Since 2014, eight states have expanded their Medicaid programs to certain non-disabled adults through a Section 1115 of the Social Security Act, rather than the traditional approach envisioned by the Patient Protection and Affordable Care Act (P.L. 111-148). Although completion of a state-led evaluation is mandatory under Section 1115 waivers, questions related to implementation are beyond the scope of required evaluations. In addition, current evaluations lack detail on whether states implemented all provisions of their waivers as initially planned.
This study, by the State Health Access Data Assistance Center (SHADAC) at the University of Minnesota under contract to MACPAC, seeks to understand how Arkansas, Indiana, Iowa, and Michigan approached the implementation of key provisions of their Section 1115 Medicaid expansion waivers – exchange plan premium assistance, enrollee contribution requirements, health savings accounts, healthy behavior incentives, and graduated copayments for non-emergency use of the emergency department. SHADAC conducted interviews with 33 individuals representing current and former state agency staff and health insurance carriers in these four states, to identify the steps states took to operationalize their programs. The report reflects experience under waivers that are currently operational rather than more recent waiver applications and approvals. The findings, statements, and views expressed in this report are those of the authors and do not necessarily reflect those of MACPAC.