States adopted budgets for state fiscal year (FY) 2018 as Congress debated legislative proposals that created a lot of uncertainty about the future of the Affordable Care Act (ACA), financing for the Medicaid expansion as well as overall financing for the Medicaid program. The federal debate was playing out as states grappled with other Medicaid budget issues related to the economy, health care costs, implementation of delivery system reforms, and addressing emerging public health issues like the opioid epidemic. This brief discusses Medicaid enrollment and spending trends for FY 2017 and FY 2018 based on interviews and data provided by state Medicaid directors as part of the 17th annual survey of Medicaid directors in all 50 states and the District of Columbia. The survey was conducted by the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) from June 2017 to August 2017, during the same timeframe that Congress was debating legislative proposals with significant implications for Medicaid. Key findings are described below and in a companion report. The methodology used to calculate enrollment and spending growth as well as additional information about Medicaid financing can be found at the end of the brief. FY 2017: Following peaks in enrollment and spending growth in 2015 due to the implementation of the ACA, Medicaid enrollment growth slowed to 2.7 percent nationally in FY 2017, down from 3.9 percent in FY 2016 (Figure 1). Total spending growth was stable at 3.9 percent, up only slightly from 3.5 percent the previous year. State Medicaid spending experienced a slight uptick from 2.4 percent in FY 2016 to 3.5 percent in FY 2017, as states that implemented the Medicaid expansion started to pay 5 percent of the costs of those enrollees in January 2017 (mid-way through the state fiscal year). However, state spending growth for Medicaid was slower than overall state general fund growth in FY 2017. FY 2018: For FY 2018, states on average project Medicaid enrollment growth to dip to 1.5 percent and total spending to increase by 5.2 percent. States attributed slower enrollment growth projections to tapering ACA related enrollment, a stable economy, and the processing of delayed redeterminations. States pointed to high cost prescription drugs and policy decisions to increase payment rates for specific provider groups as factors contributing to higher projected spending growth. Growth in the state share of Medicaid spending is expected to be slightly higher on average than for total spending due to formula-driven FMAP changes (that occur based on lagged personal income data) and, in 32 expansion states, the full-year effect of the state share for expansion enrollees, which increases from 5 percent to 6 percent in January 2018. Future Outlook: States indicated that they could face budget challenges as reductions to disproportionate share hospital payments go into effect in October 2017, if Congress fails to reauthorize the Children's Health Insurance Program (CHIP) and if legislative proposals under consideration to restructure Medicaid financing were to be enacted into law. As states started FY 2018 and looking ahead, many were concerned about volatility in state revenues that affects states ability to finance the state share of Medicaid.
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