Looking back over South Carolina's civic life, most historians would agree that Carroll Campbell has been among our state’s most effective governors. It was Campbell, a Republican with a General Assembly that was 61% Democratic, who shepherded through a comprehensive restructuring of state government in 1993.

It is hard to imagine today, but before the former Greenville congressman’s reform plan was enacted, South Carolina’s governor was hands-down America’s weakest. State agencies were run by boards and commissions, some of which included legislators. There was no governor’s Cabinet, and executive authority was diffused so widely and thinly that citizens often wondered who was in charge.

There were a number of reasons for Campbell’s success, some of which seem almost paradoxical. He was clearly very conservative, but he believed passionately in reform. He was a fan of the “too conservative” Ronald Reagan, but he also decried “horse and buggy government.” He favored shrinking the size of government and knew well the balance that the framers sought to build into public policy: Power should be concentrated just enough to ensure effective governance, but not enough to open the door to tyranny.

Campbell’s conservative but reformist legacy and his understanding of the appropriate balancing of power speaks into the final stage of a current debate; following the division of DHEC into separate environmental and health agencies, the General Assembly is taking the next step by streamlining the health functions of six state agencies into the Executive Office of Health and Policy.

Unfortunately, even after the Senate passed S.915 by a vote of 44-1 and the House by a margin of 98-15, some concerns have prevented the enactment of the legislation to establish this new department from pieces of existing ones. But those concerns aren’t based in reality:

• There is no South Carolina version of Anthony Fauci here. The governor can remove the executive secretary of Health and Policy at any time, and the General Assembly can still direct the governor to remove a Cabinet officer with a two-thirds vote in each chamber.
• Some powers will move, but no new powers will be created. In at least one case, emergency powers on the books since 1908 were modified during the S.915 amendment process to clarify that only the governor can exercise them.
• The governor’s choice for secretary will not be micromanaged with a long list of bureaucrat-friendly required qualifications in the enacting statute.
• Employees of the consolidating agencies and offices will move to positions in the new component departments, but natural redundancies will create the opportunity for savings. The General Assembly can tighten the purse strings as well.
• One of the remaining post-Campbell unelected and unaccountable governing boards, the DHEC board, is dissolving, and the health policy buck will finally stop with the governor.
• There has been no unseemly rush. The massive restructuring legislation under Campbell was accomplished in about five months. This much-less-ambitious health restructuring will have taken about the same amount of time from beginning to end. Factoring in time spent on the legislation splitting the Department of Health and Environmental Control, the Office of Health and Policy timeline has been even longer than the 1993 restructuring.
• Thanks to a subsequent reform, which established legislative oversight committees, the new agency will appear regularly before the Senate and House to answer for its actions. Citizens also have the ability to lodge a complaint about the agency with the oversight committees.

The establishment of the Executive Office of Health and Policy represents a significant opportunity — not only to save taxpayer dollars by eliminating duplication that went unaddressed in 1993 and 2014, but to serve our citizens more effectively, particularly those with complex health needs who have been underserved by the confusion that comes from existing unaligned agencies.

But the new agency will not have absolute power. The supreme authority of the governor, oversight and confirmation procedures already in place and additional safeguards built into the legislation are designed to protect the rights of citizens. There are additional political, legal and administrative remedies outside of these as well.

The Executive Office of Health and Policy is a reform whose time has come, a reform that I feel sure the Ronald Reagan Republican Carroll Campbell would have warmly embraced.

Oran Smith, senior fellow at Palmetto Promise Institute, served in the Campbell administration.

Video: Will South Carolina expand Medicaid?

Video: Could Medicaid expansion soon be on the table in South Carolina?

Strides have been made towards reducing the numbers of people without health insurance in the U.S. In August 2023 the Department of Health and Human Services announced that the national uninsured rate reached an all-time low of 7.7% during the first quarter of the year. The number of uninsured declined from 31.6 million to 25.3 million over the 2020–23 period.

Importantly, the largest drops in numbers of uninsured took place among lesser well off individuals whose household income was either below 100% or between 200% and 400% of the federal poverty level. But it’s millions of these folks, who have been disenrolled from Medicaid since the Covid-19 pandemic public health emergency ended in April of last year, who now find themselves uninsured. This harks back to the persistent issue of tens of millions of Americans lacking health insurance on any given day.

STAT News reported KFF data that roughly 21% of the people who were enrolled prior to the redeterminations, or almost 20 million, lost coverage at least temporarily. Meanwhile, 45%, or 42 million, were confirmed as Medicaid-eligible. However, for the remaining 31 million people, renewal of coverage is pending. Moreover, data show that approximately five of the more than 20 million who have been disenrolled during the post-pandemic eligibility reviews are still uninsured.

During the public health emergency caused by the Covid-19 pandemic, Medicaid’s annual (re)determinations of enrollee eligibility were paused as part of a continuous coverage provision included in the 2020 Families First Coronavirus Response Act. Through March of 2023, enrollment in Medicaid and the Children’s Health Insurance Program grew by more than 23 million people.

However, since last April Medicaid restarted the determination process to check to see if enrollees are still eligible. As a result, millions are no longer enrolled in Medicaid and have no other coverage. This has often been due to procedural and administrative reasons, meaning individuals did not complete the necessary paperwork, in part because former enrollees did not properly understand the process and specifically what was needed for them to retain coverage.

The impact on individuals varies enormously by state. For example, Utah disenrolled the highest percentage (60%) of its completed Medicaid redeterminations while Maine disenrolled the lowest (12%).

Disenrollment numbers have surpassed initial expectations set by the federal government. Last year the Biden Administration projected that 15 million in total would be removed from the rolls.

What’s concerning is that about 40% of the eligibility redetermination process remains to be completed, which implies there’s still a lot more disenrolling ahead which will result in more people added to the uninsured tally.

Many people who are no longer eligible for Medicaid can sign on to their employer’s health plan, should that be offered to them. Further, for some who must obtain their own health insurance, state marketplace exchange coverage is available. To illustrate, through November 2023, nearly 2.3 million people had transitioned from Medicaid to a private marketplace plan. This service is available in every state to help individuals, families and small businesses shop for and register with an affordable medical insurance plan. Some states have their own marketplace platforms. Other states use the federally run platforms. Created by the Affordable Care Act, these portals gives people access to health insurance plans of all types from a variety of insurers.

As the independent health insurance guide healthinsurance.org explains, in the majority of states people can sign up with a state marketplace plan at any time before July 31, 2024, as part of an extended “unwinding special enrollment period.” Also, individuals who no longer qualify for Medicaid based on their level of income may still be able to obtain subsidies to help offset the cost of their health insurance premiums.

Nevertheless, as Medicaid unwinding continues hundreds of thousands and perhaps millions more people will become uninsured. This calls to mind the longstanding discussion of both lack of health insurance for several tens of millions in America and the tenuous nature of medical coverage for many others.

There's significant variation among states when it comes to the ongoing Medicaid disenrollment process. A new Robert Wood Johnson Foundation analysis has found that while enrollment in Medicaid and the Children's Health Insurance Program (CHIP) declined by 9 million people from April to November 2023, eight states had Medicaid disenrollments surpassing 100% of projected net disenrollments.

Nationwide, aggregate net disenrollment as of November 2023 was at 60.5% of projected total disenrollment throughout the unwinding. The eight states exceeding 100% are Arkansas, Idaho, Iowa, Montana, New Hampshire, Oklahoma, South Dakota and Texas.

At the same time, 19 states had net disenrollment of 50% or less of the firm's projected total net disenrollment.

The net disenrollment rate was much higher for children than adults nationwide, largely because of exceptionally high child net disenrollment in some states. Total net disenrollment among children was 84.2% of the expected total, while total net disenrollment among adults was 50.7% of RWJ's estimates.

Seven states had adult net disenrollment greater than 100% of expected disenrollment, while 12 states had child net disenrollments that exceeded that threshold. This means current Medicaid enrollment levels in these states are below the historical trend, the report found.

States that publicized their intention to complete the unwinding in less than 12 months, states that obtained few federal waivers to streamline renewal, and states that prioritized the renewal of those likely to be ineligible all had notably higher overall net disenrollment rates relative to other states. States with any of these three characteristics had net child disenrollment over 120% of the projections, on average.

WHAT'S THE IMPACT?

In 2020, Congress passed the Families First Coronavirus Relief Act, which barred states from disenrolling people from Medicaid or child Medicaid coverage funded through CHIP during the pandemic unless they requested it. This led to record-high enrollment growth of more than 20 million Medicaid members than before the requirement.

Three years later, Congress passed legislation to end the continuous coverage requirement effective March 31, 2023, and allowed states to resume the Medicaid eligibility redetermination process, also known as Medicaid "unwinding."

Some are concerned that states are moving too fast and that many enrollees could lose coverage for procedural reasons even though they remain eligible. Others argue that slowing down the unwinding leaves ineligible people on the rolls at an unnecessary cost to both state and federal budgets.

The results from the analysis are likely to change when more recent data becomes available, particularly as more states complete the unwinding process, originally scheduled to end in June. Some variation between states may be because of their different start dates, authors said.

THE LARGER TREND

Data published by KFF in January showed an estimated 16 million beneficiaries had lost Medicaid coverage to that point.

There are reasons to expect disenrollment rates to moderate in the second half of the unwinding as states reduce procedural disenrollments and work through "likely ineligible" populations, the report said.

To date, 40 states and the District of Columbia have adopted Medicaid expansion, and 10 states have not adopted the expansion, according to a KFF report in December 2023. Originally a mandate of the ACA, Medicaid expansion was left to the determination of individual states following a ruling by the Supreme Court.

In the 10 states that have not adopted Medicaid expansion, nearly 1.5 million uninsured individuals fall into the "coverage gap," and are not eligible for Medicaid or ACA Marketplace subsidies, KFF said.

As readers of Say Ahhh! know, I have been tracking monthly data from the Centers for Medicare and Medicaid Services (CMS) on the number of people who were either previously enrolled in Medicaid or had experienced a denial or termination during unwinding who then selected a marketplace plan. At the end of April, CMS issued new data for January 2024, which was the last month of the 2024 Open Enrollment Period in nearly all states.

In January, another 1.15 million people lost their Medicaid coverage due to unwinding of the Medicaid continuous coverage protection, of which 67 percent were procedural disenrollments and 33 percent were due to a finding of ineligibility. Separately, CMS reported that nearly 484,000 people who were either previously enrolled in Medicaid in federal marketplace states or had experienced a denial or termination in state-based marketplace states selected a marketplace plan in the same month. That constituted about 42 percent.

Compared to total marketplace enrollment among those losing Medicaid in December, total January marketplace enrollment fell by 57 percent. As a result, the rate of marketplace enrollment among those disenrolled from Medicaid also decreased, compared to 83.9 percent in December — the second month of the 2024 Open Enrollment Period — and 54.2 percent in November, the first month of the Open Enrollment Period. (In addition, another 33,600 or 2.9 percent enrolled in a Basic Health Plan in New York and Minnesota in January, with nearly all of that BHP enrollment occurring in New York.) Cumulatively, through January 2024, compared to the 14.85 million people disenrolled from Medicaid, about 3.9 million or about 26.3 percent enrolled in marketplace plans. (The figure rises to 28.2 percent if including Basic Health Plan enrollment.)

As each of the blogs about previous CMS data releases noted, to provide context to these figures, federal researchers from the HHS Office of Assistant Secretary for Planning and Evaluation (ASPE) previously projected that of the 15 million people expected to lose Medicaid during the unwinding, nearly 2.7 million people — or about 18 percent —would be eligible for subsidized marketplace coverage. While this data represents only the outcome of unwinding through January, it indicates that the cumulative transition rate to marketplace coverage is significantly surpassing the expected pace, after many months of falling well short. What may have happened is that many people who were eligible for marketplace subsidies and who could have immediately enrolled in marketplace plans through a Special Enrollment Period after being disenrolled from Medicaid did not do so and became uninsured. However, after a gap in coverage, many eventually found their way to the marketplace during the 2024 Open Enrollment Period, which began on November 1, 2023. Marketplace enrollment soared to a historic high of 21.45 million during the 2024 Open Enrollment Period.

Notably, at the current pace of disenrollments, the total number of people disenrolled from Medicaid once unwinding is completed will well exceed the original 15 million projection from ASPE and the 17 million projection from other analysts such as KFF — with our latest data showing 18.8 million people have already been disenrolled. And the share of total disenrollments that are procedural terminations remains very high — 70 percent overall according to our latest data — with many of those losing coverage, especially children, likely remaining eligible. In comparison, ASPE estimated that 45 percent of those who would be disenrolled from Medicaid, including for procedural reasons, would remain eligible for Medicaid. Finally, while children’s enrollment in the marketplace rose to 2.16 million in the 2024 Open Enrollment Period, an increase of 611,000 — or about 39.5 percent — from the 2023 Open Enrollment Period, that increase offsets only a modest share of the 4.94 million in total net Medicaid enrollment losses among children (according to our latest data) since unwinding of the continuous coverage requirement began last year. Moreover, children still account for only about 10.1 percent of total marketplace enrollment in 2024.

Marketplace plans will be a valuable source of affordable, comprehensive health coverage but that will likely be the case for only several million people — and a relatively modest number of children —who lost their Medicaid coverage during unwinding, despite the large increases in transitions to marketplace plans during the Open Enrollment Period months of November, December and January. As our recent analysis of child Medicaid enrollment data shows, through December 2023, there was wide variation in Medicaid/CHIP child enrollment declines among states during unwinding of the continuous coverage requirement. Some states prioritized rapid disenrollment of children and adults, had high rates of procedural terminations and low rates of ex parte renewals and as a result, had larger child enrollment declines. But other states took a different approach. They strove to maximize successful renewal of eligible children and are adopting strategies moving forward to keep eligible children enrolled and avoid inappropriate coverage losses upon renewal.

For example, as they finish unwinding and post-unwinding, states should further improve their ex parte renewal rates, ensure full compliance with all federal requirements for Medicaid renewals, and continue the renewal flexibilities that were provided by CMS during the unwinding process. Moreover, to further increase child Medicaid enrollment to offset these large coverage losses from unwinding, states should also take up various actionable strategies to promote continuous coverage for children and families, as reinforced in a CMS Informational Bulletin issued in December. States should also take up multi-year continuous eligibility for children, which an increasing number of states are adopting, in addition to successfully implementing mandatory 12-months continuous eligibility for children which took effect on January 1, 2024. Finally, states and the federal government will need to work together on robust outreach and enrollment efforts in 2024, including back to school campaigns, to target eligible children, families and other adults who were disenrolled for procedural reasons so they can be reenrolled in Medicaid as quickly as possible.

We're nearing the six-month mark since North Carolina opened up enrollment to its expanded Medicaid program. Since December, 448,242 North Carolinians have been added to the rolls for full coverage, the state Department of Health and Human Services tells Axios.

Why it matters: The expansion meant that another 600,000 residents — nearly 6% of the state's population — became eligible for coverage they previously might not have been able to afford, from maternity care to prescription drugs.

Context: Gov. Roy Cooper has prioritized Medicaid expansion since he took office in 2017. Republicans had long been wary of expanding Medicaid benefits, initially citing financial concerns, the News & Observer reported.

• Last year, lawmakers in Raleigh reached a bipartisan agreement to expand Medicaid once a state budget was passed.
• North Carolina became the 41st state to adopt the Affordable Care Act Medicaid expansion when Cooper signed the legislation last year.

Between the lines: Medicaid signups are increasing in North Carolina's rural counties, including Edgecombe, Robeson, Swain and Graham, according to the state's Medicaid expansion dashboard.

• "Relative to the size of [the] population, we are outpacing signups in our rural communities more than urban communities," N.C. Health and Human Services Secretary Kody Kinsley recently told WRAL.
• A smaller share of the population is enrolled in large, urban counties. In Mecklenburg, for instance, 44,177 people are on the rolls — 6% of the adult population. In Wake County, the number is 27,480 people, representing 3.6% of the adult population.

Zoom out: Medicaid covers most health care services at little or no cost to patients, from emergency services to preventative care.

• Most of the prescriptions being filled under the expansion are for seizures, asthma and other chronic conditions, NCDHHS officials say.
• "Preventative, rehabilitative, services that people need and simply went without ... now will be able to benefit from," deputy secretary for NC Medicaid Jay Ludlam told Axios.

• The expansion opened up enrollment to non-elderly adults with incomes up to 138% of the Federal Poverty Level (FPL) ($34,307 for a family of three in 2023), according to the nonprofit KFF.

What's next: State health officials are working to engage with communities to get residents in need to sign up for Medicaid through town halls, distributing bilingual material, and other outreach, Ludlam says.

What they're saying: "North Carolina serves as an example to other states who have yet to expand Medicaid health care coverage, because Medicaid expansion can and will save lives," U.S. Health and Human Services Secretary Xavier Becerra said in a recent statement.

In fiscal year 2021—the first full budget year marred by the COVID-19 pandemic—states collectively spent 14.1 cents of every state-generated dollar to provide Medicaid coverage to low-income Americans; that was 1.5 cents lower than the 15-year average of 15.7 cents of every state dollar. A pandemic-related surge in tax revenue, coupled with temporary additional federal funding, contributed to the decrease in the share of state funds that were dedicated to Medicaid. But as federal pandemic aid concludes and Medicaid enrollment remains near historic highs, The Pew Charitable Trusts and other experts expect that share to rise by the end of the current budget year.

All but nine states spent a smaller share of their own dollars on Medicaid in fiscal 2021 than they had, on average, over the previous 15 years. Differences ranged from 4.5 percentage points in Tennessee to less than a tenth of a percentage point in Washington and Wisconsin.

States and the federal government share costs for Medicaid, which provides medical coverage for eligible groups of children, adults, people with disabilities, and the elderly. Medicaid is most states’ biggest expense after K-12 education.

Pew’s state Medicaid spending indicator excludes federal support, examining only the cost to states because that spending exerts pressure on their operating budgets, which rely on state-generated revenue.

Medicaid’s claim on each revenue dollar affects the share of state resources available for other priorities, such as education, transportation, and public safety. Federal law requires states to provide certain benefits for any eligible Medicaid enrollee, even during times of sluggish revenue growth. So policymakers have less control over growth in states’ Medicaid costs than they do with many other programs.

Most states posted a decrease in the share of state funds dedicated to Medicaid in fiscal 2021 compared with the previous year. Nationally, this share dropped by 1.7 percentage points—the most substantial annual drop since at least fiscal 2000. The extent of the declines ranged from 4.3 cents per state-generated dollar in California to a tenth of a percentage point in Arizona. A confluence of factors drove these significant declines, including a simultaneous increase in temporary federal Medicaid aid and higher-than-anticipated growth in tax revenue following the onset of the pandemic.

State Medicaid costs are expected to rise dramatically by the end of the current budget year. Survey data from the Kaiser Family Foundation shows that state costs rose by 13% in fiscal 2023 and are expected to increase by an additional 17.2% in fiscal 2024. In their survey responses, states identified the phaseout of enhanced federal Medicaid aid, provider rate increases, and slowing but still elevated enrollment levels as key drivers of these increased annual costs, which, coupled with weakening tax revenue collections, are likely to push up the share of state funds spent on Medicaid going forward.

State highlights

A comparison of the share of each state’s own-source revenue spent on Medicaid in fiscal 2021 with its average share over the previous 15 years shows that:

• Alaska’s share rose the most. In fiscal 2021, the state spent 15.6% of its own revenue on Medicaid, 6.2 percentage points higher than its 15-year average—equivalent to 6.2 cents more of each state-generated dollar. It was the only state where Medicaid reached its highest percentage of own-source spending since 2007.
• Besides Alaska, only North Dakota (1.4) and Kentucky (1.3) surpassed their 15-year average shares by more than 1 cent per state-generated dollar.
• Only two states spent more than one-fifth of their own revenue on Medicaid in fiscal 2021: Pennsylvania (20.2) and New York (23.6), which contributed the largest share of any state.
• The states that spent the smallest share of their own dollars on Medicaid in fiscal 2021 were Utah (4.4), Alabama (6.6), Oklahoma (7.2), Mississippi (7.7), and Hawaii and Idaho (both 8).

Trend drivers

In fiscal 2021, states collectively allocated $240.5 billion from their own resources to support health benefits for 86.3 million Medicaid recipients. This marked a 2.8% increase, or $6.6 billion in new spending, from fiscal 2020. But states’ own-source revenue grew even faster, leading to a drop in the portion of state funds dedicated to Medicaid coverage.

Higher enrollment is one of the major long-term drivers of growth in Medicaid spending; more than twice as many people were on Medicaid rolls in fiscal 2021 than in fiscal 2000. Until the onset of the COVID-19 pandemic, however, enrollment growth had been slowing. From 2000 to 2013, several factors fueled rising enrollment, including two economic downturns—which caused people to lose jobs and associated health insurance—and a gradual erosion of employer-sponsored insurance in general. From 2014 until the present day, millions more Americans joined Medicaid as most states implemented the optional expansion under the 2010 Affordable Care Act (ACA). But because the federal government absorbed the first three years of related expenses for those newly eligible enrollees, states only began picking up a portion of these costs in 2017.

Although the pandemic triggered a historic but temporary surge in Medicaid enrollment, states expect a decline in fiscal 2024 and 2025. This is largely because of the expiration of one-time federal pandemic aid and a related rule that prevented states from unenrolling individuals for the duration of the public health emergency from Jan. 31, 2020, to May 11, 2023. Strong economic conditions, including low unemployment, are also contributing to the downward trend in Medicaid enrollment, as more workers gain access to employer-provided health care.

Conversely, several factors are simultaneously exerting upward pressure on state Medicaid spending, including rising prescription drug prices and widespread increases in health care provider payment rates. Additionally, state policy choices, such as expanding coverage, or the potential impact of an economic slowdown could contribute to growth in Medicaid spending.

Medicaid spending by level of government

Medicaid is a state-administered program, but the federal government covered 60.3% to 83.5% of states’ bills for the program in federal fiscal 2021, for a total of 68% of costs. Federal spending on Medicaid grew by 12.5% that year, from $455 billion to $512 billion—the second consecutive double-digit annual increase since temporary enhanced federal aid was provided in early 2020.

The federal government covered the highest portion of state Medicaid costs in Mississippi (83.5%), New Mexico (82.6%), West Virginia (82.4%), Kentucky (81.4%), and Arizona (80.4%), and the lowest in New York (62.8%), New Hampshire (62.3%), Minnesota (60.9%), Wyoming (60.6%), and Massachusetts (60.3%).

Influence of federal policy changes

Recent changes in federal policies have significantly affected states’ financial responsibilities for Medicaid. In response to the economic challenges of the COVID-19 pandemic, the federal government increased the federal medical assistance percentage (FMAP) for Medicaid by 6.2 percentage points for the duration of the public health emergency. The enhanced FMAP, which was initially set to end on April 1, 2023, underwent a gradual phaseout throughout the 2023 calendar year, decreasing to 5% on April 1, 2.5% on July 1, 1.5% on Oct. 1, and concluding on Dec. 31.

As a condition of these enhanced federal funds, states were prohibited from removing individuals from their Medicaid programs, which lead to a surge in enrollment—from 71.1 million in February 2020 to 94.1 million by April 2023, a 32.4% increase.

The Consolidated Appropriations Act (CAA), which became effective March 31, 2023, marked the end of continuous Medicaid enrollment and allowed states to initiate unenrollment beginning in April 2023. At least 19.6 million Medicaid enrollees have been unenrolled as of April 4, 2024, according to the Kaiser Family Foundation. The CAA also initiated the phaseout of enhanced federal matching funds that concluded in December.

The federal government previously provided extra dollars to states to help cover the increased costs of higher Medicaid enrollment and declining state tax revenue associated with the 2001 and 2007-09 recessions. As the enhanced federal aid from the Great Recession tapered off between December 2010 and June 2011, states’ share of Medicaid costs spiked while their tax revenue was still recovering.

Since January 2014, the ACA has also provided an opportunity for states to expand their Medicaid programs with enhanced federal support. The law initially required states to expand Medicaid eligibility to all adults under age 65 who earn up to 138% of the federal poverty level, a change that the U.S. Supreme Court later ruled was optional for states. For states that chose to expand their coverage to this broader population, the federal government agreed to reimburse 100% of the expansion costs through 2016, then 95% of costs in 2017, and ultimately 90% from 2020 onward. As of the fiscal year that ended June 30, 2021, the time frame for this analysis, 36 states had expanded their programs in accordance with the ACA. Another four states had done so as of March 2024.

States that have expanded Medicaid coverage have typically drawn from their general funds to cover their share of the bill, and some have been able to offset the added costs with related budget savings, such as reductions in behavioral health spending. Several states also report using new or increased provider taxes and fees to help fund the expansion.

In 2006, the federal government began relieving states of prescription drug costs for “dual eligibles,” people who qualify for Medicaid and the federal Medicare program. In return, states must share some of their savings with the federal government through annual “clawback” payments, which are included in this analysis as part of state Medicaid spending.

However, the amount of federal reimbursement that states receive is just one of several factors that influence the wide range in the share of state’s own revenue spent on Medicaid. Among the other drivers are state Medicaid policy decisions—the breadth of health care services covered, eligible populations, and provider payment rates—and each state’s personal income levels. States with lower per capita income have higher federal reimbursement rates, and vice versa. The variation across states also is a function of tax and other policy decisions that determine state revenue and factors outside of policymakers’ direct control, such as state economic performance, demographics, resident health status, and regional differences in health care costs and practices. (For more information, see “State Health Care Spending on Medicaid.”)

Why Pew assesses state Medicaid spending

State Medicaid spending has a significant impact on state budgets. As the largest expense for most states after K-12 education, Medicaid's allocation from each revenue dollar directly influences the resources available for other key public services, such as education, transportation, and public safety. The federal government requires states to, among other things, provide matching funds to help cover the costs of Medicaid benefits for eligible enrollees, regardless of revenue conditions. This relative lack of state control over costs distinguishes Medicaid from many other programs and can be difficult for policymakers to navigate, especially when costs spike during economic downturns.

Justin Theal is an officer and Riley Judd is an associate on The Pew Charitable Trusts’ Fiscal 50 project.

For more than 30 years, I’ve experienced the wide range of complex issues facing healthcare providers, and I can’t remember a time when we were more concerned about the safety and security of our workforce.

South Carolina’s hospitals and health systems represent more than $28 billion in state economic impact and 77,000 employees. Many of those employees have taken an oath to “Do No Harm,” and I’m sad to say that same courtesy is not being given to them.

Healthcare workers account for roughly three-fourths of all nonfatal workplace injuries and illnesses due to violence in the workplace. According to government data, that nurse getting ready for her shift is five times more likely to be assaulted at work than employees reporting to virtually every other job.

It’s been said that the true measure of a society is how it treats the most vulnerable among us — but what about how we treat those who care for us in our most vulnerable moments?

Until now, we’ve only been able to rely on anecdotal stories from front-line workers to express this problem, but thanks to an upcoming report from the South Carolina Hospital Association and Antum Risk, we finally have actionable data to illustrate the impact of workplace violence on the state’s hospital workforce.

The South Carolina Workplace Violence Collaborative was established in 2023 to address the increased incidence of violence against healthcare workers. The collective includes aggregate data submitted by 48 South Carolina healthcare facilities, including acute care hospitals, physician practices, outpatient clinics and rehabilitation centers, in 2023. For standardization purposes and to isolate these events, only incidents of physical violence are included in the report.

South Carolina’s hospitals and health systems have created a national model for enhancing hospital safety and security with a voluntary data collective actively sharing incidents of workplace violence in their facilities, and we’re already learning valuable lessons:

• 68% of health care assaults in the state were committed against bedside nurses and nursing support in 2023.
• 96% of these incidents were initiated by patients; however, we are seeing a growing trend of assaults by patients’ family members and visitors.
• 80% of these incidents occurred in the emergency department or the patient’s room or bathroom.

Our hope is that by focusing on building a data collective around outcomes for employees, as we do for patients through our Zero Harm program, we can learn more about the conditions to eliminate preventable harm in our facilities. If we can use data to improve surgical outcomes, we should be able to apply those same principles to bolster employee safety.

South Carolina’s hospitals and health systems are already using cutting-edge solutions to improve hospital safety and security, including enhanced surveillance, elevated training for security officers, first-alert badges for staff and trained K-9 units to uphold a more secure environment for everyone, including patients, employees and visitors.

Hospitals and health systems are also providing additional resources and support for employees who are affected by violent incidents. And, we are working closely with state and local law enforcement to help ensure we have strong partnerships for addressing incidents and maintaining a healing environment in our facilities.

It’s important to spotlight this issue and the amazing feats our healthcare heroes take on every day to lead South Carolina to a better state of health. So, the simplest way to celebrate nurses today when you need care is to be kind. Extend that kindness to everyone in the hospital, from the security guards to food services. Every day they suit up for work, our hospital employees make a commitment to Zero Harm. Let’s make that same commitment to them.

South Carolina’s legislative session came to a chaotic close following last-minute votes on a litany of bills, including a controversial ban on gender-affirming care for minors, a monument to a Black icon of the Civil War and limits on children’s ability to access pornographic material.

All of that was overshadowed by an eleventh hour vote by Republican hardliners to kill a top priority of legislative leadership and Gov. Henry McMaster.

With just several minutes left until the 5 p.m. hard deadline May 9, the conservative South Carolina House Freedom Caucus used a basic procedural maneuver to kill a sweeping state health agency restructuring bill that had been in the works for months — leaving members of the Senate incensed.

“Play stupid games, win stupid prizes,” Freedom Caucus chairman Rep. Adam Morgan, R-Taylors, told reporters afterward.

Plenty of other things did happen on the session’s final day.

The House and Senate struck a deal to form a committee to commemorate Robert Smalls, a South Carolina congressmen and a Civil War hero, with a memorial on the Statehouse grounds. They finalized legislation to prohibit minors from accessing pornographic content online. And they passed a controversial ban on gender-affirming care for transgender teenagers that the American Civil Liberties Union has described as “harmful and unconstitutional.”

But while the 2024 session is over on paper, state lawmakers leave Columbia with numerous major priorities still unresolved and the expectation they will find themselves back in the Statehouse within a month to finish up.

A proposal to reform the way South Carolina selects judges — lawmakers’ top priority this session — remains in purgatory after the House and Senate were unable to come to an agreement by the 5 p.m. deadline.

That bill will now go to a six-member conference committee consisting of three House members and three members of the Senate to rectify the differences between the two sides.

A sweeping energy reform package to expedite the conversion of a defunct Lowcountry coal-fired power plant to natural gas will also go to a conference committee after a reluctant Senate rewrote the proposal into a nonbinding resolution supporting new energy development.

And legislation banning the use of “prohibited concepts” in public school curriculum remains unresolved nearly a full year after a conference committee was appointed to debate it — leaving the fate of some of the most consequential bills discussed this year in the hands of a small group of lawmakers.

“I’m hopeful that once people sit down in the same room at the same table, that many of those differences can be worked out,” Sen. Shane Massey, R-Edgefield, told reporters after session.

The last-minute flurry of bills — and the lengthy post-session workload remaining — comes after weeks of questionable clock management from both chambers.

For several weeks, members of the House continually adjourned early amid an impasse over the energy bill, amassing a legislative backlog dozens of bills deep entering the session’s final days. Some bills, including a fentanyl bill favored by Senate President Thomas Alexander, R-Walhalla, died on the floor without a vote despite passing out of the Senate in February 2023.

Meanwhile, the Senate dedicated several days of its schedule in the session’s final week to debating legislation on topics like barring private businesses from mandating vaccinations to legalizing medical marijuana — discussions that ultimately went nowhere.

The penultimate day of session, which ran well into the night May 8, was also marked by chaos in the lower chamber of the Statehouse.

Over several hours, the House Freedom Caucus attempted to run several nongermane policy proposals as amendments to the state budget that sapped up several hours of lawmakers’ time.

Many were doomed to fail: Morgan, the group’s chair, attempted to run an amendment to the budget banning the distribution of forms mandated by the federal government to give individuals an option to register to vote.

Fellow Freedom Caucus member Jordan Pace, R-Goose Creek, attempted an amendment that would have required South Carolina to recognize all gold and silver currency — foreign or domestic — as legal tender, despite the fact it is the federal government that decides what currency is legal and what is not.

The latter effort elicited mockery from more moderate members like Rep. Micah Caskey, R-West Columbia, who donned a tinfoil hat to deliver remarks deriding Pace’s amendment from the dais.

“Everyone should point and laugh at the (SC Freedom Caucus),” he wrote on social media after the vote.

The group found other ways to be disruptive.

Later in the day March 8, Rep. April Cromer, R-Anderson, ground debate to a halt using an obscure procedural motion that would have forced House Reading Clerk Bubba Cromer to read every word of the nearly 300-page health department restructuring bill. It was a gambit Palmetto Promise Institute analyst Felicity Ropp estimated would have theoretically taken nearly 14 hours to complete.

The Anderson Republican eventually relented after nearly an hour of inactivity on the House floor. Her caucus would find another way to stall it.

With less than an hour left in session, Beaufort Republican Sen. Tom Davis — who led the bill — Sen. Margie Bright-Matthews, D-Walterboro, and Sen. Shane Martin, R-Pauline, ran more than half-dozen amendments to the bill, including several regarding vaccines that even some of Martin’s colleagues acknowledged could jeopardize the bill’s success in the House.

“Don’t push it too far now,” Sen. Nikki Setzler, D-Columbia, warned Martin 40 minutes before the deadline.

“I’m not trying to,” Martin replied.

Except he did.

When the bill came back to the more conservative House, members of the House Freedom Caucus objected to a motion to allow the bill to be heard within 24 hours of it crossing over — effectively killing it.

The architect of the bill-killing motion, Freedom Caucus member and Campobello Republican Rep. Josiah Magnuson, said the effort was personal.

All session, he said, House leadership had refused to weigh their policies seriously. Their members had been allowed to be openly mocked by colleagues on the House floor, he said, adding that someone had set up a red-haired puppet in the House chambers wearing a tinfoil hat; Magnuson has red hair.

“We’ve had bills for some of these issues filed since the beginning of last session,” Magnuson told reporters. “Some of them from the last session after COVID. A lot of this has been needed to be done for years, and it has never gotten any kind of attention until they got desperate.”

House Speaker Murrell Smith, R-Sumter, denied mismanagement of the legislation played any part in the bill’s failure, instead blaming the House Freedom Caucus for playing political games at the close of session.

“Holding hostage bills like that only harms South Carolinians,” said Smith. “It doesn’t harm the members that they feel weren’t nice to them. It doesn’t harm the institution. It harms real South Carolinians.

“We’ve got people with drug disorders with drug addictions,” he added. “We’ve got people with mental health issues. And because someone wants to have a bill that’s not related to health care restructuring and wants those bills enough, they will hold something hostage … that’s just a poor commentary on the state of affairs currently happening right now.”

Correction: A previous version of this article stated Robert Smalls was South Carolina's first Black Congressman. It was actually Joseph Hayne Rainey, who was elected to represent South Carolina's First Congressional District in 1870.

The Republican led South Carolina General Assembly agreed on several bills they say will protect children, including restrictions on transgender healthcare, age verification requirements for pornography websites and curbs to prevent child abductions.

Before ending its final day of session Thursday, the House concurred with the Senate’s changes to the Help not Harm bill, which requires schools to proactively notify parents of their child’s perceived gender identity while preventing gender transition procedures for minors by surgery or puberty-blocking drugs.

The measure is now headed to the governor.

I’ve talked to some some local teacher groups, and they felt like that, if they were, if they did encounter this situation, their number one priority is to simply say, ‘we believed this was what was happening’ and they’re out of it. That’s all they have to,” said House Majority Leader Davey Hiott on Thursday about any potential encounters with transgender students.

Hiott said the bill was important to pass for many in the legislature. “I’ve never had a perfect bill in my 20 years here. I believe that was good enough to where a teacher said look, as long as we’re not having to call parents,” he said. Hiott led the original effort in the House to eliminate the teacher’s responsibility to contact parents.

The House agreed with the Senate’s amendment to take the energy bill off a suicide prevention measure. The legislation would require and one hour of suicide prevention training as part of continuing education requirements and licenses for therapy workers. It was one of a half dozen bills the House had attached with the energy legislation. With the energy bill removed, they also passed a bill allowing for counselors licensed in other states to work in South Carolina.

Constitutional Carry was already passed and signed into law. The General Assembly revised the measure Thursday to dismiss pending illegal handgun possession charges.

Here are a few other measures, now awaiting Gov. Henry McMaster’s signature.

AMENDING CONSTITUTION ABOUT VOTING, U.S. CITIZENS

Both chambers passed a Senate measure changing one word in the state Constitution about voter qualifications. If the governor signs this bill, it would become a ballot measure for South Carolinians to vote on before becoming law.

State Sen. Josh Kimbrall, R-Spartanburg, told The State the measure is to prevent non U.S. citizens from voting in local elections. Other jurisdictions, such as California and New York, have allowed non-citizens to vote in municipal elections and school board races.

“Certain jurisdictions and courts have found that every citizen is a floor not a ceiling, so were just saying only citizens would be able to vote,” Kimbrell said.

NO TAX ON PERIOD PRODUCTS, ANTISEMITISM DEFINED

The General Assembly defined antisemitism, and added guidance on how it aligns with discrimination laws based on the International Holocaust Remembrance Alliance.

They passed tax exemptions for golf club dues and feminine menustral products. And, with the governor’s signature, people will be able to hunt feral hogs from helicopters, under certain conditions.

Other bills passed include:

• allowing insurance providers to cover paid time off for family members
• rules governing the name, image and likeness of college athletes
• pay for inmates working outside prisons
• creating an assessment fee for private ambulance services
• allowing non S.C. residents to qualify for burial in the state’s veterans’ cemeteries
• enabling deer processor’s to recover fee for donated does
• prohibiting interference with farm animals being transported
• allowing photographs to provided for handicap parking placards