House Appropriations Committee receives 'Medicaid 101' briefing on costs, federal match and waiver

MONTPELIER, Vt. — On Jan. 14, 2025, the Vermont House Appropriations Committee heard a “Medicaid 101” briefing from Nolan Langloan, principal fiscal analyst at the Joint Fiscal Office, who outlined Medicaid’s share of state spending, the federal matching formula known as FMAP, and Vermont’s Global Commitment Section 1115 waiver.

Langloan said Medicaid accounted for roughly $2.3 billion in gross spending in the most recent published figures and made up about 27% of the state’s total appropriations in fiscal 2024. “Medicaid is complicated,” Langloan said during the presentation, noting that 197,000 Vermonters receive Medicaid or CHIP and that about 151,000 people—roughly 23% of the state’s population—have Medicaid as their primary insurance.

The presentation positioned Medicaid as one of the state’s largest budget items after K–12 education and explained how federal matching affects state costs. Langloan described FMAP, the Federal Medical Assistance Percentage, as a three‑year rolling formula tied to per‑capita state personal income; he said Vermont’s regular FMAP was about 59.01%, meaning the state share is about 41.2%. Langloan summarized the fiscal leverage: “For every $1 we put in, we’re getting $2.43 in service,” an explanation of the combined federal‑state spending multiple tied to that match rate.

Why it matters: Medicaid is a major driver of the human services budget and federal match fluctuations can materially change the state’s required general‑fund contribution. Committee members pressed for clarity on trends, data lags and which programs are eligible for different federal match rates.

Key points from the briefing

- Scope and enrollment: Langloan said approximately 197,000 Vermonters were enrolled in Medicaid or CHIP in the most recent counts cited; about 151,000 rely on Medicaid as their primary coverage. He distinguished primary Medicaid enrollees from people who receive Medicaid as a supplemental benefit or premium assistance for exchange plans.

- Spending and budget share: Using the most recent available published data (through 2021 in some national comparisons), Langloan reported total statewide health spending of about $6.37 billion and said Medicaid comprised roughly 25–30% of that total and about 27% of the state’s $8.7 billion appropriation in fiscal 2024.

- Federal match (FMAP): Langloan explained FMAP ranges by program and year; Vermont’s regular FMAP was shown as about 59.01% (federal) / 41.2% (state) for the budget year discussed. He noted other matches vary (for example, the CHIP match and some ACA‑related eligibility groups have higher federal shares) and that temporary federal increases—such as those tied to the American Rescue Plan or the pandemic—have altered match percentages in past years.

- Eligibility groups and labels: Langloan walked through major eligibility categories (children, pregnant people, people 65 and older, people with disabilities, and parents/caretakers) and discussed “new adults” (adults covered after ACA expansions and related state programs). He said roughly 41,000 people fell into an ACA‑related exchange subsidy bucket that receives a higher federal match under specific rules cited in the presentation.

- Global Commitment waiver (Section 1115): Langloan described Vermont’s Global Commitment to Health as the state’s Section 1115 demonstration agreement with the Centers for Medicare & Medicaid Services (CMS). He said the agreement aims to promote state innovation and must be budget‑neutral to the federal government over the waiver period; Vermont negotiates expected baselines and allowable spending under the waiver and has renegotiated terms every few years. Langloan noted the waiver has permitted programs and “investments” that would otherwise have been 100% state cost.

- Investments and reinvestment: Langloan said Vermont runs a set of “global commitment investments” under the waiver and listed roughly 69 investments totaling about $120 million that the state has structured to receive federal match. He described these as services or projects the state would not have been able to fund with federal match absent the waiver.

Questions and data limitations

Committee members asked about data lags and comparability. Langloan emphasized that some datasets he relies on (for example, the Green Mountain Care Board’s expenditure analysis and the Vermont Household Health Insurance Survey) lag by several years or have gaps; he cautioned that many published figures cited in the briefing are drawn from 2021 or earlier and may not reflect post‑pandemic redetermination impacts. He offered to provide one‑on‑one follow‑ups for members seeking deeper or updated figures.

No formal committee action was taken during the briefing. The presentation was framed as informational and committee members signaled they expect future briefings and detailed budget materials tied to Medicaid spending and waiver accounting.

Langloan concluded by offering to return for more detailed sessions on specific Medicaid finance topics; the committee recessed at the end of the presentation.

Ending

The briefing underscored Medicaid’s scale in Vermont’s budget and the degree to which federal match and waiver design shape state policy choices. Committee members requested updated data and indicated additional Medicaid briefings and budget‑adjustment work are forthcoming.