PROGRAMMATIC, ECONOMIC, AND DEMOGRAPHIC FORCES UNDERLYING MEDICAID ENROLLMENT TRENDS

This article examines the enrollment effects of congressionally mandat ed Medicaid coverage during the late 1980s. Child-related mandates wer e found to increase noncash enrollments 37% in states without a medica lly needy program, while the 1990 Omnibus Budget Reconciliation Acts l egislation added another 27%-mostly elderly poor. The evidence suggest s states responded to the mandates, in part, by shifting cash welfare children and their families to Medicaid-only status. Without continued mandates, the shift to unrestricted Medicaid block grants will likely raise the number of uninsured (mostly children) 30% or more in nonmed ically needy states versus 10% to 20% in other states. Federal Medicai d matching was found to be an inadequate incentive for states to exten d health insurance coverage to all of their poor. Cyclic variation in state economies is also found to put the poor at risk of disenrollment given state laws requiring balanced budgets.