As demographic shifts and declining rates of employer-sponsored insurance coverage cause Medicaid to grow, the program faces the same cost pressures that employers and employees are experiencing. Yet, Medicaid enrollees—who have extremely limited incomes—cannot absorb increases in out-of-pocket health costs as readily as the working population. Three approaches have gained currency as ways to cut costs without simply shifting the burden to program enrollees: 1) care management, which focuses on utilization and costs; 2) consumer engagement, intended to encourage or require enrollees to play a greater role in organizing and financing their care; and 3) employer engagement policies, such as premium assistance, which attempt to combine employer, employee, and Medicaid dollars to provide coverage to low-income working populations. In addition to efforts focused on greater program efficiency, broader health system reform will likely be needed to believe the pressures causing the program to grow faster than state or federal tax revenues.