Voters in Nebraska, Idaho and Utah approved ballot initiatives in the November 2018 elections to adopt the Affordable Care Act’s Medicaid expansion to cover more low-income adults. Under the approved ballot propositions, single adults without children making less than 138 percent of the federal poverty level (about $16,000 for an individual or $33,000 for a family of four) would become eligible to enroll in the program.
Approval of the ballot propositions is expected to extend Medicaid coverage to approximately 325,000 residents across the three states and brings the total number of expansion states to 37, including the District of Columbia. Expanding health coverage under Medicaid is a key NACo priority as it provides counties with federal resources for indigent health care, preventive care and public health, and reduces uncompensated care costs for local governments.
The success of these ballot measures could fuel expansion efforts in additional states where gubernatorial candidates made Medicaid a central campaign issue. Maine’s governor-elect Janet Mills, and Kansas’ governor-elect Laura Kelly, have both promised to approve Medicaid expansion proposals soon after assuming office. Going forward, states electing to expand Medicaid must submit state Medicaid plan amendments to the Centers for Medicare and Medicaid Services (CMS), and once approved, will become eligible to receive enhanced federal support to finance the program expansion.
States’ decisions on Medicaid expansion follow a series of legislative and executive branch proposals throughout the 115th Congress with the potential to impact the Medicaid program. In October 2018, for example, Congress passed and the president signed a comprehensive opioid response package containing provisions to partially relax Medicaid’s Institutions for Mental Diseases (IMD) exclusion for substance use disorder treatment services and suspend – rather than terminate – Medicaid benefits for justice-involved youth, two longstanding NACo legislative priorities.
At the other end of Pennsylvania Avenue, the White House has signaled support for implementing work requirements in the Medicaid program, allowing states to apply to add these requirements under Medicaid’s Section 1115 waivers. To date, the Centers for Medicare and Medicaid Services (CMS) have received waiver applications from multiple states proposing to add work requirements to the program.
Looking ahead to the 116th Congress, it remains unclear whether Congress will consider legislation that would involve substantive changes to the Medicaid program. A Democratic-led House is unlikely to revive legislation that would repeal the Affordable Care Act’s Medicaid expansion or place per capita caps on program spending. Funding clashes around Medicaid spending could arise, however, as a divided Congress negotiates FY 2020 spending levels for federal programs.
Federal and state-level decision-making on Medicaid could impact counties’ role in providing health safety-net services to residents. Although Medicaid operates as a federal-state program, counties play an integral role in financing and administering the program, as well as delivering Medicaid-eligible services to residents through county hospitals, mental and behavioral health facilities and nursing homes. Given the importance of Medicaid to counties, NACo will continue to monitor federal and state actions that would impact the program.
For more information on the relationship between the Medicaid program and counties, please see NACo’s recently released report, Medicaid and Counties: Understanding the Program and Why It Matters to Counties, which outlines the role Medicaid plays in our nation’s health system, how counties contribute to the federal-state-local partnership and key messages for advocacy.