Introduction

Forty-two states (plus DC) face budget shortfalls in fiscal year 2012, placing extraordinary pressure on state policymakers to cut public spending. As a result, many states are considering harmful Medicaid cuts: eliminating coverage for vulnerable Americans, restricting critical benefits like prescription drug coverage, imposing premiums on those who can't afford them, and slashing already-low provider reimbursement rates.

These cuts jeopardize the health and financial security of millions of seniors, people living with disabilities, children, and low-income parents that rely on Medicaid today. And the Affordable Care Act (ACA) elevates the importance of protecting state Medicaid programs by expanding Medicaid to 16 million new enrollees starting in 2014. 

Fortunately, the ACA also includes new tools to help protect against Medicaid cuts. It's "Maintenance of Effort" (MOE) provision requires states to maintain their current eligibility criteria in Medicaid for adults until 2014 and for children until 2019. But the MOE doesn't offer complete protection: it has a major loophole for states that provide coverage for adults above 133 percent FPL, and it leaves the door open to provider rate cuts, new limits on optional benefits, and cost-sharing increases (click here for more detailed information on the MOE requirement).

To prevent harm from these types of Medicaid cuts and to preserve the Medicaid program for its 2014 expansion, defenders must persuade policymakers that:

• Cutting eligibility, benefits or rates, or creating barriers to enrollment are bad ideas.
• There are better alternatives.

This guide distills lessons from Medicaid defense work in a number of states and provides tools to fight cuts and introduce the most promising alternatives.