Differences in Medicaid Expansion, Nonexpansion Program Policies

Differences between Medicaid expansion and nonexpansion states go beyond whether states opted into the Affordable Care Act allowance, a Health Affairs study found. Researchers have discovered Medicaid expansion states also have certain policies in place that nonexpansion states do not.

The study observes differences between Medicaid programs from 2000 to 2016.

“The objectives of this study were to generate a longitudinal index of state Medicaid policies along four dimensions across all fifty states and Washington, D.C., to share with the broader research community and enable comparisons of trends across both expansion and nonexpansion states,” the Health Affairs article explained.

The study drew its data from Kaiser Family Foundation’s annual survey of Medicaid programs and Children’s Health Insurance Program (CHIP), which it has been running annually since 2000, along with data from Urban Institute.

The study observed a few facets of Medicaid programs, specifically income eligibility, administrative burden, immigrant eligibility, benefit comprehensiveness, and a composite of all of them.

The study charted these indices for expansion states and for nonexpansion states.

“The index and subindices range from 0 to 100, where 100 is equivalent to states adopting all policies under a given dimension or all income eligibility groups reaching 400 percent of the federal poverty level; 0 means that none of the policies were adopted,” the researchers wrote.

Expansion states had higher indices than nonexpansion states, signifying that their Medicaid programs had more policies around these factors than programs in nonexpansion states did.

The immigrant eligibility index saw the largest distinction between expansion and nonexpansion state policies. The index mean was 44 in expansion states and 21 in nonexpansion states.

For the income eligibility index, the mean among expansion states was 45. Three states scored as high as 70 on the index, indicating a relatively high acceptance of policies.

The other three expansion states tested on this measure fell below the mean, with North Dakota exhibiting less than 30 on the scale.

Nonexpansion states had a mean of 37 on the indices for support of the policies in this dimension.

The expansion state index mean was 77 for both the administrative burden index and the benefit and copay index. The index mean for nonexpansion states on these measures were 74 and 68, respectively.

Nonexpansion and expansion states may be on different trajectories policy-wise but they are all under the same pressure in regards to their eligibility and administrative burden. These indices for both expansion and nonexpansion states saw upward trends.

“States that have not expanded Medicaid, on average, have lower index values than states that chose to expand Medicaid on schedule in 2014,” the researchers noted.

"However, this is not solely a result of these states’ failure to expand Medicaid to adults without dependents; rather, these states also perform unfavorably, on average, across a range of other measures, including income thresholds for other categorical eligibility groups, reduced administrative burden in enrollment and renewal, expanding benefits with no cost sharing, and eligibility for immigrants.”

The study found that federal policies have the ability to create more policy unity among Medicaid programs.

States can do more to expand income eligibility, the researchers discovered.

The study’s findings have limitations. There were some differences for which the surveys did not account, such as section 1115 waivers and Medicaid reimbursement rates. There also may be other missing data, given that tracking specific rule changes is challenging.

Additionally, the timeframe does not encompass changes due to the coronavirus pandemic, which may have had a profound impact on some of these measures in some states.

Medicaid programs may face a great deal of uncertainty as CMS coronavirus waivers for Medicaid come to an end. For that reason, Kaiser Family Foundation urged CMS to offer states more guidance.

The study’s findings are mainly applicable to Medicaid programs. However, other recent research around trends in Medicaid uncovered the extent to which Medicaid can be a role model for private payers on social determinants of health innovation.