Association for Public Policy Analysis & Management

It is estimated that from 2014-2017, as many as 14.5 million people became insured through Medicaid. However, while many studies have focused on state decisions to expand Medicaid or not, fewer have examined broader trends in state-level Medicaid policy that affect eligibility criteria, administrative barriers to uptake and benefit generosity, many of which pre-date the ACA. The objectives this study were 1. To generate an Index of State Medicaid Generosity along three dimensions (income eligibility limits, enrollment rules, and benefit levels) across all 50 states and DC to share with the broader research community; 2. To summarize results of the Index and 3. To examine predictors of state Medicaid generosity.

Study Design

Data from the Kaiser Family Foundation’s State Health Facts on Medicaid and CHIP programs were compiled into a longitudinal dataset. Information on each state policy decision was coded such that a higher score represents a more generous Medicaid policy choice. All scores were summed and normalized on a 0-100 scale where 100 is equivalent to a state adopting the most generous allowable policies across three dimensions (income eligibility, easing of administrative barriers to enrollment, and benefit/co-pay generosity). The results were summarized into a decomposable index for the years 2000-2016 representing all variables that were measured both pre and post-ACA. This study first reports on the findings from the State Medicaid Generosity Index (including variation in state ACA implementation). Next, the study examines predictors of state Medicaid generosity including state ideology, poverty rates and race/ethnic composition.

Principal Findings

States vary widely in overall generosity and across all three dimensions. States have generally moved in the direction of having fewer enrollment rules and towards more generous eligibility levels even in states that did not expand Medicaid. However, states have remained largely unchanged in terms of covered benefits/copays. The most consistently generous states/localities between 2000-2016 across all categories were Washington DC, New Jersey and Connecticut while the consistently least generous were Texas, Utah and South Dakota. No state has adopted all of the possible policy reforms that would maximize eligibility levels, minimize administrative barriers to enrollment and provide all allowable benefits and eliminate copays. More liberal state ideology predicted higher Medicaid generosity, however poverty and race/ethnicity did not.

Conclusions

States vary widely in their adoption of policies aimed at increasing enrollment and providing more generous coverage for participants. States that are most generous may not be the ones we expect and states vary in their generosity across different dimensions. While many researchers focus on the nature of changes in Medicaid occasioned by the Medicaid expansion, this study shows that there are a variety of other areas that states have the authority to reform to increase coverage and increase benefit levels.

Implications for Policy or Practice

Both states that have expanded Medicaid and those who have failed to do so have room to reform to their eligibility, enrollment and benefit levels to improve uptake and increase the generosity of their Medicaid programs.