Medicaid: State of the States

The Public Citizen Health Research Group has a new report out on state Medicaid programs across the U.S. The report, based primarily on data from the Kaiser Family Foundation, examines Medicaid programs based on four major criteria: eligibility, scope of services, quality of care, and reimbursement. A scoring system is used to rank states in each category and overall.

The report's major findings:

Nationally, the state Medicaid programs are severely challenged: even the best state scores only 645.9 points on a scale of 1000. And the worst state rates a score of only 317.8, i.e., less than a third of the total maximum points.

The state-by-state breakdowns reveal marked disparities between and among states. The top 10 states, ranking #1 to #10, tend to cluster in the Northeast but also include three states in the Midwest and two in the Northwest. The following states occupy the first 10 ranks, in descending order: Massachusetts, Nebraska, Vermont, Alaska, Wisconsin, Rhode Island, Minnesota, New York, Washington, and New Hampshire.

The 10 most deficient state programs have overall scores ranging from between 317.8 and 379.1 of the total 1000 points. The worst, in order from 50th to 41st, are in Mississippi, Idaho, Texas, Oklahoma, South Dakota, Indiana, South Carolina, Colorado, Alabama, and Missouri.

The overall score of top-ranked Massachusetts is more than twice that of bottom-ranked Mississippi.

Regarding the overall state-by-state rankings:

The 10 best states and the 10 worst states tend to cluster geographically. Half of those that rank in the top 10 are in the Northeast: Massachusetts, Vermont, Rhode Island, New York, and New Hampshire. Another three -- Nebraska, Wisconsin, and Minnesota -- are in the Midwest. An additional two are in the Northwest: Washington and Alaska. The 10 worst states also show a geographic pattern, with three of them in the South (Mississippi, South Carolina, and Alabama) and four in the south central part of the country: Colorado, Texas, Oklahoma, and Missouri.

The report also says that "states whose Medicaid programs rank the lowest also tend to fare poorly in overall health rankings," and that "states' ranks tend to correlate with median household income." The report finds that despite federal matching formulas intended to address inequalities, the poorest states that have the most need for the program have the worst services.

The report concludes:

Our findings make it clear that there are large numbers of people who need to be, but are not, eligible; need to have access to a wider scope of services; need to benefit from better quality health care; or need to have access to more providers than are available because state reimbursement policies make their participation difficult if not impossible. Yet these critically needed additions are "voluntary" on the part of states rather than mandated nationally. The fact that many states have chosen to go beyond the federal legal requirements suggests that they are responding to constituent needs and public pressures, and that the "floor" of mandated Medicaid coverage is clearly inadequate.

[..]

Much of the current debate has focused on the program's sustainability. But more important is the question of whether the program, as it currently operates, is worth sustaining. Each of the categories we have examined pose problems that require attention at the national level and cannot be solved on a state-by-state basis.

Here are some highlights from around the South:

Alabama

• "Alabama's Medicaid program ranks 42nd overall, brought down by its placement among the bottom three states in two of the four categories, eligibility and scope of services. These two categories are both affected by the state's failure to cover those who are made poor by their extreme medical expenses, known as the medically needy."

• "In terms of Quality of Care, however, Alabama does better than most states."

Arkansas

• "Arkansas's Medicaid program scores range widely by category. The state ranks among the bottom 10 in two of the categories assessed."

• "[A ranking of 43rd in Scope of Services] means that even if people qualify for the program, they may not have access to many services provided to Medicaid recipients in states with a broader benefits package."

• "With respect to Quality of Care, the state occupies a low rung, being ranked 45th, or 7th from the bottom. This is accounted for by the low quality of its nursing home services and its poor showing in terms of health outcomes, such as childhood immunizations and mental health care."

Florida

• "Florida's Medicaid program is 4th in enrollment numbers and 5th in spending, and the state is under pressure to control both."

• "In terms of Eligibility, Florida [ranked 27th] earns points by covering individuals that have very high medical expenses but would otherwise have too much income to qualify. But it loses points for its restricted definition of who constitute the poor..."

• "The score for Scope of Services is only 51.8 percent of the total maximum, placing Florida in 35th place nationally."

• "In terms of Quality of Care, however, Florida ranks 4th.

• "In the Reimbursement category, Florida ranks 42nd."

Georgia

• "Georgia covers those whose higher-than standard income is offset by inordinate medical bills, and therefore gets additional points for both eligibility and scope of services. These points are not enough to compensate for deficiencies in other areas, though."

• "The score for Scope of Services is only 38.2 percent of the total maximum, and Georgia ranks 4th from the bottom (#48) in this category.

• "With respect to Quality of Care, the state Medicaid program ranks 42nd, largely by accruing negative points in nursing home care."

Kentucky

• "Like several other states, Kentucky is in the process of adopting a number of changes aimed at improving health status and controlling costs."

• "Kentucky's Medicaid program ranks 20th overall but shows great variability in its ranks by category."

• "In terms of Eligibility, the program ranks 30th, largely because of its stringent income restrictions for some beneficiaries and its limitations in the State Children's Health Insurance Program (SCHIP)..."

• "The score for Scope of Services is 52.4 percent of the total value, placing Kentucky in the 34th rank."

• "The state, however, is among the top 10 scorers in the Quality of Care category. Kentucky's program ranks 6th nationally, largely because of its creditable performance in staffing its nursing homes."

Louisiana

• "Louisiana's Medicaid program was severely tested following hurricanes Katrina and Rita, which devastated great swaths of the coastal areas and displaced hundreds of thousands of persons, many of whom were vulnerable and in need of health care. The hurricanes also destroyed part of the state's medical infrastructure, especially in New Orleans, leading to the closure of several hospitals and the relocation of many health providers, including more than 3,000 physicians."

• "In terms of Eligibility, Louisiana ranks relatively high, #11, and receives 65.3 percent of the total value."

• "Quality of Care is by far the most deficient area. Here, Louisiana ranks 48th, a score that significantly lowers its overall rank. This reflects the state's dismal performance in monitoring its nursing home services as well as the state's poor rate of childhood immunizations."

Mississippi

• "Twenty years ago, Mississippi ranked last among all the Medicaid programs. The passage of time and the hurricane gusts of Katrina, alas, have not benefited the state, which once again ranks last."

• "The state ranks 49th in Eligibility. This reflects its restriction of services to those at the lowest mandated poverty level in most cases, leaving out many who cannot afford private health insurance, and its exclusion of those who are poor due to extreme health care costs, the medically needy."

• "The score for Scope of Services is the lowest in the nation..."

• "In terms of Quality of Care, it ranks 25th. This reflects a better-than-average performance in staffing and monitoring nursing care, indicators in which many other state programs are quite deficient."

North Carolina

• "The state ranks 24th with respect to Eligibility. It covers the medically needy and allows income levels higher than the mandated Federal Poverty Level requirement for some categories. However, it loses points for its scant State Children's Health Insurance Program (SCHIP) coverage."

• "The score for Scope of Services is a low 54.1 percent of the maximum total, placing the state in 32nd place."

• "In the Reimbursement category, however, the state ranks a respectable 12th. It matches the national average in its per capita spending..."

South Carolina

• "South Carolina's rank of 44th reflects a Medicaid program that is extremely deficient in all areas except one, and ranks among the 10 worst in the country overall."

• "With respect to Eligibility, the state excludes those who are poor due to high medical expenses, the medically needy, and does not extend coverage above the mandated minimum Federal Poverty Level for the elderly, blind and disabled."

• "South Carolina's rank for Scope of Services is 46th."

• "South Carolina not only provides shallow coverage for limited numbers of people, but it also fails in Quality of Care. It earns negative points in nursing home care, with scores that lower its relative rank in this category to 44th."

Tennessee

• "In 2005, the state announced a major overhaul, including drastic cuts that restricted eligibility and eliminated benefits to an estimated 170,000 TennCare enrollees. Since then, the state has proposed five programs intended to fill gaps in health coverage."

• "Although it loses points in the subcategories of women's services, and devices and equipment, Tennessee does well in the other services. As a result, the state ranks 9th in Scope of Services."

• "Similarly, the state does well in Quality of Care, occupying the 11th rank nationwide."

[Note: Tennessee is omitted from the "Reimbursement" rankings and the overall rankings because it is the "only state that does not have a fee-for-service component" and therefore cannot be compared to other states.]

Texas

• "Placing in the bottom 10 in two categories, including the one with the heaviest weight, Texas ranks a poor 48th overall. In fact, it is the only state that places consistently at the bottom, all its category-specific ranks ranging within 10 ranks."

Virginia

• "Virginia's Medicaid program shows much variation in how its stacks up by category, with ranks ranging from 9th to 42nd."

• Virginia places lowest in Eligibility, where it ranks 42nd. This poor performance is largely the result of low Federal Poverty Level caps for different populations, leaving those with slightly higher income without coverage, as well as the exclusion of some groups (e.g., tuberculosis patients, parents of children who are covered by SCHIP, the State Children's Health Insurance Program).

• "With respect to Quality of Care, however, Virginia ranks among the "Top 10," placing 9th in this category. Compared with the rest of the states, Virginia does relatively well in indicators of nursing home care and childhood immunizations."

West Virginia

• "In Eligibility, the state ranks 34th, losing points for its strict adherence to the low mandated Federal Poverty Levels needed to qualify for services, which leaves some of the poor and near-poor without coverage."

• "In Scope of Services, it ranks 20th, with few noticeable exclusions except in devices and equipment."

• "It is under Reimbursement that West Virginia gets its best relative score: it ranks 12th. The state spends more per enrollee than the national average for the population groups included in our report."

The full report (PDF format) can be found here. There are extensive charts and graphs and tables of state rankings, and a detailed explanation of the methodology used to assign scores in each category and subcategory.

As the report notes, the quality and effectiveness of Medicaid programs varies widely from state to state. And this doesn't even begin to address the health care needs of 45 million uninsured in the U.S. As stated in the report's conclusion, "Each of the categories we have examined pose problems that require attention at the national level and cannot be solved on a state-by-state basis."