Study Reveals Lessons in Early Medicaid Expansion

In a study entitled “Lessons from Early Medicaid Expansion Under Health Reform: Interviews with Medicaid Officials” released in the Medicare and Medicaid Research Review, interviews with Medicaid officials in six jurisdictions, which have participated in early expansions of Medicaid under the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), were conducted and analyzed. In these interviews, eleven officials from the “early-expander” example states of California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington were asked about their experiences with the expansion of Medicare to some or all of the low-income adults, which are to be targeted by the official Medicaid expansion in 2014. From these responses, the analysis’ authors compiled seven lessons or note-worthy results.

States with Pre-Existing Programs

In each of the six study states, the authors noted, some form of a state-funded or locally-funded health care program for low income individuals already existed before the early Medicaid expansion program came into effect. However, four of the six states were able to significantly expand enrollment under the PPACA-fueled expansion. Because in 2014 some states will be in a similar position of working off of already existing programs, significant increases in enrollment are expected, yet it is also noted in the study that the existence of a pre-existing program did not necessarily indicate greater ease in implementation.


Despite the fact these states had pre-existing programs, the study revealed that predictions of Medicaid expansion costs under PPACA are challenging. While some of the six states were able to make appropriate predictions of implementation and execution costs, others significantly underestimated costs and no reporting states overestimated the expense related to the expansion.

Barriers Remain

The report found that while the Medicaid officials from the sample states agreed the expansion aided in improvements in coverage and care, significant barriers remained in getting certain low-income individuals enrolled, keeping them enrolled, and ensuring once these individuals were enrolled they received the appropriate care. Interviews of the officials revealed optimism in terms of removing such barriers with managed care systems under Medicaid in the future but the author’s noted that reviews of the efficacy of such systems were mixed in other studies.

Behavioral Health

The study also revealed greater-than-expected use of behavioral health services, most notably, substance abuse programs. The authors highlight two potential implications of this increase for the future of this field pursuant to Medicaid expansion: (1) the possibility of major improvements in care and (2) increased state efforts to improve availability and quality of care resulting in increased provider capacity and better care coordination.

Implementation Challenges

Despite the six state’s early start in the Medicaid expansion, each of the officials from each surveyed state expressed concerns about implementation in the future. While some of the officials stated the early expansion process prepared their state for 2014 to some degree, most answers reflected issues remained for the future particularly with regard to coordinating with the new health reform marketplaces and converting their eligibility systems.

Woodwork Effect

The “woodwork effect” or the trend expected of those who were previously eligible for Medicaid to come out of the woodwork and sign up for Medicaid due to the existence of the PPACA reforms was not apparent in the six states. However, because of the official 2014 start date for the Medicaid expansion, the authors found that it would be premature to discount this effect in future expander states.

Political Context

The officials interviewed and the study’s authors agree that the political context in which Medicaid expansion is executed in a state will play a large role in the implementation process in that state. The study found that the six early expander states had a general political atmosphere that was supportive of the expansion of Medicaid. However, the states which chose to wait might not share in those views and, therefore, might experience difficulties arising from political opposition.