New year, same problem. That is how to best summarize what 2012 means for states as they continue to wrestle with the same issue that plagued them in 2011 namely, the rising cost and caseload of state Medicaid programs. In fact, at least half of the states are facing Medicaid shortfalls in their 2012 budgets. And, in terms of managing that cost, states have a limited array of tools to choose from.

Due to the structure of Medicaid, in which there is flexibility in design, states are finding themselves at different points along the continuum of concern, and approaches are varied. Texas, program, for instance, looks much different than Maine's. Texas has one of the most restrictive Medicaid programs in the country, providing no coverage at all for childless adults. Texas is expanding its use of managed care, and is set to move around 1 million beneficiaries currently in Medicaid fee-for-service into HMOs by 2013. Its eligibility is so low, there's no room to make cuts in times of fiscal constraint. And it is not expanding eligibility, Republican Gov. Rick Perry is quick to point out. Texas is hoping managed care can help improve the bottom line.

Maine, on the other hand, is a non-managed care state that has provided Medicaid coverage for childless adults up to 100 percent of the federal poverty level since 2002. However, times are tough for the state, and lawmakers are wrestling with what to do with Medicaid. Maine Republican Gov. Paul LePage has proposed a series of cuts to the state Medicaid program, including elimination of all coverage for childless adults. LePage said that, and other moves, are necessary with a $220 million Medicaid budget deficit. His plan has generated much controversy, and it is far from a done deal even in a Republican-controlled Legislature. Still, Medicaid cuts will have to be made somewhere. Wisconsin, another program with generous eligibility standards, has also put childless adult coverage on the line. Republican Gov. Scott Walker is coming under fire for his plans as well, but the state is facing a $232 million shortfall through June 2013.

And as noted here in a blog post on Jan. 6, Connecticut's Medicaid program is looking to cut costs by moving to a state-run primary-care case management program. In contrast, 11 other states are currently expanding their managed Medicaid programs in hopes of reducing costs.

These examples certainly speak to the old cliché if you've seen one state Medicaid program, you've seen one state Medicaid program. Every state has autonomy in how it administers its program, which brings its own set of challenges. Oh sure, there may be similarities, but it's tough to draw generalities. It would be like comparing the Brady Bunch to the Partridge Family. Same thing, only different. Both had the teen heartthrob element covered (Greg Brady/Marcia Brady versus Keith Partridge/Lori Partridge). Both boasted hit songs the Brady's Time To Change versus the Partridge's C'mon Get Happy. But in truth, the similarities end there. I mean let's face it, as helpful as road manager Reuben Kincaid was, he was no Alice. Just like those classic old 70s sitcoms, every state has its own individual personality, and its own Medicaid challenges.

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