Medicaid on the eve of expansion: a survey of state Medicaid officials on the Affordable Care Act

Abstract

Twenty-five states and Washington D.C. are expanding Medicaid in 2014 under the Affordable Care Act. We surveyed Medicaid directors in expanding states to assess expectations and implementation strategies regarding enrollment, costs, and access. Telephone interviews were conducted between July and November 2013, with most occurring before open enrollment began October 1. The response rate was 88%. Overall, expectations were a mixture of optimism and caution. Predicted enrollment was high: 86% of officials projected at least 50% participation among newly-eligible uninsured adults. Officials predicted most Medicaid applications will come via statebased Exchanges (32%), navigators (23%), or directly to Medicaid (45%); none thought Healthcare.gov would be the primary means of Medicaid enrollment. Over 95% think expanded coverage will improve beneficiaries’ health care and health. 57% expect the expansion to produce state savings; however, 29% expect net costs to their state over the next decade. 73% viewed it as “possible” or “likely” that the federal government will reduce the federal share of costs due to budget pressures. Lack of specialists accepting Medicaid (50%) and coverage churning (45%) were described as the most likely potential barriers to care. States are taking a range of approaches to facilitate enrollment and promote continuity of coverage between Medicaid and Exchanges.