Medicaid enrollment declined an average 0.6 percent in fiscal year 2018, largely due to a strengthening economy, according to the latest annual Kaiser Family Foundation survey of state Medicaid directors. However, average combined federal and state Medicaid spending grew by 4.2 percent, similar to the previous year’s growth, and states project an average 5.3 percent increase in spending in FY 2019. The gap between enrollment and spending growth in part reflects lower enrollment growth for children and adults, who are relatively inexpensive to cover compared to seniors and people with disabilities. Other factors include high costs for prescription drugs, and increased spending on mental health and substance-use treatment. Payment rates for inpatient hospitals increased in 24 states.