A stronger economy was a primary factor driving lower Medicaid enrollment growth and relatively steady spending growth as states finished state fiscal year (FY) 2018 and adopted budgets for FY 2019. This brief analyzes Medicaid enrollment and spending trends for FY 2018 and FY 2019 based on interviews and data provided by state Medicaid directors as part of the 18th annual survey of Medicaid directors in all 50 states and the District of Columbia. The methodology used to calculate enrollment and spending growth as well as additional information about Medicaid financing can be found at the end of the brief. Key findings are described below and in a companion report. Enrollment: A stronger economy, elimination of redetermination delays in states that had previously implemented new or upgraded eligibility systems, and enhanced verifications and data matching in a number of states resulted in flat enrollment growth in FY 2018 (-0.6%) and projected for FY 2019 (0.9%) (Figure 1). Since peaking in FY 2015, enrollment growth has continued to slow due, in part, to the tapering of ACA enrollment growth. Spending: Compared to FY 2017, total spending growth was steady in FY 2018 (4.2%) but is projected to accelerate modestly in FY 2019 (5.3%). While slower caseload growth helped to mitigate spending growth in FYs 2018 and 2019, higher costs for prescription drugs, long-term services and supports and behavioral health services, and policy decisions to implement targeted provider rate increases were cited as factors putting upward pressures on total Medicaid spending. ACA Expansion Financing: After receiving a 100% federal match rate for the expansion group for CYs 2014-2016, states began paying 5% of the costs of the Affordable Care Act (ACA) Medicaid expansion group starting in January 2017 and 6% beginning in January 2018. The declining federal match for the expansion group (which will continue to phase down to 90% by 2020) resulted in state Medicaid spending growth outpacing total spending growth (4.9% compared to 4.2%) in FY 2018, the first full state fiscal year that states were required to pay a share of expansion costs. States anticipate, however, that total spending growth will increase faster than state spending growth for FY 2019. While most states reported financing the state share of expansion costs with general fund dollars, a number of states listed other sources of financing including new or increased provider taxes / fees or savings that accrue from the expansion. Looking ahead, economic conditions and the outcome of federal and state elections are likely to have implications for Medicaid policymaking as well as for spending and enrollment trends. Potential federal efforts to further change the ACA or cap Medicaid financing as well as state ballot initiatives and other state efforts to adopt the Medicaid expansion are key issues to watch.
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