also some SBMs that also faced similar issues. Although problems persist, some progress in resolving these issues was made after the timeframe for this report.

Enrollment Trends

On net, CHIP enrollment increased by 175,020 between December 2012 and December 2013 despite slow enrollment growth in the second half of the period. CHIP enrollment increased to nearly 5.8 million as 175,020 more individuals (on net) were enrolled in coverage in December 2013 compared to December 2012. Enrollment growth over the year was on track with previous trends but slowed in the second half of this 12 month period (June 2013 to December 2013.) There were 144,412 more children on net enrolled in CHIP in June 2013 compared to December 2012; in contrast, CHIP enrollment increased by only 30,608 between June 2013 and December 2013. (Figure 3) The slow growth noted in the second half of the year (June 2013 to December 2013,) may be a reflection of the initial difficulties states and the federal government faced with IT systems and file transfers.

The net CHIP enrollment growth includes increases in 29 states and decreases in 22 states. Over half of states (29) reported enrollment increases during this period as 270,136 more children were enrolled in CHIP in these states in December 2013 compared to one year earlier. In contrast, 22 states saw enrollment declines as 95,116 fewer children were enrolled in these states in December 2013 compared to one year earlier. (Figure 4)

The three states that were driving these increases include:

• California’s CHIP enrollment increased in California by 16.4 percent as 186,200 additional children were enrolled in December 2013 compared to December 2012. It is important to note that the transition of children previously enrolled in the Title XXI Healthy Families to Medi-Cal (Medicaid) would not affect CHIP enrollment numbers reflected in this report because these children are still included in the CHIP counts. The increase in the number of children enrolled in CHIP may be related to outreach and enrollment efforts tied to expanded Medicaid and CHIP coverage programs in California, and also to the improving economy with children moving up the income scale between Medicaid and CHIP.
• Arizona saw CHIP enrollment growth of 54 percent as an additional 16,367 children were enrolled in CHIP in December 2013 compared to one year earlier due to a new temporary program, KidsCare II, that began enrolling children in May 2012. This program ended January 31, 2014; the state sent out notices to approximately 14,000 families with incomes over 133% FPL that they would need to apply for coverage through the Marketplace. The original KidsCare program still exists, but enrollment remains frozen, meaning no new applications are being accepted and children who lose this coverage due to failure to pay premiums will not be able to reenroll later. According to the state, just over 2,600 children remain enrolled in the original KidsCare program.⁵  The original KidsCare has been closed to new enrollment since December 2009 due to state budget shortfalls. CHIP enrollment steadily declined for several reporting periods, reaching its lowest level in over a decade in June 2012, when enrollment totaled only 12,238 (compared to over 64,000 before the enrollment freeze was first implemented.)
• Arkansas saw a 20 percent increase in CHIP enrollment between December 2013 and December 2012 as enrollment increased by 16,367. All of this enrollment growth occurred in the second half of the period; Arkansas actually saw a small decline in CHIP enrollment in the first six months of this period (December 2012 to June 2013.) It is likely that the sharp increase in enrollment was due in part to the state’s adoption of fast track enrollment options made available through CMS in an effort to help states launch the Medicaid expansion and efficiently enroll eligible individuals. Specifically, Arkansas was one of five states that implemented the fast track enrollment option allowing states to enroll individuals based on existing data from their Supplemental Nutrition Assistance Program. Arkansas, along with West Virginia, used this process to not only enroll adults but also children who were eligible but not enrolled.⁶ 

The largest declines in CHIP enrollment occurred in Texas, New York, and Flordia; the factors underlying these declines however are not readily apparent.

CONCLUSION

Overall, CHIP enrollment growth remained on track with previous trends, despite much slower growth seen in the second half of this period (June 2013 to December 2013.) Economic improvements apply both upward and downward pressure on CHIP enrollment; as income increases some children shift from Medicaid to CHIP while others transition off the program as their income rises above CHIP eligibility levels. Like Medicaid, CHIP programs also saw some upward (through increased outreach) and downward pressure (from enrollment systems issues) related to the implementation of the ACA. CHIP programs, along with state Medicaid programs continue to play a critical role in assuring health coverage for uninsured children. However, the future of the program remains uncertain as funding is slated to end in October 2015 unless Congress acts.

The data in this report reflect the number of children, including individuals covered under the unborn child option, enrolled in CHIP programs in each state. State CHIP officials provided data specifically for the month of December 2013. States also were asked to review data in previous reports in this series and to update data as might be appropriate for previous periods. The data for this report were requested in March 2014; responses for most states were returned by May 2014. Data for specific states in reports issued by CMS may differ from data in this report. Beyond the “point-in-time” versus “ever-enrolled” counts described below, differences occur when states provide data for this report for a point-in-time other than the final day of a quarter, when states update enrollment counts, e.g., for retroactive eligibility of a Medicaid-expansion CHIP program.

The data in this report are “point-in-time,” meaning the number of individuals enrolled in a specific month, such as December 2013. A “point-in-time” count is distinct from the “ever-enrolled” count, which is provided in reports issued by CMS. The annual count of children ever-enrolled will always exceed the number enrolled at any point- in-time, as long as new enrollments and departures occur during the year. Recent experience shows that one-third of CHIP enrollees enrolled at any time during the year were not enrolled at the end of the year.

Net Change. The data collected for this report are net changes in enrollment across the program and within select eligibility groups, taking into account the net impact of children enrolling and disenrolling from the CHIP program. Because this data are not individual level data and states do not make a distinction between enrollment among current beneficiaries and new beneficiaries, it is not possible to determine from this data the number of children that left the program and the number that newly enrolled in a given time period. For example, this data set cannot be used to determine how many of the 5.8 million beneficiaries enrolled in December 2013 had been enrolled in December 2012.

Differences between this report and preliminary data released by CMS of monthly enrollment trends. Starting in April 2014, CMS began publishing monthly reports that include total Medicaid and CHIP enrollment as part of an initiative to provide data on a broad set of Medicaid and CHIP eligibility and enrollment performance indicators to inform program management and oversight.⁷  However, this data resource, while providing some of the most timely Medicaid and CHIP enrollment data in the program’s history, is still in its early stages of development. Notable differences between that data and the data provided here include:

1. Inclusion of Medicaid. The CMS report combines enrollment figures for Medicaid (Title XIX) and CHIP (Title XXI.) We report these two groups separately; CHIP enrollment (Title XXI) is included in this report and Medicaid enrollment (Title XIX) is included in a separate report https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-snapshot-december-2013.
2. Reporting Method. CMS asks states to submit their enrollment data through an online portal each month, revising data reported for the previous month only. As discussed above, we ask states to report data for June and December of each year. States are asked to submit updated data as far back as they desire each time the data are collected.
3. Retroactive Eligibles. Medicaid expansion CHIP programs allow for up to three months of retroactive eligibility. Because of the timeliness of the data collection process, the CMS data do not generally reflect retroactive enrollment. For this report, we ask states to include retroactive enrollment whenever possible.
4. Trend. This data sources goes back to 2000, showing enrollment trends in monthly enrollment for December and June between 2000 and 2014. The CMS data captures monthly enrollment before open enrollment for the Marketplaces began (average of enrollment between June and September 2013) and enrollment for January, February and March 2014.

1. Kaiser Commission on Medicaid and the Uninsured, The Uninsured: A Primer – Key Facts about Health Insurance on the Eve of Coverage Expansions. (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) October 2013. http://modern.kff.org/report-section/the-uninsured-a-primer-2013-3-how-and-why-has-the-number-of-uninsured-people-changed/. ↩︎
2. While most children with income up to 400% FPL that do not qualify for CHIP in their state will be eligible for tax credits to purchase coverage in the Marketplace, some children will not be eligible for tax credits because a parent may have access to “affordable” employer coverage. However, the affordability test for employer coverage is based on a calculation of the individual coverage relative to a workers wages (not the cost of a family policy).  This situation is referred to as the “family glitch.” ↩︎
3. See Medicaid/CHIP MAGI Eligibility Levels by FPL, Medicaid Moving Forward 2014, Eligibility Data http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. ↩︎
4. Wesley Prater and Joan Alker, Georgetown University Center for Children and Families, Aligning Eligibility for Children: Moving the Stairstep Kids to Medicaid, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured,) August 2013. http://modern.kff.org/medicaid/issue-brief/aligning-eligibility-for-children-moving-the-stairstep-kids-to-medicaid/. ↩︎
5. “KidsCare II – Arizona’s Temporary Children’s Health Insurance Program (CHIP) ends January 31, 2014; Regular KidsCare Enrollment Update,” Arizona Health Care Cost Containment System (AHCCCS), accessed May 27, 2014. http://www.azahcccs.gov/applicants/KidsCareII.aspx. KidsCare Coverage Moving Forward. Arizona Health Care Cost Containment System (AHCCCS), (Arizona: AHCCCS,) June 26, 2013. http://www.azahcccs.gov/publicnotices/Downloads/KidsCareCoverage.pdf ↩︎
6. Artiga, Samantha. Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion. (Washington, DC: Kaiser Family Foundation,) November 2013. https://modern.kff.org/medicaid/issue-brief/fast-track-to-coverage-facilitating-enrollment-of-eligible-people-into-the-medicaid-expansion/. ↩︎
7. See Monthly Medicaid and CHIP reports, Medicaid Moving Forward 2014, Eligibility Data http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. ↩︎

As of December 2013, nearly 55.4 million individuals were enrolled in Medicaid. Compared to one year earlier, enrollment grew by 1.1 percent – the slowest rate since before the Great Recession. (Figure 1) An additional 585,000 individuals were enrolled in Medicaid programs across the country in December 2013 compared to one year earlier, a fraction of the increases seen at the height of the recession,¹  when 4 million additional individuals enrolled over a 12 month period between December 2008 and 2009. This is also the monthly period immediately before the January 2014 implementation of the adult Medicaid expansion.

This report focuses on changes in monthly Medicaid enrollment between December 2012 and December 2013. (Appendix Table A-1, which also includes data from our separate CHIP report) This is a long standing report series that collects monthly Medicaid enrollment data for December (and June, not reported here) going back to 2000. While the most recent data included in this report predate preliminary data released by CMS that show the early effects of full implementation of the ACA, this report series is an important source of historical trend data that provides the necessary context to understand these new sources of Medicaid enrollment data. In addition to providing historical trends (Appendix Tables A2-A3), these data also provide more detail about enrollment, such as the distribution of the enrollment among children, adults, or the elderly and people with disabilities, as well as Medicaid enrollment trends for each of these groups (Appendix Tables A4-A6.) While not directly comparable to the enrollment data released by CMS (see methodology for more details) – this report provides helpful context, additional detail and historical trend information not available in the CMS data.

During the period from December 2012 to December 2013, there were a number of factors likely influencing Medicaid enrollment in different directions, most notably:

Continued improvement in economic conditions resulted in slower Medicaid enrollment growth. Medicaid is a countercyclical program; when economic conditions worsen, people lose their jobs, their income declines and they become eligible for Medicaid. The reverse is also true; as economic conditions improve, unemployment declines, income rises and people no longer qualify for Medicaid coverage. During 2013, economic conditions continued to improve, particularly in comparison to the earlier recessionary periods, applying downward pressure on Medicaid enrollment growth.

Early expansion of Medicaid in some states, as well as successful outreach and enrollment efforts for new Marketplaces pushed enrollment up in some states. Implementation of the major coverage provisions of the ACA had begun but had not been completed. Broad outreach efforts to encourage individuals to apply for coverage (through Medicaid, the Marketplaces, or CHIP) were underway by December 2013, and in the past such efforts have put upward pressure on Medicaid enrollment. While the Medicaid expansion was not set to begin until January 2014 (just after this data collection period) states such as California and Colorado, which had elected to expand coverage to childless adults and parents ahead of time saw increased enrollment in these programs, boosting Medicaid enrollment totals. Changes related to the Medicaid coverage expansion in other states and other enrollment effects of the ACA more broadly would start until January 2014, the month following this data.

Problems implementing new enrollment systems for the Federally Facilitated Marketplace (FFM) and State Based Marketplaces (SBM) put downward pressure on Medicaid enrollment growth. States and the Federal Government faced IT systems challenges, particularly early on in the open enrollment period for the Marketplace, which may have applied some downward pressure on Medicaid enrollment during this period. States that relied on FFMs had significant problems with “account transfers” from the FFM to Medicaid. Many individuals were assessed or determined eligible for Medicaid through the FFMs, but because of system problems, accounts could not be easily transferred to effectuate enrollment. There were also some SBMs that faced similar issues. Although problems persist, some progress in resolving these issues was made after the timeframe for this report.

Enrollment Trends across states

(Appendix Tables A1-A3)Medicaid enrollment increased slightly to 55.4 million as 585,000 more individuals (on net) were enrolled in Medicaid in December 2013 compared to December 2012. Enrollment growth over the year was lower than previous trends but slowed even further in the second half of this 12 month period (June 2013 to December 2013) as the number of people enrolled increased by only 88,800 compared to an increase of 496,200 enrollees between December 2012 and June 2013. (Figure 2) Nearly all states saw slower enrollment growth between June 2013 and December 2013 than in the prior six month period, but the decline was particularly notable in states not expanding their Medicaid programs; virtually all of these states were also coordinating with the FFM and many faced the IT systems issues noted above.

To date, 27 states are implementing the expansion in 2014 (Figure 3). All of these states except Michigan and New Hampshire started enrolling people in the new eligibility group in January 2014; Michigan began enrolling individuals in the new eligibility group in April 2014 and New Hampshire, which passed legislation to adopt the Medicaid expansion in March 2014, plans to start enrollment for the new eligibility group in July 2014. The remaining 24 states were not implementing the expansion in 2014 although debate about the expansion was on-going in 5 states at the time of this report.² 

In contrast to previous releases of this report, nearly half of states (24) reported enrollment declines during this period as 309,400 fewer individuals were enrolled in these states in December 2013 compared to one year earlier. However, in 27 states enrollment grew during this period as 894,400 more individuals were enrolled in Medicaid in December 2013 compared to one year earlier. (Figures 4 and 5)

Enrollment Growth Across Eligibility groups

(Appendix Tables A1, A4-A6)

Enrollment growth between December 2012 and December 2013 was driven by enrollment growth among adults and children as opposed to the elderly and people with disabilities. (Figure 6)

On net, enrollment of adults and children increased by 483,600 between December 2012 and December 2013. This reflects a net increase of 577,900 adults during this period, concentrated in states expanding Medicaid in 2014. States that were driving increases include:

• California‘s increase among adults enrolled in Medicaid was driven by continued growth in its Low Income Health Program (LIHP.) Enacted as part of the state’s Bridge to Reform waiver, LIHP allowed counties to expand eligibility to adults with incomes up to 133 percent of the Federal Poverty Level (FPL), starting in July 2011. California’ LIHP enrollment increased quickly. By December 2013, total enrollment in the program reached 704,016. (These individuals were transitioned by the state in January 2014 to the new ACA Medicaid expansion group).³ 
• Colorado implemented a Section 1115 waiver program to cover childless adults with incomes below 10% FPL in early 2012 with an enrollment cap of 10,000, which was reached before the end of the first year. After deciding to implement the Medicaid expansion, the state gradually raised the enrollment cap starting in April 2013.⁴  Enrollment increased by over 7,000 between December 2012 and December 2013. (The state automatically transitioned these 17,000 individuals along with the roughly 9,000 still on the waiting list over to the new Medicaid expansion group in January 2014).⁵ 
• In late 2012, Illinois obtained a Section 1115 demonstration waiver, “CountyCare,” which provided Medicaid coverage to adults age 19-64 with incomes below 133% FPL who lived in Cook County, Illinois (which encompasses the city of Chicago and the surrounding area). The demonstration was designed to help the state and Cook County Health and Hospitals System build capacity and experience to support implementation of the Medicaid expansion in 2014 and get a jump-start on enrollment. Enrollment for the program began in February 2013; by December 2013, enrollment had reached nearly 80,000.⁶ 
• New York, a state that had expanded coverage to childless adults well ahead of the ACA, saw across the board enrollment growth, including its TANF-related groups and its expansion to safety-net adults.⁷ 
• Florida and Pennsylvania, both states not expanding in 2014 and coordinating with the FFM, saw notable enrollment growth as well. Florida saw across the board enrollment growth throughout the year, particularly among children covered under Medicaid. Pennsylvania enrollment appears to show notable growth among adults during this period, nearly all of which occurred in the second half of the year. While some of this growth is driven by an increase among some TANF-related adults, changes in reporting also occurred during this period that may result in including groups normally excluded from this report, making it appear there is higher growth than there would be otherwise.⁸ 

In contrast to adults, Medicaid enrollment of children actually saw a small decline on net during this period as 26 states saw declines in Medicaid enrollment of children (most notably in Illinois, Texas, Michigan, Georgia, and Indiana) while 25 states saw increases (most notably in Colorado, Florida, New York, Alabama and Maryland.) States that are implementing the Medicaid expansion in 2014 experienced relatively flat growth among children whereas states not implementing the Medicaid expansion in 2014 saw a more substantial decline in enrollment of children in Medicaid. Some of these children may have transitioned to CHIP as family income increased; CHIP enrollment grew during this same period by 175,020.⁹  The decline in Medicaid enrollment of children was concentrated in the second half of the period (June 2013 to December 2013) and in states not expanding Medicaid in 2014 nearly all of which opted to coordinate with the FFM; this may be a reflection of the initial difficulties states and the federal government faced with IT systems and file transfers. A few states, most notably California and Colorado, were in the process of transitioning children from their stand-alone CHIP programs to Medicaid during this period. These children are still funded through Title XXI and therefore are not included in the counts reported here; they are included in the counts reported in a separate companion report on CHIP enrollment.

Enrollment increases among the elderly and people with disabilities contributed to total enrollment growth during this period, but to a lesser extent than in recent years. Medicaid enrollment among the elderly and people with disabilities grew very little in Medicaid programs across the country during this period, as 101,400 more aged and disabled beneficiaries were enrolled in December 2013 than in December 2012 (0.7% growth compared to enrollment growth of 2.7% in the prior annual period.) Overall, enrollment grew in all but 12 states for this group; the largest declines occurred in Pennsylvania, California, Georgia, Tennessee, and Kentucky largely among disabled groups. Over two-thirds of states saw slower growth from June 2013 to December 2013 than in the previous six month period.

CONCLUSION

During 2013, Medicaid enrollment growth continued to slow to levels not seen since before the Great Recession. Changes in Medicaid enrollment growth during this period were likely influenced by a number of factors, including a continually improving economy (applying downward pressure on Medicaid enrollment) but also by the early stages of implementation of the major coverage provisions of the ACA (which likely applied both upward pressure on Medicaid enrollment from increased outreach as well as enrollment growth among early expansion states and downward pressure from IT systems issues both states and the federal government faced in the early part of the Marketplace open enrollment period.) Medicaid enrollment growth seen during this period was largely driven by increased enrollment of adults in states that are expanding Medicaid in 2014.

However, after a slow rate of growth in 2013, Medicaid enrollment appears to have increased substantially during the beginning of 2014; preliminary data from CMS shows that combined Medicaid and CHIP enrollment grew by at least 4.8 million or 8.2% during the open enrollment period. According to this preliminary data, nearly all of the enrollment growth during this period occurred in states that implemented the Medicaid expansion; these states experienced substantially higher growth in Medicaid enrollment than states that have not expanded (12.9% vs. 2.6%).¹⁰  CMS, which is collecting this data as part of efforts to collect a broad set of eligibility and enrollment performance indicators to inform program management and oversight, has indicated that more detailed information on which eligibility groups are driving enrollment in each state is anticipated to be released sometime over the summer.

This report is based on data provided by each of the 50 states and the District of Columbia. Health Management Associates (HMA) asked each state to provide the internal reports they use to track enrollment in the program. Each state’s report included total enrollment and enrollment in certain eligibility categories. Report categories are not standardized across states. Where it was possible to do so, the state enrollment data were grouped to further examine trends in specific Medicaid eligibility categories. The data tables and graphs in this document present “point-in-time” monthly Medicaid enrollment counts for the months of June and December of each year from 2000 through 2013 rather than “ever-enrolled” counts published by CMS. The data were provided to HMA by each state Medicaid program in March and April 2014.  Historical data may change over time as states change how they report their enrollment data as well as if a state provides revised data for previous time periods.

Net Change. The data collected for this report are net changes in enrollment across the program and within select eligibility groups, taking into account the net impact of individuals enrolling and disenrolling from the Medicaid program. Because these data are not individual level data and states do not make a distinction between enrollment among current beneficiaries and new beneficiaries, it is not possible to determine from this data the number of individuals that left the program and the number that newly enrolled in a given time period.

Definitions of Medicaid Enrollment. The counts provided by the states reflect all persons with Medicaid eligibility for each month. Every person with Medicaid coverage was counted as an enrollee with the exception of family planning waiver and pharmacy plus waiver enrollees. No adjustment was made for other persons who are enrolled in Medicaid categories with less than full coverage. Therefore the enrollment figures reported here include a small number of individuals that are covered by Medicaid only for emergency services and persons with Medicare and Medicaid dual eligibility enrolled as either Specified Low-Income Medicare Beneficiaries (SLMBs), Qualified Individuals (QIs), and as Qualified Medicare Beneficiaries (QMBs). To the extent possible, state-only health coverage programs and Medicaid expansion CHIP enrollees not funded by Medicaid are excluded.

Non-Disabled Children and Non-Disabled Adults. To remain consistent with other enrollment reports, such as the Medicaid Statistical Information System (MSIS), this report groups disabled children in the elderly and disabled category. However, the detail provided in enrollment reports from states varies in the level of detail available. Most states are able to provide data that breaks out the number of non-disabled children either within the same report or through a separate report. In 2 states (IL and WI) some estimation is required due to differences in report totals to determine the number of non-disabled children. For CA, data available for 2012 onward allows for breakouts of children from adults in each eligibility category reported; this data is used to estimate such breaks in data from 2011 and earlier. Additionally, there are a relatively small number of enrollees whose eligibility pathway was not identified. These individuals were included in the non-elderly non-disabled adult counts unless clearly identified as children.

State Variation in Enrollment Reports. Common variations across the states include how states count “spend-down” enrollees and whether states adjust for “retroactive” eligibiles. Some states include in their enrollment counts persons with excess income that qualify to “spend-down” to Medicaid eligibility whether or not they have incurred sufficient medical costs to become eligible for Medicaid in that month. Other states only include those individuals that have met their “spend-down” requirement. Since a primary goal of this report is to identify trends, these variations have been deemed acceptable given that the state does not change its methodology over time. Data for some states include “retroactive” eligibles, i.e., individuals whose Medicaid eligibility is established at a later date, but whose coverage is retroactive to a prior point in time. Effort was made to use reports that reflect retroactive eligibility where they exist. Yet, it is possible that additional changes occurred after the counts provided for use here.

Differences between this report and preliminary data released by CMS of monthly enrollment trends. Starting in April 2014, CMS began publishing monthly reports that include total Medicaid and CHIP enrollment as part of an initiative to provide data on a broad set of Medicaid and CHIP eligibility and enrollment performance indicators to inform program management and oversight.¹¹  However, this data resource, while providing some of the most timely Medicaid enrollment data in the program’s history, is still in its early stages of development. Notable differences between that data and the data provided here include:

1. Definition of Medicaid beneficiary. CMS limits the definition of Medicaid beneficiary to those receiving comprehensive benefits and therefore excludes populations such as 1) partial-benefit Duals (QMBs, SLMBs, QIs), 2) 1115 waivers providing limited benefits, 3) those receiving emergency services through Medicaid due to immigration status issues. The data provided in this report includes all of these groups.
2. Inclusion of CHIP. The CMS report combines enrollment figures for Medicaid (Title XIX) and CHIP (Title XXI.) We report these two groups separately; Medicaid enrollment (Title XIX) is included in this report and CHIP enrollment (Title XXI) is included in a separate report https://www.kff.org/medicaid/issue-brief/chip-enrollment-snapshot-december-2013.
3. Reporting Method. CMS asks states to submit their enrollment data through an online portal each month, revising data reported for the previous month only. As discussed above, this report is compiled from off the shelf reports states submit to Health Management Associates for June and December of each year. States are asked to submit updated data as far back as they desire each time the data are collected.
4. Retroactive Eligibles. Medicaid allows for up to three months of retroactive eligibility. Because of the timeliness of the data collection process, the CMS data do not generally reflect retroactive enrollment. For this report, we ask states to include retroactive enrollment whenever possible.
5. Trend. This data sources goes back to 2000, showing enrollment trends in monthly enrollment for December and June between 2000 and 2014. The CMS data captures monthly enrollment before open enrollment for the Marketplaces began (average of enrollment between June and September 2013) and enrollment for January, February and March 2014.
6. Enrollment by Eligibility Group. Data reported by CMS shows total enrollment across Medicaid and CHIP, but cannot, at this point in time, show enrollment by eligibility group (children, adults, aged and disabled.) This however, is something that is expected to change in the near future.

1. The Great Recession officially began in December 2007 and officially ended in July 2009 according to the National Bureau of Economic Research; however, the effects of the Great Recession continued well past this point. ↩︎
2. State Health Facts, Status of State Action on the Medicaid Expansion Decision, 2014. (Washington, DC: Kaiser Family Foundation, ) downloaded May 27, 2014. https://modern.kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. ↩︎
3. Research and Analytic Studies Division, Medi-Cal Statistical Brief: Medi-Cal Monthly Eligibles Trend Report for January 2014. (California: Department of Health Care Services,) 2014. http://www.dhcs.ca.gov/dataandstats/statistics/Documents/RASB_Issue_Brief_Medi-Cal_Eligibles_Trend_Report_for_January_2014%20(Feb%202014).pdf. ↩︎
4. Colorado Department of Health Care Policy and Financing, Colorado Medicaid Will Enroll More Childless adults from Waitlist. (Colorado: Colorado State Government,) February 21, 2013. http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251855278811&ssbinary=true. ↩︎
5. Colorado Department of Health Care Policy and Financing, Medicaid Expansion Update. (Colorado: Colorado State Government,) December, 16 2013. http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251919771103&ssbinary=true. ↩︎
6. Artiga, Samantha. Profiles of Medicaid Outreach and Enrollment Strategies: The Cook County Early Expansion Initiative. (Washington, DC: Kaiser Family Foundation,) April 2014. https://modern.kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-the-cook-county-early-expansion-initiative/. ↩︎
7. The only exception was a small decline in enrollment in its Family Health Plus program, a long-standing 1115 waiver to extend coverage to adults with income up to 150% FPL; the state reduced eligibility for this program down to 138% FPL in January 2014 and had previously reported plans to use Medicaid funds to help further subsidize coverage for those previously covered under the program purchasing coverage through the state’s Marketplace. Vernon Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz and Laura Snyder, Medicaid in a Historic Time of Transformation: Results from a 50-State Budget Survey for State Fiscal Years 2013 and 2014. (Washington, DC: Kaiser Family Foundation,) October 2013. https://modern.kff.org/medicaid/report/medicaid-in-a-historic-time-of-transformation-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2013-and-2014/. ↩︎
8. According to guidance issued by the state to counties in September 2013 (see below), the new MG category includes the following groups that are normally excluded from counts in this report: children with income between 100 and 133 percent FPL ages 6-18 who were previously eligible under CHIP (also known as stairstep children) and women enrolled in SelectPlan, the state’s family planning waiver. According to the memo, those that have submitted applications on or after October 1, 2013 will be enrolled under the new MG categories; it was not possible at the time of this report to separate out these two groups either reenrolled or newly enrolled from the others in this group. Tom Strickler, Director of Bureau Operations. Operations Memorandum #13-09-04: Medicaid Eligibility Rule Changes Under the Affordable Care Act (ACA). (Pennsylvania: Pennsylvania Department of Public Welfare,) September 27, 2013. http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/OPS1300904.pdf. ↩︎
9. Two states were not able to provide updated CHIP enrollment data for December 2013 – Missouri and North Dakota. Vern Smith, Laura Snyder and Robin Rudowitz. CHIP Enrollment Snapshot: December 2013. (Washington, DC: Kaiser Family Foundation,) May 2014. ↩︎
10. Medicaid & CHIP: March 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report, (Washington, DC: Centers for Medicare and Medicaid Services,) May 1, 2014. http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. In calculating these rates of growth, CMS excluded CT, DE, ND, ME and MO as they had not reported complete data for either the baseline period or for March 2014. Also, MI and NH were not included in the calculations for the rate of growth in expansion states as neither state had yet implemented their expansion (MI implemented in April 2014 while NH is planning to implement in July 2014.) ↩︎
11. See Monthly Medicaid and CHIP reports, Medicaid Moving Forward 2014, Eligibility Data http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/medicaid-moving-forward-2014.html#. ↩︎