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Implications of Medicaid Financing Reform for State Government Budgets

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  • Jeffrey Clemens
  • Benedic Ippolito

Abstract

We analyze potential reforms to Medicaid financing through the lens of fiscal federalism. Because substantial dollars are at stake, both the economic and political sides of intergovernmental transfers have high relevance in this setting. We show that changes in Medicaid financing formulas can shift amounts exceeding several hundred dollars per capita from "winning" states to "losing" states. In some cases, these amounts exceed 10% of states' own-source revenues. States' balanced budget requirements imply that such changes would, if not phased in gradually, require significant budgetary adjustment over short time horizons. We next show that alternative Medicaid financing structures have significant implications for states' exposure to budgetary stress during recessions. During the Great Recession, an acyclical block-grant structure would have increased states' shortfalls by 2-3.5% of own-source revenues relative to either an explicitly countercyclical block grant or the current matching system. Finally, we assess the implications of several financing structures for the extent to which they subsidize states' decisions on both the "extensive" and "intensive" margins of coverage generosity over the short and long term.

Suggested Citation

  • Jeffrey Clemens & Benedic Ippolito, 2018. "Implications of Medicaid Financing Reform for State Government Budgets," Tax Policy and the Economy, University of Chicago Press, vol. 32(1), pages 135-172.
    • Handle: RePEc:ucp:tpolec:doi:10.1086/697140
    DOI: 10.1086/697140
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    1. repec:aei:rpaper:1008586598 is not listed on IDEAS
    2. Leung, Pauline, 2022. "State responses to federal matching grants: The case of medicaid," Journal of Public Economics, Elsevier, vol. 216(C).
    3. Jonathan Gruber & Benjamin D. Sommers, 2020. "Fiscal Federalism and the Budget Impacts of the Affordable Care Act's Medicaid Expansion," NBER Working Papers 26862, National Bureau of Economic Research, Inc.
    4. Jeffrey Clemens & Stan Veuger, 2020. "Implications of the COVID-19 Pandemic for State Government Tax Revenues," National Tax Journal, National Tax Association;National Tax Journal, vol. 73(3), pages 619-644, September.
    5. Jeffrey Clemens & Stan Veuger, 2024. "Intergovernmental Grants and Policy Competition: Concepts, Institutions, and Evidence," NBER Chapters, in: Policy Responses to Tax Competition, National Bureau of Economic Research, Inc.
    6. Jeffrey Clemens & Benedic Ippolito & Stan Veuger, 2021. "Medicaid and fiscal federalism during the COVID‐19 pandemic," Public Budgeting & Finance, Wiley Blackwell, vol. 41(4), pages 94-109, December.
    7. repec:aei:journl:y:2020:id:1008578025 is not listed on IDEAS
    8. repec:aei:rpaper:1008570714 is not listed on IDEAS
    9. Pauline Leung, 2021. "State Responses to Federal Matching Grants: The Case of Medicaid," Working Papers 647, Princeton University, Department of Economics, Industrial Relations Section..

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    More about this item

    JEL classification:

    • H72 - Public Economics - - State and Local Government; Intergovernmental Relations - - - State and Local Budget and Expenditures
    • H75 - Public Economics - - State and Local Government; Intergovernmental Relations - - - State and Local Government: Health, Education, and Welfare
    • H77 - Public Economics - - State and Local Government; Intergovernmental Relations - - - Intergovernmental Relations; Federalism

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