States Focus on Quality and Outcomes Amid Waiver Changes: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2018 and 2019


Medicaid now provides health insurance coverage to one in five Americans and accounts for nearly one-sixth of all U.S. health care expenditures.1 The Medicaid program constantly evolves due to changes in federal and state policies, the economy, and other state budget and policy priorities. As of July 26, 2018, all states had enacted a new or revised budget for FY 2019 with only three states enacting a budget after the fiscal year began.2,3 This represented a significant improvement from the prior year when a number of states called special sessions in 2017 to complete their FY 2018 budgets and 11 states started FY 2018 without a fully enacted budget.4 A stable economy and improvements in state revenue growth resulted in surpluses in many states at the beginning of FY 2019 when this survey was conducted.5

Report findings are drawn from the 18th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Family Foundation (KFF) and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD). (Previous reports are archived here.6) This year’s KFF/HMA Medicaid budget survey was conducted from June through September 2018 via a survey sent to each state Medicaid director in June 2018 and then a follow-up telephone interview. An acronym glossary and the survey instrument are included as appendices to this report.

The District of Columbia is counted as a state for the purposes of this report; the counts of state policies or policy actions that are interspersed throughout this report include survey responses from the 51 “states” (including DC). All 50 states and DC completed surveys and participated in telephone interview discussions between July and September 2018.7 Given differences in the financing structure of their programs, the U.S. territories were not included in this analysis but a separate survey was fielded and results will be released in another report.

This report examines Medicaid policies in place or implemented in FY 2018, policy changes implemented at the beginning of FY 2019, and policy changes for which a definite decision has been made to implement in FY 2019 (which began for most states on July 1, 20188). Policies adopted for the upcoming year are occasionally delayed or not implemented for reasons related to legal, fiscal, administrative, systems, or political considerations, or due to delays in approval from CMS. Key findings of this survey, along with state-by-state tables, are included in the following sections of this report:

Executive Summary Eligibility and Premiums

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