Identify the top 5 points that every U.S. citizen should know about:A-Medicaid,B- Medicare andC- the Affordable Care Act.

2013 Medicaid a PriM er The Kaiser Commission on Medicaid and the Uninsured provides information\ and analysis on health care coverage and access for the low-income popul\ ation, with a special focus on Medicaid’s role and coverage of the uninsured. Begun in 1991 and based in the Kaiser Family Foundation’s Washington, DC office, the Commission is the largest operating program of the Foundation. The Commission’s work is conducted by Foundation staff under the guidance of a bipartisan group of national leaders and experts in health care and publ\ ic policy. MEDICAID A PRIMER Key Informati on on the N ation ’ s H ealt h Coverage Pr ogram for Lo w-Income People March 2013 v 00 v 00 TABLE OF CONTENTS Introduction……............................................................................. ............1 Th e Medicaid program is the largest health insurance program in the U.S., covering millions of the poorest individuals and families in the nation. As such, Medicaid is also a key source of health care financing . Medicaid covers many people with disabilities and complex needs, and the program has been an imp ortant locus of innovation and improvement in health care delivery and payment. The Affordable Care Act (ACA) expands Medicaid significantly beginning in 2014.

The expanded Medicaid program is integral to the broader framework the ACA creates to cover the uninsured. What is Medicaid? .....................................................................................3 Medicaid is the main publicly financed health coverage program for low-income Americans, most of whom lack access to the private health insurance system. Medicaid is also the dominant source of coverage for nursing home and community-based long-term services and supports .

The program provides core support for the health centers and safety-net hospitals that serve low-income and uninsured people and provide essential community services like trauma care and neonatal intensive care. States design and administer their own Medicaid programs within broad federal guidelines. Who Does Medicaid Cover? ...................................................... .................7 Medicaid covers more than 62 million people, or 1 in 5 Americans. It covers more 1 in 3 children and some of their parents, and 40% of all births. It also covers millions of people with severe disabilities, and provides extra assistance to poor Medicare beneficiaries. Historically, the program has excluded most non-elderly adults, but the ACA expands Medicaid beginning in 2014, making it broadly a program for people under age 65 with income at or below 138% of the federal poverty level . Each state will decide whether to adopt the Medicaid expansion. What Does Medicaid Cover? ................................................................... .13 Medicaid covers a wide spectrum of services to meet its beneficiaries’ diverse needs. Medicaid benefits for children are uniquely comprehensive; adult benefits vary significantly by state.

Medicaid covers many long-term services and supports that private coverage and Medicare exclude or limit, as well as services like non-emergency transportation and translation services that improve access for low-income people. The A CA establishes new minimum standards for the Medicaid benefits that most adults who gain Medicaid due to the ACA expansion will receive. What is the Impact of Medicaid on Access to Care? ……………………….......…20 Medicaid coverage of children and pregnant women has led to increased access to care and improved child health and birth outcomes. Children with Medicaid fare as well as privately insured children on core measures of preventive and primary care. Relative to the uninsured, adults with Medicaid have increased access to preventive and primary care and reduced out- of- pocket burdens, and they are less likely to forgo care due to cost. Still, provider shortages and low provider participation in Medicaid, particularly among specialists, are a major concern, and exp anded coverage can be expected to increase current pressures on access. Federal and state actions to address these challenges will be important to improve access. vi 00 vi 00   How  Much  Does  Medicaid  Cost? ........................................... ...................25 Medicaid spending  totaled  about  $414  billion  in  FY  2010.  Roughly  two ‐thirds  of  Medicaid   spending  is  attributable  to  seniors  and  people  with disabilities.  “Dual  eligible”  beneficiaries,  who   are  enrolled  in  both  Medicare  and  Medicaid,  account  for  nearly  40%  of  all  Medicaid  spending.  Through  the  economic  downturn,  the  main  driver  of  Medicaid  spending  was  enrollment  growth.   Medicaid  spending  per  person  has  been  rising  more  slowly  than  medical  care  inflation  and  private  insur ance premiums.      How  is  Medicaid  Financed? ................... ....................... ............................31   Medicaid is  financed  jointly by  the  federal  government  and the  states.  The  federal  government   matches  state  Medicaid  spending. The  federal  match  rate varies  across states  based  on  a   formula  and  ranges  from  a  minimum  of  50%  to  much  higher  levels  in  poorer  states.  Medicaid  is  a  countercyclical  program  that  expands  during  economic  downturns,  when states’  fiscal capacity   is  also  most  strained.  Under  the  ACA,  the federal  match  rate  for the adults  who  are newly   eligible  for  Medicaid  due  to  the  expansion  will  be  100%  in  the  first  three  years  and  at least  90%   thereafter.        Looking  Ahead ………………………………………………………\ …………………………......34   Medicaid is  the  foundation  of  the  public‐private  insurance  system the  ACA  creates   to cover   nearly  all  Americans.  When  the  ACA  is  implemented,  important  changes  in  Medicaid  will occur   across  the states.  The  changes  will be  most  far‐reaching  in the  states  that  adopt  the  Medicaid   expansion,  but  regardless  of  what  individual  states  decide  about  implementing  the  expansion,   significant  changes in  this  important  pro gram  will  take  place  in all  states.  How  the Medicaid   reforms  play  out  in  the  coming  years  will influence  the extent  to which  the  ACA’s  goals for  coverage,  individual  and  community  health,  and cost  control  are  realized.      Tables ………………………………………………\ ………………………………………………\ . ……39  1 00 1 00 INTRODUCTION The Medicaid program was established in 1965 by the same federal legislation that established Medicare . Originally conceived as a medical assistance supplement for people receiving cash welfare assistance – the poorest families with dependent children, and poor aged, blind, and disabled individuals – the Medicaid program has been expanded over time by Congress and the states to address widening gaps in the private health insurance system. Medicaid now covers over 62 million Americans, more than Medicare or any single private insur er. Medicaid covers more than 1 in 3 children and over 40% of births. In addition, millions of persons with disabilities rely on Medicaid, and so do millions of poor Medicare beneficiaries, for whom Medicaid provides crucial extra help. More than 60% of people living in nursing homes are covered by Medicaid. During economic downturns like the recent Great Recession, Medicaid has provided a coverage safety-net for many Americans affected by loss of work and declining income – especially, children. As a mainstay of health coverage, Medicaid is also a major source of health care financing, funding a sixth of total national spending on personal health care (Figure 1), and providing core support for health centers and safety-net hospitals that are the backbone of the delivery system serving low-income and uninsured people .

Medicaid is an engine in state economies, too . While Medicaid already plays an integral role in our health care system, the Patient Protection and Affordable Care Act * (Affordable Care Act, or ACA), signed by President Obama on March 23, 2010, ushers in a significant new chapter in the program’s evolution. Under the ACA, Medicaid eligibility will expand in 2014 to reach millions more poor Americans – mostly, uninsured adults. *Health reform actually comprises two separate pieces of legislation, the ACA (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010, or HCERA (P.L. 111-152). 16% 18% 8% 31% 7% Total HealthServices andSupplies Hospital Care ProfessionalServices Nursing Facility Care Prescription Drugs NOTE: Includes neither spending on CHIP nor administrative spending. Definition of nursing facility care was revised from previous years and no longer includes intermediate care facilities for individuals with intellectual disabilities (ICF/ID) or residential facilities for mental health or substance abuse treatment, but now includes continuing care and retirement communities (CCRC).

SOURCE: CMS, Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2013. Data for 2011.

T o t a l National Spending (billions) $2,279 $851 $723 $149 $263 Medicaid as a share of national health care spending:

Medicaid’s Role in Financing Health Care Figure 1 2 00 2 00 This federal reform of Medicaid establishes the program as the coverage pathway for most low- income people and the foundation of the broader public-private system of health coverage created under the new law. The ACA also makes other key investments and improvements to strengthen the program.

Soon after enactment of the ACA, a number of states challenged the constitutionality of several provisions of the law, including the Medicaid expansion, in National Federal of Independent Business v. Sebelius . In its June 28, 2012 ruling on the case, the Supreme Court upheld the law’s constitutionality. However, the Justices limited the enforceability of the Medicaid expansion, effectively converting it to a state option. Thus, each state will decide whether to implement the Medicaid expansion . But regardless of states’ decisions regarding the expansion, many other ACA changes to the Medicaid program will take effect across the states on January 1, 2014 . Given the broader role that Medicaid is slated to play in the coming years, and the new environment of health coverage and care in which it will operate, understanding the Medicaid program and how it fits into our health care system is more important than ever. The purpose of this Primer is to lay a foundation for that understanding by explaining the basics of Medicaid , providing key current information about the program, and describing significant changes in Medicaid that are on the horizon. 3 00 3 00 WHAT IS MEDICAID? Medicaid is the nation’s main public health insurance program for low-income people. Most Medicaid beneficiaries lack access to private insurance and many have extensive needs for care.

Medicaid is also the dominant source of long-term care coverage in the U.S. As a major insurer of low -income people, Medicaid provides key financing for the safety-net institutions and providers that serve the low-income and uninsured population, as well as the larger public. Medicaid is financed through a federal-state partnership, and each state designs and operates its own program within broad federal guidelines. Medicaid’s structure has enabled the program to evolve and facilitated state innovation. Wh at is Medicaid? Medicaid is the nation’s publicly financed health and long-term care coverage for low-income people . Enacted in 1965 as Title XIX of the Social Security Act, Medicaid is an entitlement program that was initially established to provide medical assistance to individuals and families receiving cash assistance, or “ welfare.” As an entitlement program, Medicaid provides assistance to all individuals who meet the criteria for eligibility; enrollment freezes and waiting lists for benefits are not allowed. Over the years, especially as private health insurance has eroded , both Congress and the states have expanded Medicaid to reach more uninsured Americans living below or near poverty. Today, Medicaid covers a broad low-income population, including pregnant women, children and some parents in both working and jobless families, children and adults with diverse physical and mental health conditions and disabilities, and poor elderly and disabled Medicare beneficiaries. Currently, Medicaid also leaves out man y of the poor, due to a federal exclusion of adults without dependent children, limited eligibility for parents in many states, and an array of barriers to participation . The ACA is expected to change this environment significantly. The new law provides for a broad expansion of Medicaid to adults under age 65 with income at or below 138% of the federal poverty level (FPL), effective January 1, 2014, with full federal funding for the newly eligible group in the first three years and at least 90% funding thereafter. However, following the Supreme Court ’s decision on the ACA, each state will decide whether or not to implement the Medicaid expansion. What is Medicaid’s r ole in our health care system? Medicaid fills large gaps in our health insurance system (Figure 2). Medicaid provides health coverage for millions of children and parents in low-income families who lack access to the private insurance system that covers most Americans . Medicaid also covers millions of people with chronic conditions and disabilities wh o are excluded from private insurance or cannot afford it or for whom such insurance, designed for a generally healthy population, is inadequate.

Finally, Medicaid provides extra help for millions of low-income Medicare beneficiaries, known as “dual eligible” beneficiaries, assisting them with Medicare premiums and cost-sharing and covering key services, especially long-term care, that Medicare excludes or limits . Because poverty disproportionately affects racial and ethnic minorities, Medicaid plays a particularly important coverage role for these populations. 4 00 4 00 Medicaid provides a coverage safety-net during economic downturns. Because Medicaid eligibility is tied to having low-income, and enrollment caps and waiting lists are not allowed, Medicaid operates as a safety-net. During economic downturns, many individuals and families affected by unemployment, loss of job-based health coverage, and declining income become eligible for Medicaid and the program expands to cover them. It is estimated that, for every one percentage point increase in the unemployment rate, Medicaid enrollment grows by 1 million. 1 Medicaid funding is the dominant source of financing for safety-net providers that serve low- income and uninsured people (Figure 3). In 2010, Medicaid payments on behalf of enrollees accounted for more than one-third (35%) of safety-net ho spitals’ total net revenues. 2 In addition, s upplemental Medicaid payments known as “DSH” payments financed 24% of the costs of uncompensated care provided by these hospitals, and other supplemental Medicaid funding financed another 11%. Community health centers, which provide care in many underserved areas, also rely heavily on Medicaid patient revenues, which account ed for 38% of their total operating revenues in 2011. 3 Medicaid is the main source of coverage and financing for long-term services and supports (LTSS). Nearly 10 million Americans, about half of them elderly and about half of them children and working-age adults with disabilities, need LTSS. 4 LTSS are largely not covered by either Medicare or private insurance, but Medicaid covers nursing home and other institutional care as well as a broad range of home- and community-based LTSS that support independent living.

Medicaid finances 40% of all long-term care spending, and more than 6 of every 10 nursing home residents are covered by Medicaid. Over half of Medicaid long-term care spending is for institutional care, but a steadily growing share – 45% in 2011, up from 20% in 2000 – is going to home and community-based care. 5 Medicaid’s Role in Filling Coverage Gaps Health Insurance Coverage 31 million children & 16 million adults in low -income families; 16 million elderly and persons with disabilities State Capacity for Health CoverageFY 2013 FMAPs range from 50% to 73.4% MEDICAID Support for Health Care System and Safety -Net 16% of national health spending; 35% of safety -net hospital net revenues Assistance to Medicare Beneficiaries 9.4 million aged and disabled —20% of Medicare beneficiaries Long -Term Care Assistance 1.6 million institutional residents; 2.8 million community -based residents Figure 2 5 00 5 00 How is Medicaid structured? Medicaid is financed through a federal-state partnership. The cost of Medicaid is shared by the federal government and the states. The federal government matches state Medicaid spending based on a formula specified in the Social Security Act . By statute, the federal match rate is at lea st 50% in every state, but the lower a state’s per capita income, the higher the federal match rate it receives. The states administer Medicaid within broad federal guidelines and state programs vary widely . Each state must have a single agency that administers Medicaid, subject to oversight by the Centers for Medicare and Medicaid Services (CMS) in the U.S. Department of Health and Human Services (HHS). State participation in Medicaid is voluntary but all states participate.

Federal law specifies cor e requirements that all state Medicaid programs must meet as a condition of receiving federal Mediaid funding. However, beyond the core requirements, states have broad flexibility regarding eligibility, benefits, provider payment, delivery systems, and other aspects of their programs, and Medicaid really operates as more than 50 distinct programs – one in each state, the District of Columbia, and each of the U.S. Territories. Every state has a document called a Medicaid state plan that describes its program in detail. To make a change in its Medicaid program, a state must submit and receive CMS approval of a state plan amendment (SPA). Sta tes can seek federal waivers to test new approaches to operating their Medicaid programs outside of regular federal rules, with federal Medicaid matching funds. Section 1115 of the Social Security Act gives the HHS Secretary authority to waive statutory and regulatory requirements for health and welfare programs, including Medicaid, for research and demonstration purposes that are “likely to assist in promoting the objectives of the program .” Under longstanding administrative policy, federal Medicaid spending under a Section 1115 Medicaid Financing of Safety-Net Providers Commercial27% Medicare21% Uninsured2% Other4% Medicaid35% Federal/state/local payments 11% Total = $47 billion SOURCES: Data for hospitals from America’s Safety Net Hospitals and Health Systems, 2010, National Association of Public Hospitals and Health Systems, May 2012. Health center data from 2011 Uniform Data System (UDS), BPHC/HRSA/HHS. Medicaid38% Federal 330 Grants17% Other Grants & Contracts24% Medicare6% Private7% Uninsured/Self-Pay6% Other Public 2% Total = $12.7 billion Safety-Net Hospital Net Revenues b y P a y e r , 2010 Health Center Revenues b y P a y e r , 2011 Figure 3 6 00 6 00 waiver must be “budget-neutral,” meaning that it cannot exceed th e amount of projected federal spending absent the waiver. States have used Section 1115 waivers for a wide array of purposes, including to expand coverage to adults otherwise excluded from the program, to make changes in benefits and cost- sharing not otherwise allowed under federal rules, and to implement changes in their Medicaid delivery and/or payment systems. States have also obtained narrower Section 1115 waivers to implement initiatives focused on specific populations (e.g., people with HIV) or services (e.g., family planning services). Many states also have Section 1915 “program waivers” that permit them to mandate managed care for certain beneficiaries who are normally exempt from such mandates, and to obtain federal matching funds to provide community-based LTSS to beneficiaries who would otherwise need nursing facility care. Medicaid’s structure enables the program to evolve and facilitates state innovation. Broad state flexibility in program design and guaranteed federal matching funds ha ve enabled Medicaid to respond to economic and demographic changes and to address emergent needs – for example, by expanding during economic downturns, providing a coverage safety-net for many affected by the HIV/AIDS pandemic, and providing immediate, short-term benefits for 350,000 New Yorkers following the 9/11 terrorist attacks. Further, states have harnessed Medicaid’s leverage as a major source of coverage and financing to drive innovation and improvement s in care, including more patient-centered and coordinated care and wider use of community-based alternatives to institutional long-term care, and to advance payment reforms that align incentives with quality and health outcome goals. Both the general public and those with experience in the program view Medicaid favorably. A large majority of Americans view Medicaid as a very important program and would be willing to enroll in the program if they needed health care and qualified. Over half of adults have a friend or family member who has benefited from Medicaid or have received Medicaid benefits themselves. 6 Findings from surveys and focus group studies show a high degree of satisfaction with Medicaid among families with program experience. 7 They value both the breadth of Medicaid’s benefits and the affordability of the coverage. 7 00 7 00 WHO  DOES  MEDICAID  COVER?    By design,  Medicaid  covers  low ‐income  people.  Currently,  the  program  covers  more  than 62 million  Americans,  or  1  in  every  5,  including  many  with  complex  health  care needs.  Medicaid  plays  an especially   large  role  in  covering  children and  pregnant  women;  it  also  covers  millions  of  individuals  with  severe  disabilities  and  provides  extra  assista nce  for  millions  of  poor  Medicare  beneficiaries.  Medicaid historically   has  exclud ed most  non‐ elderly  adults,  but  the  ACA  expands  Medicaid  to  people  under  age  65 with  income   at  or below  138%  of  the  federal  poverty level,  effective  January 1,  2014.  The  expanded  Medicaid  program   is  integral  to  the  broader  framework  the ACA  creates  to co ver  the  uninsured.  Following  th e Supre me  Court’s  ruling  on  the  ACA,  each  state  will decide  whether  or  not  to  adopt  the Medicaid  expansion.   However,  all  states  must  comply  with  ACA  requirements  to  simplify  and  streamline  Medicaid  eligibility  and  enrollment  to  ensure  seamless  coordination  between  Medicaid  and  th e  health  insurance  exchanges,  the  other  new  major  coverage  p athway  for  the  uninsured.         What  is  Medicaid’s  coverage  role?       Medicaid  is  a  bedrock  source of  coverage  for  children.  Medicaid,  together  with the  smaller   Children’s  Health  Insurance  Program  (CHIP),   covers more  than  1  in  every  3  children  and more   than  half  of  all  low‐income  children.  Medicaid  is  particularly  important  for  children  with  disabilities  and  special  needs. Because  of  Medicaid  and  CHIP,  the uninsured  rate  among  children  has  declined  substantially  over  the  last  decade.     Medicaid  covers  certain  low ‐income  people,  including  many wi th complex  health  care needs.   Most  of  the  people  Medicaid  covers  are in  working  families  but  lack  access  to  job ‐based  health   insurance  or  cannot  afford  the  premiums.  Most  are also  unable  to  obtain  individual  (non ‐group)   health  insurance,  either  because  they  cannot  afford  it  or,  in  the  case  of adults,  because  they  are   turned  down  for  coverage  based  on  their  health  status  (children  can  no  longer  be  rejected  for  coverage  based  on pre‐existing  health conditions).  Overall,  Medicaid beneficiaries  are  much   poorer  and  in significantly  worse  health  than  low‐income  people  with  private  in su rance.        Individuals  who  qualify  for  Medicaid  have a  federal  entitlement  to  coverage.  Medicaid  is  an   entitlement  program.  That  means  that  any  person  who  meets  his  or  her  state’s  Medicaid   eligibility  criteria  has a  federal  right  to  Medicaid  coverage  in that  state;  the  state  cannot  limit  enrollment  in  the  program  or  establish  a  waiting  list.  The  guarante e of  coverage  and  the  obligation  of  states  and  the  federal  government  to  finance  it  distinguish  Medicaid from  CHIP  and  other  block  grant  programs,  in which  funding  levels  are  pre‐set  and  enrollment  can  be  capped.       Who  can  qualify  for  Medicaid?    States  must  cover  federal  core  groups  of  low ‐income  individuals  and  have  broad  flexibility  to   expand  coverage.  The  federal  core  groups  that  states  must  cover  to  receive  federal  Medicaid  matching  funds  are  pregnant  women, children,  parents,  elderly  individuals,  and  individuals  with   disabilities,  with  income  below  specified  minimum  thresholds,  such  as  100%  or  133%  of  the   federal  poverty  level (FPL).  One  group  that  historical ly has  bee n excluded  from  the  core  groups   is  non ‐elderly  adults  without  dependent  children  (“childless  adults”).  States  can  choose  to   extend  Medicaid  eligibility  to  people  in  the  core  groups  who  have  income  above  the  federal   minimum  thresholds  and  receive  federal  matching  funds. 8   8 00 8 00 Medicaid’s  Role  for  Selected  Populations SOURCE:  KCMU  and  Urban  Institute  analysis  of  2012  ASEC Supplement  to  the  CPS;  birth  data  from  Maternal  and  Child  Health  Update:  States  Increase  Eligibility  for  Children's  Health  in  2007 , National  Governors  Association,  2008;  Medicare  data  from  MCBS  Cost  and  Use  file,  2009;   Functional  Limitations  from KCMU  Analysis  of  2011  NHIS data. 63% 50% 15% 20% 41% 40% 70% 35% 27% 45% Nursing  Home  Residents People  with  HIV  in  Regular  Care Non‐ elderly  Adults with  Functional  Limitations Medicare  Beneficiaries Births  (Pregnant  Women) Parents  <100%  FPL Children  <100%  FPL All  Children Non‐ elderly  100 ‐199%  FPL Non ‐elderly  <100%  FPL Percent  with  Medicaid  Coverage:

Families Aged & Disabled Figure 4 Medicaid  eligibility  is  limited  to  American  citizens  and  certain  lawfully  present immigrants.   Only  American  citizens  and  specific  categories  of  lawfully  present  immigrants  can  qualify  for  Medicaid,  and  most  lawfully  present  immigrants  are  barred  from  enrolling  in  Medicaid  during   their  first  five  years  in the  U.S.  States  have  an  option  to  eliminate  the  five ‐year  wait  for  lawfully   present  children  and  pregnant  women  but  not for  other  adul ts. As  of  January  2013,  half  of  all   states  had  adopted  the  option  for  one  or  both  groups. 9 Undocumented  immigrants  are  ineligible   for  Medicaid.      Medicaid  payments  for  emergency  services  may  be  made  on  behalf  of  individuals  who  would  be  eligible  for  Medicaid  but  for their  immigration  status, including  lawfully  present  immigrants  who   are  ineligible  or  in  the  five ‐year  waiting  period  for  coverage  and  undocumented  immigrants.   Some  states  have  used  state ‐only funds  to  cover  lawfully  present  or  undocumented  immigran ts  who  are  not  eligible  for  Medicaid,  although  these  programs  are  often  limited  to  certain  groups   and/or  provide  a limited  scope  of  services.      Documentation  of  citizenship  and identity  is required . Federal  law  requires  most  individuals    applying  for  Medicaid  coverage  for  the first  time  to document  their  citizenship  st atus  and   identity. 10     Who  is  covered  currently?       Medicaid covers  more  than  62  million  Americans,  or  1  in  every  5.  Medicaid  beneficiaries   include  low‐income  individuals  of  all  ages,  including  newborns,  children  and parents,  pregnant  women,  individuals  with  diverse  physical,  developmental,  and  intellectual  disabilities  and   mental  illnesses,  and  poor  elderly  and  disabled  Medicare  beneficiaries,  including  many  with   long ‐term  care  needs.  Half  the  people  with  HIV  who  are  in  regular  care are  covered  by   Medi caid. 11 The  program  plays  a  particularly  large  role  for  certain  subpopulations  who  are   disproportionately  likely  to  be  poor  and  who  lack  access  to private  coverage  due  to  their  low  income  or  health  status  (Figure  4).     9 00 9 00 Medi c 2009 , child r inco m and  C progr 70%  o   Medi c cove r Twen eligib inten s redu c over  4     Medi c typic a 1, 20 1 for  a  f than   5 Medi c abou t progr unins Arka n Medi c inco m caid is the  la r  Medicaid  co ren.  CHIP  buil me  families  w i CHIP,  all  child r ams  cover  m of all  poor  ch i caid is a  key   s rage  of  pregn a ty  states  no w ility  at  highe r sive  care  for  p ce  infant  mor t 40%  of  births   caid coverag ally have  mu c 13,  33  states   family of  thr e 50%  FPL.  In  a caid.  Reflecti n t 40%  of  poo r am,  and poo r ured.  Sharp   v nsas to 215%   caid benefits   me adults’  ac c rgest  source   o vered nearly   ds  on  Medic a ith  income  t o ren  below  20 0 ore  than  1  in  ildren  and  50 source  of  co v ant  women   b w cover  preg n r income  leve pregnant  wo m tality,  rates  o in the  U.S.  a n e of  low ‐inc o ch  more  limit e set  income  e l ee  in  2013),  i n ddition,  as  m ng their  mor e r parents  and r adults  are   m variation  in  s t in  Minnesot a to any  non ‐ d cess to  Medic of  health  ins u 31 million  c h aid,  covering   oo high  to  qu a 0%  FPL  are e l every  3  chil d %  of  childre n verage  for  pr e beyond  the fe nant  women   u ls.13 Medicai d men  and  thei of  low  birth  w nd is  the  larg e ome  adults  la g ed  eligibility   f ligibility for  w ncluding  16  s t entioned,  fe d e constrained   just  a  quart e more  than  tw o tate  income   e a (Figure  6),  a isabled  child l aid coverage urance  for  c h hildren,  inclu d close  to 8  mi l alify  for  Medi ligible  for  pu b dren.  At  any   g n between  10 0 egnant  wom e deral  minim u up  to  185%  F P d improves  a c r babies,  hel p eight,  and  av est  source  of   gs far  behin d for  parents  t h working  pare n tates that  lim deral  law  has     eligiblity,  an er  of  poor  chi o‐ and‐ a‐half   t eligibility  thre nd  the  small   less adults,  t r across  the c o hildren  in  the   ding roughly   1 llion children caid.  In  mos t blic  coverage given  point  d u 0%  and  200 % en.  Most  sta t um  income  el PL  and  anoth ccess  to  pren ping  to impr o voidable  birth public  fundi n d Medicaid  c o han for  childr e nts at  a  level   b ited eligibilit y excluded  m o y  given  poin t ldless  adults   times as  likel y sholds  for  w o number  of  s t ranslate  into  m ountry. 15   U.S.  Over  th e 1 million  fost e  in  low ‐ and  m t states,  bet w . Together,  t h uring  the  yea r % FPL. 12   tes  have  exp a ligibility  level   er  17 states   p atal care  an d ove  maternal     defects.  Me d ng  for  family   overage  of  c h en  (Figure  5) . below  100%   F y to  parents   e ost childless   a t during  the  y are  covered   b y as  poor  chi l orking  paren t tates that  pr o marked  ineq u e course  of  F Y er  care   moderate ‐ ween Medicai d he two   r, they  cover   anded  of  133%  FPL . provide   d neonatal   health  and   dicaid  funds   planning. 14    hildren.  State . As  of  Janua r FPL  ($19,530   earning less  adults  from   ear,  only   by the   ldren  to  be  ts,  from  16%   i ovide  full  uities  in  low ‐ Y  d  .  s   ry   in   10 00 10 00     Medicaid  covers 9.3  million  non ‐elderly  people  with  disabilities,  including  1.5 million  children.   Medicaid  provides  health  and  long‐term  care  coverage  for  people  with severe  physical  and   mental  health  conditions  and  disabilities  (e.g.,  cerebral  palsy,  Down Syndrome,  autism).  Often,   these  individuals  cannot  obtain  coverage  in  the  private  market  or  the  coverage  available  to  them  falls  short  of  their  health  care  needs.  Medicaid  provides  pe ople  with  dis abilities  access  to  a   fuller  range  of  the  services  they  need,  helping  to  maximize  their  independence  and,  in  the  case  of  some  disabled  adults,  supporting  their participation  in  the  workforce.  Medicaid  covers  a  large   majority  of  all  poor  children  with disabilities.      Medicaid  provides  assis tance  for  over  9  million  low‐income  Medicare  beneficiaries . In  2012,   the  federal  Medicare  program  provided  health  insurance  for 50 million  Americans,  including   about  42  million  seniors  and  9  million  non ‐elderly  individuals  with  permanent  disabilities. 16 One  in  every  5  Medicare  beneficiaries  is  also  covered  by  Medicaid,  based  on  low  income.  These   individuals,  known  as  “dual  eligible”  beneficiaries,  are much  poorer  than  other  Medicare   enrollees,  and  in  worse  health.  Medicaid  assists  dual  eligible  beneficiaries  with  Medicare   premiums  and  cost ‐sharing  and  covers  important  services  that  Medicare limits  or  does  not   cover,  especially  LTSS.  In 2009,  dual  eligible  beneficia ries  accounted  for  15%  of  Medicaid   enrollees  but  38%  of  all  Medicaid  spending.      What  about  participation  in  Medicaid?      While  participation  in Medicaid  is  high  compared  with other  voluntary  programs,  many  people   who  are  eligible  are  not  enrolled  and  remain  uninsured.  About 85%  of  children  who  are  eligible   for  Medicaid  or  CHIP  participate. 17 However,  participation  rates  among  adults  are  lower  – 63%   for  adults  overall  and  only 38%  among  childless  adults. 18  More  than 70%  of  uninsured  children   are  potentially  eligible  for  Medicaid  or  CHIP  but  not  enrolled.  Some  low‐income  families  are  not   aware  of  the  programs  or  do  not  believe  they  are  eligible,  indicating  that  more  effective   outreach  is  needed.  Research  also shows  that  documentation  and  other  administrative   NOTES: The  federal  poverty  line  (FPL)  for a  family  of  three  in  2013  is $19,530.  Several  states  also  offer  a  benefit  package  that  is  more   limited  than  Medicaid  to  parents  at  higher  income  levels  through  waiver  or  state ‐funded  coverage.    SOURCE:  Based  on  the  results  of a  national  survey  conducted  by  KCMU  and  the  Georgetown  Uni versity  Center  for  Children  and   Families,  2013. Medicaid  Eligibility  for  Working  Parents, by   Income January  2013 WY WI WV WA VAVT UT TXTN SD SCRI PA OR OKOH ND NCNY NM NJ NH NV NE MT MOMS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC    DE CT CO CA AR AZ AK AL 50%  ‐99%  FPL  (17  states)<50%  FPL  (16 states) >100%  FPL  (18 states  including  DC) Figure  6 11 00 11 00 requirements can pose significant obstacles to enrollment and cause many enrolled children and families to lose their Medicaid coverage at renewal time. This “churning” in Medicaid disrupts coverage and care and increases the number of individuals without insurance. To improve participation in Medicaid, states have increasingly simplified and streamlined Medicaid enrollment and renewal processes. Important streamlining steps required by the ACA have already been implemented in many states over the last decade, mostly for children. Today, few states require face- to-face interviews for either children or adults applying for or renewing Medicaid. Likewise, few impose asset tests for children or pregnant women, and about half have eliminated asset tests for other adults. Over two-thirds of states now have electronic online applications in Medicaid or CHIP, and over half offer online renewal. 19 Most states verify citizenship for Medicaid and CHIP eligibility purposes through an electronic data match with the Social Security Administration . States have also invested in outreach and enrollment assistance. Nearly all states offer in- person assistance at eligibility offices and a toll-free assistance hotline, and most provide assistance at the local level . The CHIP Reauthorization Act of 2009 (CHIPRA) established a program of grants to states for outreach and enrollment of children in Medicaid and CHIP, and federal performance bonuses for states that simplified enrollment and renewal for children and increased their enrollment and retention. How will the ACA affect who is covered?

The ACA opens Medicaid to millions of uninsured adults . The ACA expands Medicaid by establishing a new Medicaid eligibility group for adults under age 65 with income at or below 138% FPL.  These adults make up about half the uninsured. Accounting for enrollment among adults who gain Medicaid eligibility due to the expansion, as well as increases in participation among children and adults eligible for Medicaid prior to the ACA, Medicaid enrollment is expected to increase by 21.3 million by 2022. 20 21 (Note: The ACA does not change Medicaid eligibility for the elderly and people with disabilities.)  The Medicaid expansion is effectively a state option . Although the ACA required states to expand Medicaid, in its June 28, 2012 ruling on the constitutionality of the ACA, the Supreme Court curtailed HHS’ ability to enforce the requirement. Specifically, the Justices ruled that HHS cannot withhold federal matching funds for the “traditional” Medicai d program if a state does not implement the Medicaid expansion. The Court’s decision effectively converted the Medicaid expansion to a state option. States that do expand Medicaid must expand it to the 138% FPL threshold to receive the enhanced federal match.

 Non-citizens will continue to face restrictions from Medicaid under the ACA. Lawfully present immigrants will continue to face the five-year waiting period or, in the case of some categories, remain excluded from Medicaid. Undocumented immigrants will remain ineligible for Medicaid.  The ACA establishes 133% FPL as the income eligibility threshold for the Medicaid expansion population , but because it also provides that the first 5% of income is automatically disregarded, the effective income eligibility threshold is 138% FPL. For simplicity, 138% FPL is used in the Primer. 12 00 12 00 State adoption of the Medicaid expansion would help reduce the number of uninsured.

Without the Medicaid expansion, the ACA would reduce the number of uninsured in 2022 by an estimated 15.1 million (28%) . If all states adopted the Medicaid expansion, the number of uninsured in 2022 would decline by 25.3 million (48%) – an additional 10.1 million people. 22 The ACA simplifies Medicaid eligibility and calls for a “no wrong door” enrollment system, with seamless coordination between Medicaid and the new exchanges. Regardless of their decisions on whether to implement the Medicaid expansion, on January 1, 2014, all states must implement a number of provisions in the ACA that support the seamless coordination between coverage programs that the law requires. For most non-elderly applicants, states must replace the myriad methods of counting income they now use to determine Medicaid eligibility with Modified Adjusted Gross Income (MAGI), as defined in the Internal Revenue Code. States must also use a single, streamlined application for Medicaid, CHIP, and subsidies for exchange coverage developed by the HHS Secretary, unless they receive approval for an alternative application. Individuals must be able to apply online, by telephone, fax, and mail, and in person.

Finally, states must streamline the enrollment process by eliminating in-person interviews and asset tests and relying first on electronic data matches rather than documents to verify eligibility criteria; they must also provide application assistance.

In 2011, HHS began providing a time-limited enhanced federal match rate (90%) for state expenditures to upgrade or replace aging Medicaid eligibility and enrollment systems to meet these requirements. Nearly all states applied for and received such funds, and most states have already begun moving forward to develop the capabilities and improvements that the ACA requires. E ffective Medicaid outreach, as well as application assistance, will be important for the ACA to achieve its coverage goals. Reductions in the number of uninsured will hinge to a large extent on high rates of participation in Medicaid. Robust and sustained outreach efforts will be important, especially to engage childless adults, who are largely new to Medicaid . Because the Medicaid-eligible population is diverse along many dimensions (e.g., age, income, race/ethnicity/language, health status, work status, urban/suburban/rural location), both broad and targeted outreach efforts will be needed. In addition, application assistance will be important – particularly, direct one- on-one assistance for hard- to-reach gro ups, such as individuals with limited English proficiency and families with mixed immigration status. Past experience suggests that this assistance is most effective when provided by individuals from the community being served, who can provide culturally competent help and have appropriate language skills. Increased awareness of and interest in coverage as the ACA is implemented will present new opportunities for Medicaid outreach, marketing, and assistance. 13 00 13 00 WHAT DOES MEDICAID COVER? Medicaid covers a broad array of health and long-term care services, including many services not typically covered by private insurance. Cost-sharing is restricted to minimize financial barriers to access for the low- income people Medicaid serves . Medicaid benefits for children are uniquely comprehensive, while federal law gives states more latitude in defining the benefit package for adults. Under t he ACA, most adults who become newly eligible for Medicaid due to the Medicaid expansion will receive Alternative Benefit Plans (ABP) . ABPs must include the ten “essential health benefits” defined by the ACA and also meet other requirements . The ACA also establishes a new state Medicaid option for “health homes” to improve care for people with multiple chronic conditions, and increases states’ opportunities to expand access to home and community-based LTSS . What does the Medicaid benefit package include? Because of the diverse and complex needs of the Medicaid population, Medicaid covers a broad range of both health and long-term care benefits. Medicaid covers a diverse population, including children and parents, pregnant women, people with physical and mental disabilities and chronic diseases of all kinds, and seniors. To address the spectrum of their needs and their limited ability to pay for c are out-of -pocket, Medicaid covers benefits typically covered by private insurance, but also many additional services, such as oral and vision care , transportation, and nursing home and community-based long-term care . Services provided by federally qualified health centers and certain other providers are also covered, reflecting the special role of these providers in serving t he low-income population. States use numerous tools, such as prior authorization and case management, to manage utilization in Medicaid. Federal law specifies a set of “mandatory services” that states must cover for the traditional Medicaid population. Most Medicaid beneficiaries are entitled to receive the mandatory services listed below, subject to a determination of medical necessity by the state Medicaid program or a managed care plan under contract to the state:  Physicians’ services  Hospital services (inpatient and outpatient)  Laboratory and x-ray services  Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under age 21  Federally-qualified health center (FQHC) and rural health clinic (RHC) services  Family planning services and supplies  Pediatric and family nurse practitioner services  Nurse midwife services  Nursing facility services for individuals 21 and older  Home health care for persons eligible for nursing facility services  Transportation services States have flexibility to cover many additional services that federal law designates as “optional .” Many of these optional services are particularly vital for persons with chronic conditions or disabilities and the elderly. Examples include prescription drugs (which all states cover), personal care services, rehabilitation services, and habilitation services. Notwithstanding their “optional” designation in statute, the fact that states choose to cover many of these 14 00 14 00 services in their Medicaid programs is evidence that they are widely considered to be essential for the Medicaid population. Nonetheless, when states are under severe budget strains, as in the recent economic recession, optional benefits like dental services for adults are particularly vulnerable to cuts, despite their importance and the well-documented adverse health consequences of reduced access to care . About one-third of total Medicaid spending is attributable to optional services. 23 Commonly offered optional services include: How do Medicaid benefits differ from typical private insurance benefits? The pediatric Medicaid benefit , known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) , encompasses a comprehensive array of health services. EPSDT is a mandatory benefit that entitles Medicaid enrollees under age 21 to all services authorized by federal Medicaid law, including services considered optional for other populations (e.g., dental care) and often not covered by private health insurance. In addition to screening, preventive, and early intervention services, EPSDT covers diagnostic services and treatment necessary to correct or ameliorate children’s acute and chronic physical and mental health conditions. EPSDT covers services that are particularly important, often on an ongoing basis, for children with disabilities, such as physical therapy, personal care, and durable medical equipment. Private health insurance often excludes or limits these services. The conception of medical necessity in EPSDT is expansive, consistent with the emphasis in Medicaid on promoting children’s healthy development and maximizing their health and function. Accordingly, service limits that states may impose on adults, such as a limit on physical therapy sessions, or a maximum number of prescriptions per month, cannot be applied to children. As a model of uniform, comprehensive benefits that apply to a population nationally, EPSDT is unique in both Medicaid and the broader insurance market.

In addition to acute health services, Medicaid covers a wide range of LTSS that Medicare and most private insurance exclude or narrowly limit. Medicaid LTSS include services provided in nursing facilities and ICF/ID, as well as a wide range of services and supports needed by people , young and old, to live independently in the community – home health care, personal care, durable medical equipment and supplies, rehabilitative servic es, case management, home and community-based services, and other services. Both federal and state Medicaid policy have increasingly supported home and community-based alternatives to institutional long-term care,  Prescription drugs  Clinic services  Care furnished by other licensed practitioners  Dental services and dentures  Prosthetic devices, eyeglasses, and durable medical equipment  Rehabilitation and other therapies  Case management  Nursing facility services for individuals under age 21  Intermediate care facility for individuals with intellectual disabilities (ICF/ID) services  Home and community -based services (including under waivers)  Inpatient psychiatric services for individuals under age 21  Respiratory care services for ventilator - dependent individuals  Personal care services  Hospice services 15 00 15 00 driven partly by the Supreme Court’s Olmstead decision concerning the civil rights of people with disabilities in public programs.

The broad spectrum of services that Medicaid covers is particularly important for people with chronic illnesses and disabilities who depend on Medicaid. Medicaid beneficiaries include pre- term babies , people with Alzheimer’s disease, children and adults with mental illness, intellectual and developmental disabilities, and physical disabilities, people with HIV, and many others with high needs . Medicaid covers services that reflect the diverse and often extensive needs of the people it covers. The program fills major gaps in coverage for mental health and long-term care services. States can impose premiums and cost-sharing in Medicaid subject to specific federal limitations, exemptions, and an aggregate cap. Premiums are prohibited for children and adults with income at or below 150% FPL, but states have limited flexibility to charge Medicaid premiums for people at higher income levels. Cost-sharing is largely prohibited for mandatory children and limited to nominal amounts (specified in regulations) for adults below 100% FPL .

Other children and adults up to 150% FPL can be charged more cost-sharing, and those above 150% FPL can be charged still more, including any amount for non-emergency use of the emergency department ( ED). States can terminate Medicaid coverage if premiums are not paid and can permit providers to deny care if Medicaid patients, except for mandatory children and poor adults, do not pay their cost-sharing amounts. 24 Several services are exempt from cost-sharing, including preventive services for children, emergency services, family planning services and supplies, and pregnancy-related services including tobacco cessation services. Certain groups are also exempt, such as terminally ill individuals and individuals living in institutions. For all Medicaid beneficiaries, aggregate premiums and cost-sharing are capped at 5% of quarterly or monthly family income. CMS recently issued a proposed rule that would streamline Medicaid premium and cost-sharing regulations and give states additional flexibility, including authority to charge differential cost- sharing for preferred and non-preferred drugs and non-emergency ED use. How do states define their Medicaid benefit packages?

In general, a state must provide the same Medicaid benefit package to all its residents.

Generally, federal Medicaid law requires states to cover the same benefits statewide for all individuals in the federal core groups, and the covered services must be comparable, regardless of individuals ’ diagnoses or conditions. States define the amount, duration, and scope of the Medicaid services they cover, but federal law requires that coverage of each mandatory and optional service be “sufficient in a mount, duration, and scope to reasonably achieve its purpose. ” However, states have limited authority to provide narrower benefits to some groups. In the Deficit Reduction Act of 2005 (DRA), Congress changed the law to permit states to provide some groups with more limited benefits modeled on any of four specified “benchmark” plans, and to offer different benefits to different enrollees. The benchmark plans are: 16 00 16 00 The BCBS Standard PPO option under the Federal Employees Health Benefit Plan (FEHBP);  A generally available state employee plan;  The HMO with the largest commercial, non-Medicaid enrollment; and  Secretary-approved coverage appropriate for the population States providing benchmark (or benchmark-equivalent) coverage must still provide EPSDT benefits for children. Most groups are exempt from mandatory enrollment in benchmark coverage, including mandatory pregnant women and parents, individuals with severe di sabilities, individuals who are medically frail or have special needs, dual eligible beneficiaries, people with long-term care needs, and specified other groups. Only eight states have used the DRA benchmark authority, and all but one used the Secretary-approved coverage option. Most states used the authority to target additional benefits to certain groups, but some used it to provide reduced benefits, conditioning access to “enhanced” benefits on beneficiaries ’ health behaviors. Medicaid benefits vary considerably from state to state. Medicaid benefit packages vary widely from state to state. States cover different optional services. They also define amount, duration, and scope differently. Except with regard to children, states can place limits on covered services – for example, by capping the number of physician visits or prescription drugs that Medicaid will cover. Finally, while federal law includes a “medically necessary” standard to ensure appropriate use of Medicaid services, states define and apply the medical necessity standard somewhat differently. How do Medicaid enrollees receive their care ? Medicaid beneficiaries obtain their care primarily from private providers and health plans.

Medicaid is publicly financed, but it is not a government-run health care delivery system. On the contrary, states pay physicians, hospitals, and other providers for services furnished to Medicaid beneficiaries. State Medicaid programs purchase services on a fee-for-service basis or through risk-based contracts with managed care plans, or by using a combination of these as well as other approaches. Most Medicaid beneficiaries are enrolled in managed care plans. Nearly three-quarters of Medicaid beneficiaries receive all or at least some of their care through managed care arrangements (Figure 7). 25 The two main models of managed care in Medicaid are managed care organizations (MCO) and primary care case management (PCCM). MCOs are paid on a capitation basis – that is, they are paid a monthly premium for each enrolled beneficiary in exchange for assuming the financial risk for providing comprehensive Medicaid benefits or a defined s et of benefits (e.g., ambulatory care, dental services ). About half of all Medicaid beneficiaries are enrolled in these risk-based managed care plans. In contrast, PCCM programs build on the fee-for-service system . Medicaid pays contracted primary care providers (PCP) a small monthly per-enrollee fee to provide case management services to Medicaid beneficiaries assigned to them, including coordination and monitoring of primary health services and referrals for specialist care. 17 00 17 00 States are expanding managed care to more complex populations and are also pursuing managed LTSS. The vast majority of Medicaid enrollees in managed care arrangements are children and parents in low-income families, a relatively healthy population. Increasingly, though, many states are moving individuals with more complex needs, including people with disabilities and special needs and dual eligible beneficiaries, in to risk-based MCOs on a mandatory basis. In addition, there is growing interest among states in providing long-term services and supports through risk-based MCOs. Only about a dozen states now operate such programs, but a new demonstration program established by the ACA to test models for integrating care and aligning financing for dual eligible beneficiaries has generated more state activity in this area. 26 States are using a variety of approaches to rebalance their long-term care delivery systems in favor of community settings. As the demand for LTSS provided in the community continues to grow, efforts to make Medicaid benefits more flexible and involve consumers in determining and managing their services are spreading and gaining momentum. Many states allow some form of consumer direction of personal care services, giving the Medicaid beneficiary more control over hiring, scheduling, and paying personal care attendants. The ACA provides states with increased opportunities to expand access to home and community-based services, and the law extends an existin g demonstration program , known as “Money Follows the Person,” that provides enhanced federal matching funds to states for each Medicaid beneficiary they transition from an institution to the community. Safety-net providers play a major role in delivering health care to the Medicaid population. Whether they use managed care, fee-for-service, or a combination of delivery systems, many states rely heavily on community health centers in the underserved areas where many low- income people reside, and on public and other safety-net hospitals. These providers are often uniquely prepared and competent to meet the diverse social as well as health care needs of the Medicaid population. Comprehensive Medicaid Managed Care Penetration by State, October 2010 NOTE: Includes enrollment in MCOs and PCCMs. Most data as of October 2010.

SOURCE: KCMU/HMA 50-State Survey of Medicaid Managed Care Programs, September 2011. WY WI WV W A V AVT UT TXTN SD SCRI P A OR OK OH ND NCNY NM NJ NH NV NE MT MOMS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL 51% - 65% (15 states)0% - 50% (9 states) 80%+ (9 states) 66% - 80% (18 states including DC) US Overall = 65.9%Figure 7 18 00 18 00 State Medicaid programs have been innovators in the area of delivery system reform. Given high rates of disability and chronic disease in the Medicaid population and the public dollars at stake, both the opportunities and the incentives to improve care and accountability in Medicaid are great. Many states have developed model programs to improve disease management and enhance the coordination of care for people with ongoing and complex needs. A growing number of states are reforming primary care delivery by aligning Medicaid payment incentives with patient-centered care that emphasizes coordinated and team-based care. How will Medicaid benefits work under the ACA? Medicaid benefits for adults in the expansion group will be based on the Medicaid benchmark s already in law, but all benchmarks must include the ACA’s ten “essential health benefits.” Most newly eligible adults will receive Medicaid benefit packages based on or equivalent to the four benchmark plans described earlier. However, beginning January 1, 2014, all benchmark plans – for both new eligibles and the traditional population – must include the ten essential health benefits (EHBs) identified in the ACA and required of plans offered through the new exchanges. * The ACA also requires Medicaid benchmark plans to include family planning services and supplies and meet mental health parity requirements; a ny benchmark-equivalent plans must include prescription drugs and mental health services. The groups currently exempt from mandatory enrollment in benchmark plans are retained and carry over to the expansion population. Thus, for example, expansion adults who are medically frail or have long-term care needs will be entitled to traditional Medicaid benefits and cannot be required to enroll in benchmark coverage. Going forward, the Medicaid benchmark coverage options are known as “Alternative Benefit Plans” (ABP). Traditional Medicaid benefits and ABPs could differ within a state . The ACA requirement that Medicaid ABPs include the ten EHBs does not apply to traditional Medicaid benefits. Thus, it is possible that, within a state, traditional adult beneficiaries might not receive important benefits that expansion adults receive, such as recommended preventive services. At the same time, it is possible that ABPs could lack important benefits that traditional Medicaid covers. CMS guidance has indicated that states could harmonize and strengthen Medicaid benefits by using th e Secretary-approved ABP option and optional Medicaid benefits to align their ABPs and traditional Medicaid benefits as closely as possible. By taking these steps, states could reduce disruptions in services when individuals shift between Medicaid eligibility groups, and rationalize coverage for mixed-Medicaid families. New federal initiatives reinforce and accelerate state efforts to improve the delivery of care. Th e ACA established a new state option to implement “health homes” for Medicaid beneficiaries with chronic conditions, including severe mental illness. Health homes involve the integration and coordination of primary, acute, mental and behavioral health, and long-term services and supports. More integrated care for dual eligible beneficiaries is another key ACA *The ten essential health benefits specified in the ACA are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. 19 00 19 00 priority. To advance that goal, the law created a new Medicaid-Medicare Coordination Office within CMS, as well as a multi-state demonstration program to test new models of integrated service delivery and payment for dual eligible beneficiaries. In addition, a new Innovation Center in CMS is charged with testing an array of payment and service delivery reforms for the broader population. The ACA creates new state opportunities to expand access to home- and community-based LTSS. The health reform law expands states’ Medicaid options to provide LTSS in the community, both enlarging the scope of covered services and expanding access to them by broadening the financial and functional criteria for eligibility. The ACA also provides increased financial incentives for states to shift more long-term care services out of institutional settings and into the community.

20 00 20 00 WHAT  IS  THE  IMPACT  OF MEDICAID  ON ACCESS  TO  CARE?     Medicaid  coverage  of children  and  pregnant  women has  led  to  increased  access  to care  and  improved   child  health  and  birth  outcomes.  Children with  Medicaid  fare  as  well  as  privately  insured  children  on  core   measures  of  preventive  and  primary  care.  Relative  to  their  uninsured  counterparts,  adults  with Medicaid   have  increased  access  to an d  use  of preventive  and primary  care  and  reduced  out ‐of ‐pock et bu rdens,  and   they  are  less  likely  to  delay  or forgo  care  due  to  cost.  Still, provider  shortages  and  low  provider  participation  in  Medicaid,  particularly  among  specialists,  are  a  major  concern,  and expanded  coverage  under  the  ACA  can  be  expected  to increase  current  pressur es  on  access.      What  does  the  research  on  access  to care  in  Medicaid  show?       Medicaid  increases  access  to  care  and  lowers  financial  barriers  to  care.  Expansions  of  Medicaid  to  children  and  pregnant  women  have  led  to  increased  access  to  and  use of  medical  care  and   improved  child  health  and birth  outcomes;  expansions  to  cover  more  parents  have  increased   rates  of  cancer  screening  and  decreased  the likelihood  of  going  without  doctor  care due  to   cost. 27 28 29 30  National  data   show  that,  among  both  children  and non ‐elderly  adults,  the   uninsured  are  much  more  likely  to  report  no  usual  source  of  care  and  delaying  or  forgoing   needed  care due  to cost  (Figure  8).  A  recent  analysis  examining  access  among low ‐income  adults   with  chronic  conditions  found  that  those  enrolled  in  Medicaid  had  higher  utilization  and   spending  than  their  unins ured  counterparts  with  the  same  illnesses,  and  lower  out‐of‐pocket  burdens.  They  were  much  more  likely  to  have  had  a  recent  check‐ up and  much  less  likely  to   report  being  unable  to  access  necessary  medical  care. 31         A  new  study  provides  powerful  evidence  of  the  impact  of  Medicaid  on adults’  access  to  care.  The  recent  Oregon  Health  Study, using  a  unique  experimental  research  design, compared  access   between  adults  who  gained  Medicaid  through  a  lottery  and  a control  group of low ‐income   adults  who  did  not  win  the lottery  and  remained  un insured.  The  first ‐year  results  of  the  study   Access  to  Care  by  Health  Insurance  Status,  2011 2% 2% 1% 10% 7%4% 3% 2% 1% 10% 12% 10% 28% 20% 11% 53% 30%26% No Usual  Source of  Care Postponed Seeking  Care  Due to  Cost Went  Without Needed  Care  Due to  Cost No  Usual  Source of  Care Postponed Seeking  Care  Due to  Cost Went  Without Needed  Care  Due to  Cost Employer/Other  Private Medicaid/Other  Public Uninsured NOTE:  In  past  12  months.

Respondents  who  said  usual  source  of  care  was  the  emergency  room  were  included  among  those  with  no  usual  source  of  care.  All  differences  between  the  uninsured  and  the  two  insurance  groups  are  statistically  significant  (p<0.05).

SOURCE:  KCMU  analysis  of  2011  NHIS data. Children Non ‐Elderly  Adults Figure 8 21 00 21 00 show that Medicaid significantly increased the probability of having a usual source of primary care, the use of recommended preventive care, and the use of outpatient care, prescription drugs, and hospital care. 32 In addition, the Medicaid adults had lower out-of-pocket medical costs, less medical debt, and better self-reported physical and mental health. The gains in access for the adults with Medicaid were large as well as significant. On key measures on access to preventive and primary care, children in Medicaid and CHIP fare as well as children with private insurance, but adults face more difficulty . A recent HHS report shows that, on several core measures of preventive and primary care, access and quality are fairly comparable between children with Medicaid or CHIP and children with private insurance, and th e percentages of children who had at least one primary care visit during the year were high in both insured groups.

33 However, the low shares of children receiving all recommended well-child visits, childhood and adolescent immunizations, and screenings reveal troubling gaps in access for children in both insured groups, sometimes but not always worse for children with public coverage. Other research shows that children with Medicaid and CHIP are on par with privately insured children in terms of access to dental care. Importantly, working-age adults with Medicaid have greater difficulty obtaining needed medical care than similar adults with private insurance. 34 Medicaid restricts cost-sharing, lowering financial barriers to access. Compared to low-income privately insured people, Medicaid enrollees are substantially less likely to face high financial burdens for health care. 35 A large body of research shows that cost-sharing impedes access to services, particularly for individuals with low income and significant health care needs. Such individuals often end up either delaying or not seeking needed care. 36 For Medicaid patients as well as privately insured patients, the majority of emergency department (ED) visits are for urgent or serious symptoms. Medicaid patients do use EDs at significantly higher rates than people with private insurance. However, a recent study found that, in both groups, about three-quarters of all ED visits are for symptoms triaged as emergent, urgent, or semi-urgent by ED staff. About 10% of ED visits by Medicaid patients are for non- urgent symptoms, compared to 7% for privately insured patients. Adults with Medicaid have higher ED use than privately insured adults across all medical conditions, which is consistent with their higher burden of illness and disability. Also, adult Medicaid patients more often ha ve a secondary diagnoises of a mental disorder, and a larger share of their visits involve more than one major diagnosis. 37 Findings from other research indicate that barriers to timely primary care, including wait times for an appointment, no after- hours care at the doctor’s office or clinic, and lack of transportation, are associated with increased ED us e. 38 Evidence on access in MCOs relative to fee-for-service is limited and mixed. Federal law and regulations contain extensive state and MCO requirements to ensure access to care in Medicaid managed care, but the evidence on how access in Medicaid managed care and fee-for-service compares is mixed and s uggests that the details of states’ managed care programs matter. 39 Managed care has the potential to structure a provider network and coordinated delivery system for Medicaid beneficiaries who m ay face difficulty in the fee-for-service environment locating providers willing to serve them. But access can be jeopardized in managed care if provider networks are inadequate, beneficiary outreach, assistance, and appeals processes are lacking, or plans do not effectively connect enrollees with care. These issues are becoming more 22 00 22 00 important as states expand mandatory managed care to populations with complex health care needs, for whom disruptions in existing patient-provider relationships are also a major concern. How do provider shortages and participation affect access? A large majority of physicians serving children participate in Medicaid and CHIP, but only about half accept all new Medicaid and CHIP patients. A recent report of the General Accountability Office shows that 83% of primary care physicians (PCP) and 71% of specialists serving children participate in Medicaid and CHIP. However, among PCPs who participate, only 45 % accept all new Medicaid and CHIP patients (children), compared to 77% who accept all new privately insured children. Among participating specialty care physicians, about half accept all new children covered by Medicaid and CHIP, while almost 85% accept all new privately insured children. 40 Shortages and geographic inequalities in the distribution of health care providers and low Medicaid participation by some provider types result in gaps in access. Although access to primary care in Medicaid is quite robust, many states report challenges to ensuring enough providers, including dental and specialty providers, to serve Medicaid beneficiaries. 41 General sh ortages of physicians and other providers are worse in underserved areas, creating time, distance, and cost barriers to access for residents of these communities, and shortages are amplified in Medicaid by low provider participation. In provider surveys, low payment rates and administrative hassles cons istently emerge as the leading barriers to provider acceptance of Medicaid. 42 Transportation has also emerged as a key barrier to access. 43 The expansion of Medicaid and private coverage under the ACA will likely increase current pressures on access.

Actions to address workforce challenges and low provider participation in Medicaid will be important to improve access. Increased state outreach to providers, higher and quicker payment, and streamlined enrollment and billing processes for providers may help foster increased participation. States could also seek to increase the supply of providers willing to serve Medicaid patients by liberalizing scope- of-practice laws related to nurse practitioners and dental therapists. 44 But closing access gaps is also a matter of workforce planning and investment (e.g., training more primary care physicians, and developing a more diverse workforce) that states may have limited levers to influence. 45 A special commission known as MACPAC monitors access and payment in Medicaid and CHIP.

The Medicaid and CHIP Payment and Access Commission (MACPAC), established by CHIPRA, is charged with monitoring access in both Medicaid and CHIP, identifying gaps, and making recommendations to Congress concerning payment and access issues. MACPAC reports to Congress every March and June on issues of key interest in Medicaid and CHIP and also maintains important statistics on many aspects of the program that are fundamental to understanding the program and guiding policy.

How is quality monitored and promoted in Medicaid? States use an array of data and payment strategies to improve quality in Medicaid. Increasingly, states are using standardized data to measure and improve the quality of care provided by managed care plans and other providers in Medicaid. Most states require Medicaid MCOs to provide utilization and performance data using the Healthcare Effectiveness Data and 23 00 23 00 Information  Set (HEDIS),  and  most  MCOs  also  use  a  patient  satisfaction  survey  called  the   Consumer  Assessment  of  Healthcare  Providers  and  Systems  (CAHPS)  as  a quality  gauge.  In  recent  years,  more  states  have  begun  to  publicly  report  the  quality  data  they  collect  to  help  beneficiaries  choose  plans  and  to drive  performance  improvements.  A  growing  number  of  states   require  MCO  accreditation  by  a  re cogni zed accreditation  organization,  or  reward  it  through  preferential  contracting  and  other  approaches. 46 Also,  pay ‐for‐performance  (P4P)  systems  now   in  place  in  most  states  financially  reward  high  performance  by  MCOs  and/or  physicians,   hospitals,  nursing  homes,  and other  providers.

47 48    MCO  quality  is  subject  to  external  reviews  of quality.  Federal  law requires  all  states  with  MCOs   to  contract  with  an  External  Quality  Review  Organization  (EQRO) to  provide  an independent   assessment  of  the  quality  performance  of  Medicaid  plans.  EQRO  reviews  assess  access to,   timeliness  of,  and  outcomes  of  the  care  that  each  MCO  is  responsible  for providing.  EQROs  also   validate  “performance  improvement  pr ojects”  that  st ates  require  plans  to  conduct  in  a  wide   range  of priority  areas,  such  as  improving  birth  outcomes,  access  to  pediatric  specialists,  and   improving  outcomes for  chronic  conditions. 49     States  are  using  health  information  technology  (HIT)  to  improve  quality and  safety  in   Medicaid,  and  substantial  federal  investments  are  likely  to  foster  greater  HIT  activity.   Medicaid  programs  in  most  states  have  initiatives  for  electronic  prescribing  and  electronic   health  records  (EHR)  or  electronic  medical  records  (EMR)  to  promote  better  coordination  of   care.  Some  states  are  using  Medicaid  claims data  to  design  evidence ‐based re commendations   for  care;  some  are  facilitating  data ‐sharing  among  agencies  and  providers  that  care  for  children. 50 The  American  Recovery  and  Reinvestment  Act  of 2009  (ARRA)  provided  more than   $20  billion  in  Medicaid  funding  for incentive  payments  to  physicians,  hospitals,  and  other   providers  as  they  adopt,  implement,  upgrade,  or  demonstrate  “meaningful  use”  of  EHR   technology,  such  as  electronic  prescribing  and  exchange  of health  information  to  improve  quality.  ARRA  also  provided  90%  federal  matching  funds for  states  to  administer  the  EHR  incentives.

51    Numerous  HHS  efforts  are  focused  on  measuring,  reporting  on, and  improving  the  quality  of   care  received  by  children  in  Medicaid  and  CHIP.  In December  2012,  the  HHS  Secretary  released  state ‐specific  information  from  the  second  year of  reporting  on  the  initial  core  set  of  health   quality  measures  for  children  in  Medicaid  and CHIP. 52 The  pediatric  quality  measures  will  be  updated   annually  to ensure  that  the  measures  are  relevant  to  current  care  delivery  approaches,   reflect  new  clinical  guidelines,  and  respond  to  other  developments.  HHS  also  has  national  efforts   underway  to  improve  the quality  of  perinatal  care and  oral  health  care provided  to children  in   Medicaid  and  CHIP.      What  does  the  ACA  do  to  improve  access  to  care  in  Medicaid?    The  ACA  temporarily  boosts  Medicaid  payment  rates  to  Medicare  levels for  primary  care   physicians.  In 2012,  Medicaid  fees  for  primary  care  services  averaged  59%  of  Medicare  fees  for  the  same  services,  and the Medicaid ‐to‐Medicare  fee  ratio  for  services  overall  was 66%. 53 The   ACA  requires  states  to  pay  primary  care  physicians  at  least  Medicare  rates  for  many  primary   care  services  in  2013  and  2014,  in  both  fee ‐for‐service  and  managed  care.  The  magnitude  of  the   primary  care  fee  increase  for  the  affected  services  –  73%  on  average  –  is  unprecedented  in   Medicaid  (Figure  9).  Full  federal  funding  is  available  for the  difference  between  the  f ees  states   paid as of July 1, 2009 and Medicare rates in 2013 and 2014. The purpose of the fee increase is to improve support for physicians already serving Medicaid patients, and to promote wider Medicaid participation among primary care physicians in preparation for the Medicaid expansion . The fee increase also aligns Medicaid payment more closely with service delivery reforms that emphasize preventive and primary care. New models of patient-centered care are aimed at improving care, particularly for those with the most complex needs. The ACA contains a multitude of new Medicaid options, incentives, and initiatives designed to promote more patient-centered, coordinated, and integrated care that are expected to improve both access to care and the quality of care . Among these new Medicaid avenues are the new health home option for individuals with chronic illness and the demonstrations of integrated care and payment models for dual eligible beneficiaries. The ACA establishes a program of voluntary reporting of adult quality measures in Medicaid.

The Medicaid adult quality measures program required by the ACA is modeled closely on the program for children. In 2012, HHS published an initial core set of quality measures for Medicaid-eligible adults, covering areas such as prevention, care coordination, and chronic disease management. By September 30, 2014, HHS must collect, analyze, and make publicly available the information voluntarily reported by the states. Also on the quality front, CMS has issued guidance on a recommended core set of quality measures for assessing the Medicaid health home service delivery model introduced by the ACA. 2424 Figure 9 Average Medicaid Fee Increases for ACA Primary Care Services in 2013, by State NOTE: TN has no Medicaid FFS program.

SOURCE: 2012 KCMU/Urban Institute Medicaid Physician Fee Survey. WY WI WV WA VAVT UT TX TN SD SCPA OR OKOH ND NC NM NJ NV NE MT MOMS MN MI MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL NY US Overall = 73% NH MA RI Average fee increase for ACA services 1-24% (9 states) 50-99% (12 states) 100-200% (6 states) 25-49% (21 states including DC) 0% (2 states) 25 00 25 00 HOW MUCH DOES MEDICAID COST? In FY 2011 , Medicaid spending excluding administration totaled about $ 414 billion. Spending is distributed across a broad array of health and long-term care services. During the recent economic recession, t he main driver of Medicaid spending was enrollment growth; as the economy has begun to recover, enrollment growth has slowed somewhat, and spending changes are instead driven by changes in service mix and utilization. Roughly two-thirds of Medicaid spending is attributable to seniors and people with disabilities, and a relatively small share of Medicaid beneficiaries with very high costs account for more than half of total spending. Dual eligible beneficiaries account for nearly 40% of all Medicaid spending.

Medicaid spending per enrollee has been rising more slowly than medical care inflation, private insurance premiums, and national health spending per person. Medicaid spending will rise under the ACA as millions of additional people become eligible for the program and others who are already eligible enroll. What does Medicaid cost? In FY 2011, federal and state Medicaid spending excluding administration totaled about $414 billion , including payments for Medicare premiums and “DSH” payments (Figure 10). Two - thirds of Medicaid spending was attributable to acute care, including payments to managed care plans (24%). A little less than a third (30% ) of spending went toward long-term care. Medicaid administrative costs accounted for an additional 5% of total Medicaid spending (data not shown).

Medicaid makes special payments to hospitals that serve a disproportionate share of low- income and uninsured patients. In FY 2011, 4% of Medicaid spending was attributable to supplemental payments to hospitals that serve a disproportionate share of low-income and uninsured patients, known as “DSH” payments. 54 These payments help to support safety-net hospitals, including children’s hospitals, that provide substantial uncompensated care in Medicaid Expenditures by Service, FY 2011 NOTE: Includes DSH payments and payments to Medicare. Excludes administrative spending, adjustments and payments to the Territories.

SOURCE: Urban Institute estimates based on FY 2011 data from CMS-64, prepared for KCMU. Total = $413.9 billion Inpatient 14.6% Physician/ Lab/ X-ray 3.6% Outpatient/Clinic 6.8% Drugs 3.6% Other Acute 9.3% Payments to MCOs 24.1% Nursing Facilities 12.5% I C F/ MR 3.3% Mental Health 0.9% Home Health and Personal Care 13.5% Payments to Medicare 3.6% DSH Payments 4.2% AcuteCare65.6% Long-Term Care 30.2% Figure 10 26 00 26 00 addition to essential community services such as trauma and burn care and neonatal intensive care. 55 What drives Medicaid costs ? During the recent economic downturn, enrollment growth was the dominant driver of Medicaid costs. Several factors contribute to Medicaid costs and spending, including enrollment, health care cost inflation, demographic trends, and the use of services by Medicaid enrollees. During the Great Recession, enrollment growth was the chief driver of Medicaid spending, as more people became eligible for program due to rising unemployment and declining income. In state fiscal year 2012, Medicaid spending increased at one of the lowest annual rates on record – 2% on average across the states – as the economy started to improve and enrollment growth slowed. 56 Although children and their parents make up the majority of Medicaid enrollees, most Medicaid spending is attributable to the elderly and people with disabilities (Figure 11).

Children and non-elderly adults, including pregnant women, make up three-quarters of the Medicaid population but account for only about a third (34%) of Medicaid spending. The elderly and disabled make up one-quarter of the Medicaid population, but account for about two-thirds o f spending (65%) . Notably, growth in per-enrollee spending for the elderly and disabled has been slow in recent years . Medicaid spending per enrollee varies sharply by eligibility group . In 2009, per enrollee payments for children covered by Medicaid were about $2,3 00, compared to $2,9 00 per non- elderly adult, $ 15,840 per disabled enrollee, and $13,150 per elderly enrollee (Figure 12). Higher per enrollee expenditures for disabled and elderly beneficiaries reflect their more intensive use of both acute and long-term care services. Medicaid Enrollees and Expenditures, FY 2009 NOTE: Percentages may not add to 100 due to rounding.

SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.

MSIS FY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS- 64. Total = 62.7 million Total = $346.5 billion Children 49% Children 20% Adults 26% Adults 14% Elderly 10% Elderly 23% Disabled 15% Disabled 42% Enrollees Expenditures Figure 11 27 00 27 00 The 5% of Medicaid beneficiaries with the highest costs account for over half of all Medicaid spending. As is true for all payers, spending in Medicaid is highly skewed. That is, a very small group of high-cost enrollees accounts for a large share of total spending. In FY 2009, the 5% of beneficiaries with the highest health and long-term care costs accounted for 54% of all Medicaid spending (Figure 13 ).The disabled individuals among these high-cost beneficiaries alone accounted for 30% of total Medicaid expenditures. Medicaid Payments Per Enrollee by Acute and Long-Term Care, FY 2009 $2,240 $2,887 $9,565 $3,401 $6,275 $9,748 Children Adults Disabled Elderly Acute Care Long-Term Care SOURCE : KCMU and Urban Institute estimates based on FY 2009 MSIS and CMS- 64 data. MSIS FY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS- 64. $2,900 $2,305 $15,840 $13,149 $13 $65 Figure 12 Highest-Cost 5% of Enrollees Account for Over Half of Medicaid Spending, FY 2009 SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.

Spending does not include Medicaid payments to Medicare.

MSIS FFY 2008 data were used for PA, UT, and WI, but adjusted to 2009 CMS- 64. 95% 46% 5% 54% Enrollees Expenditures Total = 62.7 million Total = $346.5 billion Top 5% of Spenders Bottom 95% of Spenders Figure 13 28 00 28 00 Almost 40% of all Medicaid spending for medical services is attributable to dual eligible beneficiaries. In 2009, dual eligible beneficiaries – low-income individuals who are enrolled in both Medicare and Medicaid – made up 15% of the Medicaid population, but accounted for 38 % of Medicaid spending (Figure 14) . Two -thirds of Medicaid spending for dual eligible beneficiaries wa s for long-term care services. Until 2006, Medicaid covered prescription drugs for dual eligible beneficiaries because Medicare did not include a drug benefit. A Medicare drug benefit was added in 2006, but states help finance it by making required monthly “clawback” payments to the federal government that roughly reflect what they would spend if they still paid for prescription drugs for dual eligible beneficiaries. In FY 2012, estimated state clawback payments totaled $8.1 billion. 57 How effectively is Medicaid spending managed? When the health status and needs of its beneficiaries are taken into account, Medicaid is a low-cost program. Medicaid enrollees are in significantly worse health than the low-inco me, privately insured population. When health status differences are controlled, per capita spending for both adults and children is lower in Medicaid than under private insurance. Medicaid’s lower spending levels are due mostly to lower provider payment rates; differences in access to specialists and expensive technology for those in fair or poor health may also be a factor. 58 On a per enrollee basis, Medicai d spending has been growing more slowly than growth in underlying medical care inflation and private health insurance premiums. Over the period 2007-2010, Medicaid spending per enrollee grew an average of 2.5% percent per year. The comparable rate of growth in national health expenditures per capita was 3.3% and the rate for per enrollee private health insurance costs (i.e., premiums) was 5.5% (Figure 15 ). 59 Dual Eligible Beneficiaries as a Share of Medicaid Enrollment and Spending, FY 2009 SOURCE: KCMU/ Urban Institute analysis of data from MSIS and CMS-64, 2010. 85% 62% 15% 38% Total Enrollment 62.7 million Total Spending $358.5 billion Figure 14 Dual eligible beneficiaries Other Medicaid beneficiaries 29 00 29 00     Cost ‐containment  is  a  major  focus  in  state  administration  of the  Medicaid  program.  States   have  implemented  a  range  of  strategies  to  control  costs in Medicaid,  such  as  provider  rate  restrictions,  benefit  restrictions,  and utilization  controls. For example,  nearly  all  states  use   sophisticated  pharmacy  management  tools,  including  preferred  drug  lists  and  prior   authorization,  to  manage  drug  spending . States  have  also  impleme nted delivery  system  reforms  to  improve  care and  reduce  spending  growth,  including  managed  care,  patient ‐centered  medical   homes,  and health  homes,  and they  have made  important  strides  in  shifting  the  delivery  of  LTSS   from  institutions  into  the  community. 60    Program  integrity  measures  at  both  the  federal  and  state  level  help  to  ensure  proper  payment   and  improve  Medicaid’s  efficiency.  Ensuring program integrity  in Medicaid  is  the  responsibility   of  both  the  federal  government  and  the  states.  States  are  responsible  for the daily  management   of  Medicaid,  including  verifying  eligibility,  licensing  and  enrolling providers,  paying providers  and  detecting  and addressing  improper  payment,  conducting  audits,  mo nitoring  qua lity, and   investigating  and prosecuting  provider  fraud  and  abuse.  The  federal  government  monitors  and   enforces  state  compliance  with  federal  rules,  reviews  state  agency  performance,  audits and   investigates  suspected  fraud,  imposes  sanctions,  and provides  guidance  and  training   to the   states. 61     What  impact  will  the  ACA  have  on  Medicaid  costs?    If  all  states  expand  Medicaid,  total  national  Medicaid  spending during the  2013 ‐2022  period  will  increase  by 16%  (relative  to  what  would  have  happened  without  the  ACA).  If  all  states   implemented  the  Medicaid  expansion,  total  national  Medicaid  spending  during  the  ten‐year  period  2013 ‐2022  would  increase  by  an  estimated  $1 trillion,  or  16%,  relative  to  projected   Medicaid  spe nding  over  that  period  without  the  ACA. 62 The  federal  government  would  pay  93%   of  the  increase  in  Medicaid  costs  if  all  states  adopted  the  expansion;  specifically,  the  federal   government  would  pay  $952  billion  over  2013 ‐2022  and  states  would  pay  $76  billion.  While   Figure  15 Average  Annual  Growth  in  Medicaid  Spending  vs.   Health  Spending  Benchmarks,  FY  2007 ‐2010 2.5% 3.3% 5.5% Medicaid  services per  enrollee National  Health Expenditures per  capita Private health  insurance per  enrollee SOURCE:  Medicaid  estimates  from  Urban  Institute  analysis  of  data  from  MSIS,   CMS ‐64,  and  KCMU  and  Health  Management   Associates  data,  2011.  Private  health  insurance  and  GDP  data  from  CMS  Office  of  the  Actuary,  National  Health  Statistics  Group,  2011.   Medical  care  CPI  from  the  Bureau  of  Labor  Statistics,  Consumer  Price  Index  Detail  Report  Ta b l e s ,  2011. 30 00 30 00 total  Medicaid  spending  would  increase  by  16%,  federal  spending  would  increase  by  26%  and   state  spending  would  increase  by  3%,  though  the results  would  vary  by  state.          The federal  government  will  bear  the  lion’s  share  of  the  new  costs.  The  very  large  federal  share   of  the  increased  ten ‐year  Medicaid  spending  if  all  states  expanded  Medicaid is  explained  by  the   fact  that  most  additional  spending  would  be  attributable  to the  adults  in  the  Medicaid   expansion  group, for  whom  the  federal  match  is  between  90% and  100%  (depe nding on  the   year).  States  may  also  have  some  new costs  over the  decade  because  of  the  small  required  state  share  (up  to  10%)  for  the expansion  population  and  due  to slightly  higher participation  among   people  who are  eligible  for  Medicaid  under  pre‐ ACA  eligibility  rules.      Increased  state  costs  asso ciated  with  expanding  Medicaid  may be  offset,  in  part,  by  reduced   state  spending  for health  under  other  programs.  Expanded  Medicaid  coverage of  the  low‐ income  population  and  the  increased  federal  funds  to  states  may  lead  to  reductions  in  other   state  spending  for  health,  such as  spending  for  state  coverage  initiatives,  indi gent  care,  the   mental  heal th system,  and  other  programs.  These  sources  of  savings  are  not  reflected  in   estimates  of  the  costs  to  states  of  implementing  the  Medicaid  expansion.         31 00 31 00 HOW IS MEDICAID FINANCED? Medicaid is financed jointly by the federal government and the states. The federal government matches state Medicaid spending. The federal match rate varies across states based on a formula and ranges from a minimum of 50% to much higher levels in poorer states. Medicaid is a countercyclical program that expands during economic downturns, when states’ fiscal capacity is also most strained. Under the ACA, the federal match rate for the adults who are newly eligible for Medicaid due to the expansion will be 1 00% in the first three years and at least 90% thereafter. If all states implemented the Medicaid expansion, the federal government would finance 93% of the total increase in Medicaid spending over the 2013-2022 decade. State Medicaid dollars and federal matching funds have a multiplier effect in state economies, supporting jobs and economic activity, and yielding increased state revenues from taxes.

Who pays for Medicaid?

Medicaid is financed through a partnership between the federal government and the states. The federal government matches state Medicaid spending according to a formula in the federal Medicaid law. The federal match rate, known as the Federal Medical Assistance Percentage, or FMAP, varies based on state per capita income – the lower a st ate’s per capita income, the higher the state’s FMAP. The FMAP for services ranges from a federal floor of 50% to 73.4%, currently, in the poorest state, Mississippi (Figure 16). The FMAP for most Medicaid administrative costs is 50%, but an enhanced federal match rate of 90% is available for certain services and state activities. The federal government funds about 57% of Medicaid spending overall. Medicaid is the largest source of federal revenue flowing to states. At the same time that Medicaid is a major spending program, it is also the largest source of federal revenue to the states . Federal Medicaid dollars accounted for estimated 44% of all federal grants to states in state fiscal year 2011. 63 In FY 2012, Medicaid accounted for 7.1% of federal budget outlays. 64 Figure 16 WY WI WV W A V AVT UT TXTN SD SCRI P A OR OK OH ND NCNY NM NJ NH NV NE MT MOMS MN MI MA MD ME LA KY KS IA IN IL ID HI GA FL DC DE CT CO CA AR AZ AK AL 67 -74% ( 11 states including DC)60-66% ( 12 states)51-59% ( 14 states)50% (14 states) Federal Medical Assistance Percentages (FMAP) FY 2013 NOTE: Rates are rounded to nearest percent. These rates will be in effect October 1, 2012 through September 30, 2013.

SOURCE: Federal Register, Nov, 30, 2011 (Vol. 76, No. 230), pp. 74061-74063. 2011-11 -30/pdf/2011-30860.pdf 32 00 32 00 States commit substantial funds to Medicaid. In FY 2011, states overall spent 16.7% of their general funds on Medicaid. It was the second- largest item in most states’ general fund budgets, after elementary and secondary education, which accounted for 35.1% of state general fund spending that year. 65 Medicaid spending pressures are a perennial issue at the state level. This is because states have limited fiscal capacity to meet the many competing demands they face and must balance their budgets. State budget pressures intensify during economic downturns, when state revenues decline at the same time that Medicaid enrollment is growing . Medicaid is a major engine in state economies. Economic research shows that state Medicaid spending has a “multiplier effect” as the money injected into the state economy through the program percolates through it, generating successive rounds of earning and purchasing by businesses and residents. This economic activity supports jobs and yields additional income and state tax revenues. Compared with other state spending, Medicaid spending is especially beneficial because it also triggers an infusion of new federal dollars into the state economy, intensifying the multiplier effect. 66 How does Medicaid’s financing structure support the program? Medicaid’s financing structure gives states flexibility to respond to changing needs and supports state efforts to cover the uninsured. When states spend their dollars on Medicaid, they draw down federal matching funds. Thus, the matching system at least doubles the impact of state investment in Medicaid and increases states’ capacity to respond to changes in health care needs, demographics, health care prices, and the econom y, and to disasters and epidemics.

In contrast, federal block grant programs distribute a fixed sum of federal dollars to states based on projected need or a pre-set formula, with limited flexibility to respond to actual conditions.

The guarantee of federal matching payments in Medicaid provides an incentive to states to invest in health care and discourages them from reducing coverage and benefits. At the same time, states have a stake in managing Medicaid costs to constrain their own spending. The FMAP formula does not adequately address the countercyclical nature of the Medicaid program. Medicaid is a countercyclical program. That is, during economic downturns, when people lose their jobs and income declines, Medicaid enrollment expands, b ut state tax revenues also shrink, reducing state capacity to afford the increased enrollment. The FMAP formula, which uses lagged data and is based solely on per capita income, does not adequately increase federal assistance to states when economic conditions are weak. On two occasions, most recently in 2009 in ARRA, Congress has increased the FMAP temporarily to provide fiscal relief to state Medicaid programs during recessions. States used these federal funds to address shortfalls in Medicaid and across their budgets. The additional federal support under ARRA in the period of deepest recession proved a critical source of state revenue and resulted in the first decline in state Medicaid spending in the program’s history. 67 How does the ACA affect Medicaid financing?

The ACA provides almost full federal funding for the costs of adults newly eligible for Medicaid under the expansion. Under the ACA, the federal government will finance 100% of the costs states incur to cover the newly eligible adults in the first three years of reform (2014-2016) and at least 90% thereafter. If all states adopted the Medicaid expansion, the federal government 33 00 33 00 would  finance  93% of  the  total  increase  in  Medicaid  spending  attributable  to  the  ACA  over  the   ten‐year  period  2013 ‐2022,  and  states  would  finance  7%, but this distribution  would  vary  by   state  (Figure  17).            The  ACA  provides  an  enhanced   federal match  for  selected  services  and  purposes.  The ACA   provides  for  a temp orary  90%  federal  match  for  specific  services  provided  under  the  new  health   home  option  for  beneficiaries  with  multiple  chronic  conditions.  The  law  also provides  a  100%   federal  match  for the increase  in  Medicaid  primary  care fees  to  Medicare  fee  levels  in  2013  and  2014.  The  ACA  creates  and  extends  several  opportunities  for  enhanced  federal  matching  funds   to  states  to  im prove  support  for  home  and  community ‐based LTSS.  In  addition,  to  help  states   prepare  to  implement  the  streamlined  eligibility  systems  required  by  the  ACA,  HHS has  made  available  a temporary  90%  federal  administrative  matching  rate  for  the costs  of  upgrading  Medicaid  eligibility  an d enrollment  systems,  and  a 75 % rate  for maintenance  and operations  of   systems  built  using  these funds.        The  ACA  reduces  federal DSH  allotments.  Corresponding  to  expansions  in  coverage  under  the   ACA,  the law  also called  for a reduction  in  federal  Medicaid  DSH  allotments  to  states  by  $14.1   billion  over  the  period  20 14 ‐2019;  by  2 019,  the  reductions  will  represent  a  50%  cut  in DSH   payments  relative  to  the  pre ‐ACA  baseline.  The amount  by which  any  individual  state’s   allotment  is  reduced  will  be  determined  by  a  methodology  to be  developed  by  the  HHS  Secretary.  Under  the  methodology,  the  largest  percentage  reductio ns are  to  apply  to  states  with   the  lowest  percentages  of  uninsured  individuals  and  states  that  do  not  target  their  DSH   payments  to  hospitals  with  high  volumes  of  Medicaid  inpatients  or  high  levels  of   uncompensated  care.  The  ACA  did  not  anticipate  that  states  would  be  able  to  opt  out  of  the   Medi caid exp ansion,  leaving  larger numbers  of  uninsured.  Thus,  there  is  no  provision  in  the  law  to  adjust  a  state’s  DSH reduction  if  it  does  not  expand  Medicaid.  As  of  this  writing,  the  Secretary   had  not released  plans  regarding  distribution  of  the  DSH  reductions.     Medicaid  Spending  under  the  ACA,  2013‐ 2022 State  and  Federal  Share  of  Baseline  and  New  Spending NOTE:  Individual  components  may not  sum  to  totals  due  to  rounding.   SOURCE:  Urban Institute  estimates  prepared  for  KCMU,  October  2012.   To t a l Medicaid  Spending  under  ACA,  2013 ‐2022  =  $7,368   To t a l New   Medicaid   Spending  under   ACA  =  $1,029   93% Federal 7%  State   New State   Spending  under   ACA=  $76 New  Federal   Spending  under   ACA  =  $952 Baseline  Federal   Spending,  No  ACA $3,659 Baseline  State   Spending,  No  ACA   $2,680 Dollars  in  billions: Figure  17 34 00 34 00 LOOKING AHEAD When the ACA is fully implemented in a few short months, important changes in Medicaid will occur across the states. The changes will be most far-reaching in the states that adopt the Medicaid expansion and coordinate it with the new exchanges and other insurance affordability programs, as envisioned by the ACA, to create a seamless system of coverage that will reach nearly all Americans. But regardless of what individual states decide about implementing the expansion, significant changes in Medicaid – from simplified eligibility and streamlined enrollment to payment increases for primary care physicians, and from changes in benefits and delivery systems to changes in financing – will take place in all states, enhancing the program’s operations and increasing its potential impact. Now and going forward, Medicaid will remain integral to our health care system, continuing to ensure coverage and care for millions of people in our nation. These people include many low- income children and working families with fairly typical health care needs, but also many children and adults with chronic illnesses and disabilities and elderly and disabled Medicare beneficiaries with complex and high-cost needs. Medicaid is vital to the health and well-being of it s beneficiaries, connecting them with needed services and supports and protecting them against out- of-pocket burdens they cannot afford. As Medicaid becomes an even larger source of coverage, financing, and innovation, understanding the program will be essential for policymakers, providers, educators and students, the media, and the general public, many of whom the Medicaid program touches.

Further, how the changes in Medicaid play out in the coming years will influence how fully the ACA’s goals for coverage, individual and community health, and cost control are realized. Going forward, the important tasks of analyzing, monitoring, and improving Medicaid as it evolves will remain key public policy and public health priorities. 35 00 35 00 Endnotes 1 Holahan J and B Garrett Rising Unemployment, Medicaid, and the Uninsured . Kaiser Commission on Medicaid and the Uninsured. January 2009. #7850.

2 In Uncertain Times, Safety Net Hospitals Maintain Commitment to Serve: Results of the 2010 NAPH Hospital Characteristics Survey. National Association of Public Hospitals and Health Systems. May 2012. 3 2011 Uniform Data System (UDS), BPHC/HRSA/DHHS. 4 Medicaid ’s Role in Meeting the Long-Term Care Needs of America’s Seniors. Kaiser Commission on Medicaid and the Uninsured. January 2013. #8403. 5 Medicaid and Long-Term Care Services and Supports. Kaiser Commission on Medicaid and the Uninsured.

June 2012. #2186- 09.

6 Kaiser Health Tracking Poll. May 2011. #8190. 7 Enrolling Children in Medicaid and SCHIP: Insights from Focus Groups with Low-Income Parents. Kaiser Commission on Medicaid and the Uninsured. May 2007. #7640; Rising Health Pressures in an Economic Recession: A 360-Degree Look at Four Communities. Kaiser Commission on Medicaid and the Uninsured.

August 2009. #7949.

8Federal Core Requirements and State Options in Medicaid: Current Policies and Key Issues . Kaiser Commission on Medicaid and the Uninsured. April 2011. #8174.

9 Getting Into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost- Sharing Policies in Medicaid and CHIP, 2012-2013 , January 2013, Kaiser Commission on Medicaid and the Uninsured. #8401.

10 Deficit Reduction Act of 2005 (P.L. 109- 171) 11 An Update on the ACA & HIV: Medicaid Health Homes. Kaiser Commission on Medicaid and the Uninsured. 2012. #8393.

12 KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS. 13 Getting into Gear for 2014 op. cit. 14 Maternal and Child Health (MCH) Update: States Increase Eligibility for Children’s Health in 2007 , National Governors Association Center for Best Practices. 2008; and Salganikoff A et al. Medicaid’s Role for Women Across the Lifespan: Current Issues and the Impact of the Affordable Care Act . Kaiser Family Foundation. January 2012. #7213-03.

15 Getting into Gear for 2014 op. cit. 16 Medicare at a Glance. Kaiser Family Foundation. November 2012. #1066- 15. 17 Kaiser Family Foundation . 18 Sommers B et al. “ Reasons for the Wide Variation in Medicaid Participation Rates Among States Hold Lessons For Coverage Expansion in 2014 .” Health Affairs. May 2012.

19 Getting into Gear for 2014 op. cit. 20 Holahan J et al. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State - by -State Analysis. Kaiser Commission on Medicaid and the Uninsured. November 2012. #8384. 21 Recent estimates by the Congressional Budget Office (CBO) that reflect assumptions about state take- up of the Medicaid expansion indicate a smaller increase in Medicaid coverage (12 million by 2023) See Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision. Congressional Budget Office. July 2012. And Spending and Enrollment Detail for CBO’s February 2013 Baseline: Medicaid. 22 The Cost and Coverage Implications of the ACA Medicaid Expansion op. cit. 23 Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options. Kaiser Commission on Medicaid and the Uninsured. January 2012. #8239.

24 Premiums and Cost-Sharing in Medicaid. Kaiser Commission on Medicaid and the Uninsured, February 2013. #8416. 25 A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey . Kaiser Commission on Medicaid and the Uninsured. September 2011. #8220. 36 00 36 00 \ 26 Summer L. Examining Medicaid Managed Long-Term Services and Support Programs: Key Issues to Consider. Kaiser Commission on Medicaid and the Uninsured. October 2011. #8243 27 Perry M and G Kenney . Preventive Care for Children in Low-Income Families: How Well Do Medicaid and State Children’s Health Insurance Programs Do? Pediatrics 120(6). December 2007.

28 Marquis S and S Long. The Role of Public Insurance and the Public Delivery System in Improving Birth Outcomes for Low-Income Pregnant Women . Medical Care 40(11). November 2002.

29 T Selden and J Hudson. Access to Care and Utilization Among Children: Estimating the Effects of Public and Private Coverage . Medical Care 44(5 Suppl). May 2006.

30 Long S et al. How Well Does Medicaid Work in Improving Access to Care? Health Services Research 40(1), February 2005.

31 The Role of Medicaid for Adults with Chronic Illness . Kaiser Commission on Medicaid and the Uninsured.

November 2012. #8383.

32 Finkelstein A et al. The Oregon Health Insurance Experiment: Evidence from the First Year. NBER Working Paper No. 17190. Issued July 2011 . 33 2012 Annual Report on Quality of Care for Children in Medicaid and CHIP. DHHS. December 2012. 34 States Made Multiple Program Changes, and Beneficiaries Generally Reported Access Comparable to Private Insurance. General Accountability Office. November 2012.

35 Shen Y and S McFeeters. Out-of-Pocket Health Spending Between Low- and Higher-Income Populations:

Who is at Risk of Having High Expenses and High Burdens ?” Medical Care 44(3), March 2006.

36 Premiums and Cost-Sharing in Medicaid: A Review of Research Findings. Kaiser Commission on Medicaid and the Uninsured, February 2013. #8417.

37 Sommers A et al. Dispelling Myths About Emergency Department Use: Majority of Medicaid Visits are for Urgent or More Serious Symptoms. Research Brief No. 23. Health System Change. July 2012.

38 Cheung P et al. Changes in Barriers to Primary Care and Emergency Department Utilization. Archives of Internal Medicine 171(15). August 2011.

39 Sparer M. Medicaid Managed Care: Costs, Access and Quality of Care . Research Synthesis Report No.

23. Robert Wood Johnson Foundation. September 2012.

40 Medicaid and C HIP: Physicians’ Willingness to Serve Children . General Accountability Office. June 2011. 41 States Made Multiple Changes op. cit. 42 Zuckerman S et al. Trends in Medicaid Physician Fees 2003- 2008. Health Affairs Web Exclusive 28(3).

April 2009. 43 States Made Multiple Changes op. cit. 44 Improving Access to Adult Primary Care: Exploring the Potential Role of Nurse Practitioners and Physician Assistants . Kaiser Commission on Medicaid and the Uninsured. March 2011. #8167.

45 Physician Shortages to Worsen without Increases in Residency Training . Association of American Medical Colleges. Available at: esidency_tr.pdf 46 A Profile of Medicaid Managed Care Programs op. cit. 47 The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession. Kaiser Commission on Medicaid and the Uninsured. September 2009. #7985 48 A Profile of Medicaid Managed Care Programs op. cit. 49 Ibid. 50 E-Health Snapshot: A Look at Emerging Health Information Technology for Children in Medicaid and SCHIP Programs . Kaise r Commission on Medicaid and the Uninsured and The Children’s Partnership.

November 2008. #7837.

51 Federal Support for Health Information Technology in Medicaid: Key Provisions in the American Recovery and Reinvestment Act . Kaiser Commission on Medicaid an d the Uninsured and The Children’s Partnership. August 2009. #7955 52 2012 Annual Report on Quality of Care for Children in Medicaid and CHIP. DHHS. December 2012. 37 00 37 00 \ 53 Zuckerman S and D Goin. How Much Will Medicaid Physician Fees for Primary Care Rise in 2013?

Evidence from a 2012 Survey of Medicaid Physician Fees . Kaiser Commission on Medicaid and the Uninsured. December 2012. #8398. 54 Urban Institute estimates based on data from CMS-64, prepared for Kaiser Commission on Medicaid and the Uninsured.

55 Results of the 2010 NAPH Hospital Characteristics Survey . National Association of Public Hospitals and Health Systems. May 2012.

56 Medicaid Today; Preparing for Tomorrow A Look at State Medicaid Program Spending, Enrollment and Policy Trends . Kaiser Commission on Medicaid and the Uninsured. October 2012. #8380.

57 State Expenditure Report: Examining Fiscal Year 2010-2012 State Spending . National Association of State Budget Officers. December 2012. 58 Hadley J and J Holahan . Is Health Care Spending Higher under Medicaid or Private Insurance? Inquiry 40.

Winter 2003/2004.

59 Enrollment-Driven Expenditure Growth: Medicaid Spending during the Economic Downturn, FFY2007- 2010. Kaiser Commission on Medicaid and the Uninsured. May 2012.

60 Medicaid Today; Preparing for Tomorrow op.cit. 61 Program Integrity in Medicaid: A Primer . Kaiser Commission on Medicaid and the Uninsured. July 2012.


62 The Cost and Coverage Implications of the ACA Medicaid Expansion op. cit. 63 State Expenditure Report op. cit. 64 The Budget and Economic Outlook: Fiscal Years 2013 to 2023 . February 2013. Congressional Budget Office. 65 State Expenditure Report op.cit. 66 Medicaid: Good Medicine for State Economies. Families USA May 2004; The Role of Medicaid in State Economies: A Look at the Research . Kaiser Commission on Medicaid and the Uninsured. January 2009 .


67 State Fiscal Conditions and Medicaid Program Changes, FY 2012- 2013. Kaiser Commission on Medicaid and the Uninsured. November 2012. #7580. 39 00 39 00 TABLES Table 1: Medicaid Enrollment by Group, FY 2009 Table 2: Medicaid Income Eligibility as a Percent of Federal Poverty Level (FPL), 2013 Table 3: Medicaid Payments by Group, FY 2009 Table 4: Medicaid Payments Per Enrollee by Group, FY 2009 Table 5: Medicaid Expenditures by Type of Service, FY 2011 Table 6: Federal Medical Assistance Percentages (FMAP), FY 2009 - FY 2013 Table 7: Selected Measures of Health Needs among Adults 40 00 40 00 Table 1 Medicaid  Enrollment  by Group,  FY 2009 Total State Number Number % Number % Number % Number % United States 62,692,70 0 6,124,70 0 10% 9,290,20 0 15% 16,490,70 0 26% 30,786,10 0 49% Alabama 954,80 0 121,00 0 13% 206,50 0 22% 157,50 0 16% 469,80 0 49% Alaska 121,30 0 8,500 7% 15,400 13% 25,600 21% 71,700 59% Arizona 1,721,30 0 103,80 0 6% 150,10 0 9% 689,50 0 40% 777,90 0 45% Arkansas 698,80 0 69,600 10% 138,50 0 20% 113,90 0 16% 376,80 0 54% California 11,027,60 0 998,50 0 9% 1,015,40 0 9% 4,583,30 0 42% 4,429,50 0 40% Colorado 618,30 0 49,800 8% 81,000 13% 112,80 0 18% 374,80 0 61% Connecticut 586,70 0 69,000 12% 73,100 12% 141,40 0 24% 303,30 0 52% Delaware 207,20 0 14,300 7% 24,200 12% 82,000 40% 86,700 42% District  of Columbia 170,20 0 15,700 9% 37,000 22% 40,100 24% 77,500 46% Florida 3,420,90 0 445,50 0 13% 568,00 0 17% 671,60 0 20% 1,735,80 0 51% Georgia 1,818,70 0 170,50 0 9% 290,10 0 16% 295,10 0 16% 1,063,00 0 58% Hawaii 247,20 0 24,300 10% 26,400 11% 93,000 38% 103,50 0 42% Idaho 227,80 0 17,000 7% 39,100 17% 30,000 13% 141,80 0 62% Illinois 2,698,80 0 209,60 0 8% 318,90 0 12% 700,40 0 26% 1,470,00 0 54% Indiana 1,145,60 0 85,200 7% 158,90 0 14% 248,50 0 22% 652,90 0 57% Iowa 522,70 0 43,000 8% 77,500 15% 152,00 0 29% 250,30 0 48% Kansas 372,50 0 36,400 10% 72,900 20% 52,400 14% 210,80 0 57% Kentucky 885,00 0 95,700 11% 229,20 0 26% 138,80 0 16% 421,30 0 48% Louisiana 1,148,90 0 112,40 0 10% 212,60 0 19% 209,30 0 18% 614,70 0 54% Maine 358,00 0 60,800 17% 66,300 19% 100,10 0 28% 130,90 0 37% Maryland 862,40 0 73,200 8% 133,40 0 15% 221,90 0 26% 433,90 0 50% Massachusetts 1,619,50 0 170,00 0 10% 258,10 0 16% 685,60 0 42% 505,80 0 31% Michigan 2,018,60 0 137,90 0 7% 332,90 0 16% 438,00 0 22% 1,109,70 0 55% Minnesota 879,10 0 96,000 11% 126,80 0 14% 234,10 0 27% 422,20 0 48% Mississippi 754,30 0 88,700 12% 161,10 0 21% 121,10 0 16% 383,40 0 51% Missouri 1,065,30 0 94,300 9% 203,60 0 19% 184,90 0 17% 582,40 0 55% Montana 115,00 0 10,600 9% 20,900 18% 19,900 17% 63,600 55% Nebraska 253,50 0 23,900 9% 36,700 14% 39,700 16% 153,10 0 60% Nevada 290,40 0 25,800 9% 40,900 14% 55,600 19% 168,10 0 58% New  Hampshire 159,30 0 15,500 10% 27,600 17% 21,400 13% 94,800 60% New  Jersey 1,010,10 0 148,50 0 15% 169,80 0 17% 140,50 0 14% 551,30 0 55% New  Mexico 546,50 0 36,100 7% 62,400 11% 112,60 0 21% 335,50 0 61% New  York 5,208,10 0 591,90 0 11% 669,90 0 13% 1,945,60 0 37% 2,000,70 0 38% North Carolina 1,813,30 0 182,50 0 10% 309,10 0 17% 360,90 0 20% 960,80 0 53% North Dakota 75,300 9,200 12% 11,100 15% 15,600 21% 39,500 52% Ohio 2,180,60 0 176,50 0 8% 378,50 0 17% 519,10 0 24% 1,106,40 0 51% Oklahoma 799,90 0 66,300 8% 115,80 0 14% 155,40 0 19% 462,40 0 58% Oregon 564,50 0 55,700 10% 90,900 16% 129,90 0 23% 287,90 0 51% Pennsylvania 2,199,40 0 235,70 0 11% 538,50 0 24% 427,60 0 19% 997,60 0 45% Rhode  Island 204,80 0 28,100 14% 40,900 20% 42,100 21% 93,700 46% South  Carolina 892,60 0 83,300 9% 150,80 0 17% 192,00 0 22% 466,50 0 52% South  Dakota 128,10 0 12,500 10% 17,800 14% 20,900 16% 76,800 60% Tennessee 1,502,40 0 149,40 0 10% 307,90 0 20% 285,90 0 19% 759,10 0 51% Texas 4,488,20 0 439,60 0 10% 599,80 0 13% 585,30 0 13% 2,863,40 0 64% Utah 294,90 0 15,400 5% 37,300 13% 80,000 27% 162,10 0 55% Vermont 182,00 0 20,200 11% 23,300 13% 70,800 39% 67,700 37% Virginia 945,50 0 105,90 0 11% 167,00 0 18% 151,50 0 16% 521,20 0 55% Washington 1,159,30 0 87,800 8% 182,10 0 16% 226,10 0 19% 663,30 0 57% West  Virginia 416,90 0 41,700 10% 115,50 0 28% 60,600 15% 199,00 0 48% Wisconsin 1,028,30 0 146,30 0 14% 148,00 0 14% 296,70 0 29% 437,30 0 43% Wyoming 82,400 5,700 7% 10,700 13% 12,100 15% 53,900 65% Source: Kaiser  Commission on Medicaid  and the Uninsured  and Urban Institute  estimates based on  data from FY 2009 MSIS,  2012.

Because  2009 data were  unavailable,  2008 MSIS data were  used for PA, UT,  WI.

Notes:  Subtotals  may not sum to totals  due to rounding.     The pathway to eligibility  of nearly 1,000 enrollees in CA was unknown.  These enrollees are included  in national  totals.  Enrollment  (rounded to nearest  100) Aged Disabled AdultChildren 41 00 41 00 Table 2 Medicaid  Income Eligibility  as a Percent of Federal Poverty Level  (FPL), 2013 State Infants Children 1‐5 Children 6‐19 Pregnant  Women Working Parents Other Working Adults Alabama 133% 133% 100% 133%23%NA Alaska 150% 150% 150% 175%78%NA Arizona 140% 133% 100% 150%106%100% (closed) Arkansas 133% 133% 100% 162%16%NA California 200% 133% 100% 200%106%NA Colorado 133% 133% 133% 185%106%20% (closed) Connecticut 185% 185% 185% 250%191%70% Delaware 185% 133% 100% 200%120%110% District  of Columbia 185% 133% 100% 185%206%211% Florida 185% 133% 100% 185%56%NA Georgia 185% 133% 100% 200%48%NA Hawaii 185% 133% 100% 185%133%133% Idaho 133% 133% 100% 133%37%NA Illinois 133% 133% 100% 200%139%NA Indiana 200% 133% 100% 200%24%NA Iowa 133% 133% 100% 300%80%NA Kansas 150% 133% 100% 150%31%NA Kentucky 185% 133% 100% 185%57%NA Louisiana 133% 133% 100% 200%24%NA Maine 185% 133% 125% 200%200%NA Maryland 185% 133% 100% 250%122%NA Massachusetts 185% 133% 114% 200%133%NA Michigan 185% 150% 150% 185%64%NA Minnesota 275% 275% 275% 275%215%75% Mississippi 185% 133% 100% 185%29%NA Missouri 185% 133% 100% 185%35%NA Montana 133% 133% 100% 150%54%NA Nebraska 150% 133% 100% 185%58%NA Nevada 133% 133% 100% 133%84%NA New  Hampshire 185% 185% 185% 185%47%NA New  Jersey 185% 133% 100% 185%200% (closed  > 133%) NA New  Mexico 185% 185% 185% 235%85%NA New  York 200% 133% 100% 200%150%100% North Carolina 185% 133% 100% 185%47%NA North Dakota 133% 133% 100% 133%57%NA Ohio 150% 150% 150% 200%96%NA Oklahoma 133% 133% 100% 185%51%NA Oregon 133% 133% 100% 185%39%NA Pennsylvania 185% 133% 100% 185%58%NA Rhode  Island 185% 133% 100% 185%181%NA South  Carolina 150% 150% 150% 185%89%NA South  Dakota 133% 133% 100% 133%50%NA Tennessee 185% 133% 100% 185%122%NA Texas 185% 133% 100% 185%25%NA Utah 133% 133% 100% 133%42%NA Vermont 225% 225% 225% 200%191%160% Virginia 133% 133% 100% 133%30%NA Washington 200% 200% 200% 185%71%NA West  Virginia 150% 133% 100% 150%31%NA Wisconsin 300% 185% 100% 300%200%NA Wyoming 133% 133% 100% 133%50%NA Source:   Getting into  Gear for 2014:  Findings from a 50‐State Survey of Eligibility,  Enrollment, Renewal,  and Cost ‐Sharing Policies in  Medicaid  and CHIP,  2012‐2013. Based on  a national survey conducted  by the  Kaiser Commission  on Medicaid  and the Uninsured   with  the Georgetown  University Center  for Children and Families,  2013. Available  at:

Notes:  Income eligibility  levels for working adults  are based on  a family of three for parents and  based on an individual  for childless adults.

The 2013 federal poverty  levels are $19,530  for a family  of three and  $11,490 for an individual.     42 00 42 00 Table 3 Medicaid  Payments by  Group, FY 2009 Total State $$ % $ %$ % $ % United State s $346,490 $80,536 23% $147,160 42% $47,823 14% $70,969 20% Alabama $3,897 $1,000 26% $1,450 37% $321 8% $1,127 29% Alaska $1,065 $181 17% $398 37% $152 14% $335 31% Arizona $8,341 $979 12% $2,464 30% $2,999 36% $1,899 23% Arkansas $3,242 $875 27% $1,459 45% $141 4% $767 24% California $38,892 $10,512 27% $16,519 42% $4,919 13% $6,939 18% Colorado $3,375 $813 24% $1,441 43% $363 11% $757 22% Connecticu t $5,619 $1,708 30% $2,408 43% $545 10% $958 17% Delaware $1,232 $205 17% $422 34% $375 30% $229 19% District  of Columbia $1,556 $346 22% $856 55% $158 10% $196 13% Florida $14,258 $3,527 25% $6,182 43% $1,726 12% $2,824 20% Georgia $7,237 $1,395 19% $2,611 36% $1,305 18% $1,925 27% Hawaii $1,271 $315 25% $428 34% $326 26% $202 16% Idaho $1,289 $217 17% $663 51% $134 10% $275 21% Illinois $12,744 $2,118 17% $5,077 40% $2,211 17% $3,338 26% Indiana $5,768 $1,240 21% $2,494 43% $797 14% $1,238 21% Iowa $2,843 $611 21% $1,413 50% $321 11% $499 18% Kansas $2,366 $537 23% $1,166 49% $195 8% $468 20% Kentuck y $5,213 $934 18% $2,390 46% $645 12% $1,244 24% Louisiana $5,628 $960 17% $2,756 49% $653 12% $1,258 22% Maine $2,468 $562 23% $1,186 48% $213 9% $508 21% Maryland $6,340 $1,326 21% $2,880 45% $883 14% $1,251 20% Massachusett s $12,275 $3,110 25% $5,060 41% $2,033 17% $2,073 17% Michigan $10,022 $2,088 21% $4,209 42% $1,588 16% $2,138 21% Minnesota $7,214 $1,644 23% $3,348 46% $848 12% $1,374 19% Mississippi $3,689 $867 24% $1,562 42% $406 11% $853 23% Missouri $6,928 $1,318 19% $3,052 44% $650 9% $1,909 28% Montana $845 $242 29% $331 39% $87 10% $185 22% Nebraska $1,538 $367 24% $652 42% $108 7% $411 27% Nevada $1,245 $210 17% $543 44% $131 11% $361 29% New  Hampshire $1,111 $303 27% $463 42% $68 6% $277 25% New  Jerse y $8,352 $2,628 31% $3,724 45% $677 8% $1,322 16% New  Mexico $3,204 $190 6% $1,106 35% $587 18% $1,321 41% New  Yor k $46,665 $13,314 29% $20,017 43% $8,321 18% $5,013 11% North Carolina $11,058 $1,946 18% $4,961 45% $1,465 13% $2,686 24% North Dakota $573 $191 33% $245 43% $52 9% $85 15% Ohio $13,335 $3,335 25% $6,246 47% $1,721 13% $2,034 15% Oklahoma $3,878 $693 18% $1,616 42% $453 12% $1,116 29% Oregon $3,540 $927 26% $1,402 40% $582 16% $629 18% Pennsylvania $16,270 $5,012 31% $6,937 43% $1,579 10% $2,742 17% Rhode  Island $1,755 $427 24% $799 46% $192 11% $336 19% South  Carolina $4,625 $911 20% $2,010 43% $625 14% $1,078 23% South  Dakota $709 $149 21% $285 40% $84 12% $192 27% Tennessee $7,124 $1,118 16% $3,026 42% $1,176 17% $1,803 25% Texas $21,919 $3,872 18% $8,369 38% $1,793 8% $7,884 36% Utah $1,615 $186 12% $715 44% $256 16% $457 28% Vermont $971 $222 23% $375 39% $182 19% $192 20% Virginia $5,550 $1,114 20% $2,485 45% $576 10% $1,375 25% Washington $6,194 $1,275 21% $2,684 43% $869 14% $1,366 22% West  Virginia $2,441 $535 22% $1,228 50% $206 8% $472 19% Wisconsin $6,675 $1,868 28% $2,818 42% $1,076 16% $913 14% Wyoming $528 $112 21% $229 43% $50 10% $136 26% Source: Kaiser  Commission on Medicaid  and the Uninsured  and Urban Institute  estimates based on  data from FY 2009 MSI S and CMS ‐64 reports,  2012. Because  2009 data were  unavailable,  2008 MSIS data were  used for PA, UT,  and WI . Spending  for these states was then adjusted  to 2009 CMS‐64 spending levels Notes:  Subtotals  may not sum to totals  due to rounding.    The pathway to eligibility  of nearly 1,000 enrollees in California was unknown.  Their spending  is included  in state and  national total s Payments (in  millions) Aged Disabled AdultChildren 43 00 43 00 Table 4 Medicaid  Payments Per  Enrollee by Group, FY 2009 State Total Aged Disabled Adult Children United States $5,527 $13,149 $15,840 $2,900 $2,305 Alabama $4,081 $8,265 $7,020 $2,035 $2,398 Alaska $8,782 $21,286 $25,793 $5,916 $4,666 Arizona $4,846 $9,438 $16,415 $4,350 $2,441 Arkansas $4,639 $12,564 $10,534 $1,237 $2,036 California $3,527 $10,528 $16,269 $1,073 $1,567 Colorado $5,458 $16,332 $17,803 $3,215 $2,021 Connecticut $9,577 $24,761 $32,954 $3,854 $3,158 Delaware $5,944 $14,330 $17,412 $4,578 $2,645 District  of Columbia $9,143 $22,094 $23,140 $3,946 $2,531 Florida $4,168 $7,917 $10,883 $2,569 $1,627 Georgia $3,979 $8,183 $8,999 $4,424 $1,811 Hawaii $5,140 $12,961 $16,180 $3,508 $1,953 Idaho $5,658 $12,802 $16,942 $4,486 $1,938 Illinois $4,722 $10,105 $15,921 $3,157 $2,271 Indiana $5,035 $14,552 $15,689 $3,206 $1,896 Iowa $5,438 $14,207 $18,236 $2,109 $1,993 Kansas $6,352 $14,761 $15,999 $3,724 $2,218 Kentuck y $5,890 $9,759 $10,430 $4,649 $2,952 Louisiana$4,899 $8,548 $12,963 $3,122 $2,047 Maine $6,895 $9,242 $17,899 $2,126 $3,879 Maryland $7,352 $18,106 $21,590 $3,981 $2,883 Massachusetts $7,579 $18,288 $19,602 $2,965 $4,098 Michigan $4,965 $15,139 $12,642 $3,625 $1,926 Minnesota $8,206 $17,119 $26,402 $3,624 $3,254 Mississippi $4,890 $9,775 $9,697 $3,352 $2,225 Missouri $6,504 $13,971 $14,986 $3,513 $3,278 Montana $7,348 $22,824 $15,846 $4,382 $2,910 Nebraska $6,069 $15,344 $17,745 $2,728 $2,687 Nevada $4,286 $8,117 $13,265 $2,359 $2,149 New  Hampshire $6,978 $19,616 $16,793 $3,185 $2,918 New  Jersey $8,268 $17,705 $21,936 $4,817 $2,399 New  Mexico $5,862 $5,247 $17,744 $5,215 $3,936 New  York $8,960 $22,494 $29,881 $4,277 $2,505 North Carolina $6,098 $10,664 $16,050 $4,059 $2,796 North Dakota $7,608 $20,763 $22,135 $3,351 $2,153 Ohio $6,116 $18,900 $16,501 $3,315 $1,838 Oklahoma $4,848 $10,464 $13,952 $2,913 $2,414 Oregon $6,272 $16,646 $15,415 $4,482 $2,185 Pennsylvania $7,397 $21,268 $12,883 $3,692 $2,748 Rhode  Island $8,566 $15,211 $19,525 $4,569 $3,584 South  Carolina $5,181 $10,936 $13,331 $3,254 $2,312 South  Dakota $5,536 $11,874 $16,001 $4,011 $2,492 Tennessee $4,742 $7,484 $9,826 $4,115 $2,376 Texas $4,884 $8,808 $13,953 $3,063 $2,753 Utah $5,475 $12,088 $19,154 $3,199 $2,821 Vermont $5,331 $11,018 $16,079 $2,564 $2,835 Virginia $5,870 $10,522 $14,879 $3,801 $2,639 Washington $5,343 $14,519 $14,738 $3,846 $2,059 West  Virginia $5,855 $12,820 $10,635 $3,397 $2,371 Wisconsin $6,491 $12,766 $19,050 $3,625 $2,089 Wyoming $6,405 $19,518 $21,496 $4,164 $2,527 Source: Kaiser  Commission on Medicaid  and the Uninsured  and Urban Institute  estimates  based on  data from FY  2009 MSIS and CMS ‐64 reports,  2012.

Because  2009 data were  unavailable,  2008 MSIS data were  used for  PA, UT,  and  WI.

Spending  for these states was then adjusted  to 2009 CMS‐64 spending levels.

Payments per  Enrollee 44 00 44 00 Table 5 Medicaid  Expenditures  by Type of Service,  FY 2011 Total State $$% $% $% United States $413,85 6 $271,57 0 65.6% $124,98 4 30.2% $17,302 4.2% Alabama $4,755 $2,840 59.7% $1,465 30.8% $449 9.4% Alaska $1,305 $827 63.4% $463 35.5% $15 1.2% Arizona $8,990 $6,822 75.9% $2,002 22.3% $166 1.8% Arkansas $4,006 $2,568 64.1% $1,376 34.4% $62 1.5% California $54,907 $39,615 72.1% $13,017 23.7% $2,275 4.1% Colorado $4,381 $2,778 63.4% $1,418 32.4% $185 4.2% Connecticut $6,116 $3,055 50.0% $2,859 46.7% $201 3.3% Delaware $1,406 $1,068 76.0% $332 23.6% $6 0.4% District  of Columbia $2,141 $1,358 63.4% $710 33.1% $73 3.4% Florida $18,28 6 $13,057 71.4% $4,870 26.6% $360 2.0% Georgia $8,111 $5,673 69.9% $2,028 25.0% $410 5.1% Hawaii $1,620 $1,488 91.9% $112 6.9% $20 1.2% Idaho $1,535 $1,042 67.9% $468 30.5% $25 1.6% Illinois $12,997 $8,759 67.4% $3,828 29.5% $410 3.2% Indiana $6,606 $3,942 59.7% $2,337 35.4% $327 4.9% Iowa $3,38 4 $1,852 54.7% $1,450 42.9% $82 2.4% Kansas $2,693 $1,463 54.3% $1,160 43.1% $70 2.6% Kentucky $5,720 $3,892 68.0% $1,625 28.4% $203 3.5% Louisiana $6,66 4 $3,980 59.7% $2,083 31.3% $600 9.0% Maine $2,377 $1,653 69.5% $673 28.3% $52 2.2% Maryland $7,468 $5,259 70.4% $2,120 28.4% $88 1.2% Massachusetts $13,233 $9,582 72.4% $3,651 27.6% $0 0.0% Michigan $12,14 6 $9,092 74.9% $2,666 22.0% $388 3.2% Minnesota $8,423 $5,220 62.0% $3,11 4 37.0% $89 1.1% Mississippi $4,457 $2,948 66.1% $1,306 29.3% $204 4.6% Missouri $8,091 $5,135 63.5% $2,257 27.9% $700 8.6% Montana $961$572 59.6% $372 38.7% $17 1.8% Nebraska $1,680 $973 57.9% $669 39.8% $39 2.3% Nevada $1,575 $1,089 69.1% $398 25.3% $88 5.6% New  Hampshire $1,365 $620 45.4% $596 43.7% $149 10.9% New  Jersey $10,579 $5,382 50.9% $3,928 37.1% $1,270 12.0% New  Mexico $3,395 $3,017 88.9% $349 10.3% $29 0.9% New  York $53,882 $28,201 52.3% $22,523 41.8% $3,158 5.9% North Carolina $10,547 $7,10 4 67.4% $3,035 28.8% $409 3.9% North Dakota $708$267 37.6% $440 62.1% $2 0.3% Ohio $15,709 $8,968 57.1% $6,079 38.7% $663 4.2% Oklahoma $4,269 $3,03 4 71.1% $1,192 27.9% $44 1.0% Oregon $4,433 $3,003 67.7% $1,377 31.1% $53 1.2% Pennsylvania $20,533 $12,37 6 60.3% $7,288 35.5% $869 4.2% Rhode  Island $2,112 $1,662 78.7% $327 15.5% $123 5.8% South  Carolina $5,128 $3,40 4 66.4% $1,19 4 23.3% $531 10.3% South  Dakota $759$491 64.7% $267 35.2% $1 0.1% Tennessee $8,026 $6,918 86.2% $969 12.1% $139 1.7% Texas $28,565 $20,605 72.1% $6,381 22.3% $1,579 5.5% Utah $1,766 $1,31 4 74.4% $428 24.2% $24 1.4% Vermont $1,333 $1,178 88.3% $118 8.9% $37 2.8% Virginia $7,009 $4,478 63.9% $2,336 33.3% $195 2.8% Washington $7,447 $4,817 64.7% $2,281 30.6% $349 4.7% West  Virginia $2,758 $1,57 4 57.1% $1,110 40.3% $73 2.7% Wisconsin $6,961 $5,272 75.7% $1,689 24.3% $0 0.0% Wyoming $534$284 53.2% $249 46.7% $1 0.1% Source: Kaiser  Commission on Medicaid  and the Uninsured  and Urban Institute  estimates based on  data from CMS (Form 64).

Notes:  Does not  include administrative  costs, accounting  adjustments, or the U.S.  Territories.   Figures may not  sum to totals due to rounding.    *Acute  care services  includes  inpatient,  physician,  lab, X‐ray, outpatient,  clinic,  prescripton  drugs, family planning,   dental, vision,  other practitioners' care,  payments to managed care organizations,  and payments to Medicare.

**Long ‐term care services  include nursing  facilities,  intermediate care  facilities for the mentally retarded,  mental health, home health  services, and personal  care support  services.

"DSH  Payments"  refers to disproportionate  share hospital payments.   Acute  Care* Long‐Term Care** DSH Payments Expenditures  (in millions) 45 00 45 00 Table 6 Federal  Medical Assistance  Percentages, FY 2009‐2013 State FY 2009 FY 2010 FY 2011* FY 2012 FY 2013 Federal Funds  Sent to State  for Each Dollar  of State  Medicaid  Spending,  FY 2013   Alabama 77.5%77.5%68.5%68.6%68.5% $2.18 Alaska 61.1%62.5%50.0%50.0%50.0% $1.00 Arizona 75.9%75.9%65.9%67.3%65.7% $1.91 Arkansas 80.5%81.2%71.4%70.7%70.2% $2.35 California 61.6%61.6%50.0%50.0%50.0% $1.00 Colorado 61.6%61.6%50.0%50.0%50.0% $1.00 Connecticut 61.6%61.6%50.0%50.0%50.0% $1.00 Delaware 61.6%61.8%53.2%54.2%55.7% $1.26 District  of Columbia 79.3% 79.3%70.0%70.0%70.0% $2.33 Florida 67.6%67.6%55.5%56.0%58.1% $1.39 Georgia 74.4%75.0%65.3%66.2%65.6% $1.90 Hawaii 67.4%67.4%51.8%50.5%51.9% $1.08 Idaho 79.2%79.2%68.9%70.2%71.0% $2.45 Illinois 61.9%61.9%50.2%50.0%50.0% $1.00 Indiana 74.2%75.7%66.5%67.0%67.2% $2.05 Iowa 70.7%72.6%62.6%60.7%59.6% $1.47 Kansas 69.4%69.7%59.1%56.9%56.5% $1.30 Kentucky 79.4%80.1%71.5%71.2%70.6% $2.40 Louisiana 80.8%81.5%63.6%61.1%61.2% $1.58 Maine 74.4%74.9%63.8%63.3%62.6% $1.67 Maryland 61.6%61.6%50.0%50.0%50.0% $1.00 Massachusetts 61.6%61.6%50.0%50.0%50.0% $1.00 Michigan 70.7%73.3%65.8%66.1%66.4% $1.98 Minnesota 61.6%61.6%50.0%50.0%50.0% $1.00 Mississippi 84.2%84.9%74.7%74.2%73.4% $2.76 Missouri 73.3%74.4%63.3%63.5%61.4% $1.59 Montana 77.1%78.0%66.8%66.1%66.0% $1.9 4 Nebraska 67.8%68.8%58.4%56.6%55.8% $1.26 Nevada 63.9%63.9%51.6%56.2%59.7% $1.48 New  Hampshire 60.2%61.6%50.0%50.0%50.0% $1.00 New  Jersey 61.6%61.6%50.0%50.0%50.0% $1.00 New  Mexico 79.4%80.5%69.8%69.4%69.1% $2.23 New  York 61.6%61.6%50.0%50.0%50.0% $1.00 North Carolina 74.5%75.0%64.7%65.3%65.5% $1.90 North Dakota 70.0%70.0%60.4%55.4%52.3% $1.10 Ohio 72.3%73.5%63.7%64.2%63.6% $1.75 Oklahoma 75.8%76.7%64.9%63.9%64.0% $1.78 Oregon 72.6%72.9%62.9%62.9%62.4% $1.66 Pennsylvania 65.6%65.9%55.6%55.1%54.3% $1.19 Rhode  Island 63.9%63.9%53.0%52.1%51.3% $1.05 South  Carolina 79.4%79.6%70.0%70.2%70.4% $2.38 South  Dakota 70.6%70.8%61.3%59.1%56.2% $1.28 Tennessee 74.2%75.4%65.9%66.4%66.1% $1.95 Texas 69.9%70.9%60.6%58.2%59.3% $1.46 Utah 80.0%80.8%71.1%71.0%69.6% $2.29 Vermont 70.0%70.0%58.7%57.6%56.0% $1.27 Virginia 61.6%61.6%50.0%50.0%50.0% $1.00 Washington 62.9%62.9%50.0%50.0%50.0% $1.00 West  Virginia 83.1%83.1%73.2%72.6%72.0% $2.58 Wisconsin 69.9%70.6%60.2%60.5%59.7% $1.48 Wyoming 58.8%61.6%50.0%50.0%50.0% $1.00 Source: Kaiser  Commission on Medicaid  and the Uninsured  calculations based on FY 2009 ‐2013 FMAPs published  in the Federal Register  as follows:

FY  2009  FMAP Vol.  74, No. 75, pp.  64697‐64699;  FY 2010  FMAP Vol. 75,  No. 209, pp. 66763‐66765;  FY 2011  FMAP Vol.  76, No. 107, pp.  32204‐32207 ; FY 2012  FMAP Vol.  75, No. 217, pp.  69082‐69084;  FY 2013  FMAP Vol.  76, No. 230, pp.  74061‐74063.

Note:  FY 2009  and FY 2010  FMAPs reflect  additional federal Medicaid  funding available  though the American  Recovery and Reinvestment Act  (ARRA) of 2009.   *FY  2011  FMAPs took effect on  July 1, 2011, when enhanced funding  under ARRA expired. 46 00 46 00 Table 7 Selected  Measures of Health Needs  Among Adults State #% United States 20,191,70042%10.4% 6.2%35.8% 19.1% Alabama 331,90041%15.5%11.1% 37.6% 33.7% Alaska 49,40044%12.0% 6.3%34.0% 23.6% Arizona 460,30040%10.3% 8.1%37.6% 28.9% Arkansas 232,90047%17.0% 9.2%40.1% 18.9% California 3,201,00046%8.4%8.9%39.1% 15.8% Colorado 283,00044%8.2%6.0%36.2% 18.6% Connecticut 117,10030%8.6%6.4%36.2% 12.2% Delaware 35,90029%11.2% 7.7%31.4% 21.4% District  of Columbia 28,50025%10.0% 8.0%38.9% 43.0% Florida 1,601,10053%9.9%8.7%37.0% 22.5% Georgia 842,80049%10.5% 9.8%34.4% 15.5% Hawaii 50,40023%7.7%7.8%29.4% 3.7% Idaho 116,10050%11.2% 7.7%38.3% 27.2% Illinois 845,60044%8.2%8.2%40.9% 28.5% Indiana 330,80035%11.3% 9.1%38.0% 15.2% Iowa 131,70036%9.4%6.9%30.6% 18.6% Kansas 148,90041%10.6% 8.0%31.6% 20.5% Kentucky 305,30041%16.4%10.1% 36.8% 17.9% Louisiana 419,70050%13.0%10.3% 34.9% 57.8% Maine 42,90025%14.4% 7.4%38.0% 5.1% Maryland 259,00037%8.4%8.9%32.7% 13.7% Massachusetts 101,60012%9.2%7.2%35.2% 12.4% Michigan 576,60038%11.9% 9.2%37.3% 18.2% Minnesota 166,50031%8.4%6.2%32.5% 7.7% Mississippi 246,90046%15.1%11.3% 33.7% 54.3% Missouri 353,20040%12.6% 8.0%33.8% 30.0% Montana 72,50050%11.8% 6.2%34.2% 28.8% Nebraska 78,60038%9.2%7.1%33.0% 4.6% Nevada 242,00053%9.0%8.1%35.0% 20.3% New  Hampshire 44,70037%9.2%7.0%37.1% 3.2% New  Jersey 500,00044%7.8%8.3%32.1% 0.7% New  Mexico 181,30046%12.3% 8.1%34.1% 40.5% New  York 1,019,70031%9.1%8.4%37.7% 22.7% North Carolina 671,00047%11.7% 9.3%32.8% 10.1% North Dakota 27,50039%9.2%6.9%32.9% 28.1% Ohio 655,60038%12.0% 9.4%35.2% 10.6% Oklahoma 253,30047%15.2%10.1% 36.4% 22.2% Oregon 238,50041%11.2% 7.2%36.2% 19.8% Pennsylvania 547,70032%11.0% 8.7%37.1% 6.7% Rhode  Island 54,60036%10.2% 6.8%37.9% 14.7% South  Carolina 383,90047%12.2% 9.9%33.8% 25.7% South  Dakota 44,70042%9.7%6.4%28.9% 25.9% Tennessee 400,30039%13.9%10.2% 30.1% 14.5% Texas 2,531,60058%10.3% 9.8%35.4% 22.2% Utah 125,00038%8.3%7.1%38.1% 15.1% Vermont 16,80022%11.4% 5.8%37.7% 3.5% Virginia 412,50043%9.3%8.1%31.4% 15.9% Washington 386,00041%10.7% 7.4%36.6% 18.2% West  Virginia 117,20036%18.4%10.7% 34.0% 11.6% Wisconsin 225,90033%8.9%7.1% 33.6% 15.8% Wyoming 30,70047%11.1% 6.6%35.4% 34.5% % Adults  with Uninsured  Adults  <139%  FPL 1 Sources:  1. Urban Institute  and Kaiser  Commission  on Medicaid  and the Uninsured  estimates based on  the Census  Bureau's March 2011  and 2012 Current  Population  Survey (CPS: Annual  Social and Economic  Supplements).  2. Erickson, W.,  Lee, C., von Schrader, S.  (2010, March 17). Disability  Statistics from the 2008   American  Community  Survey (ACS). Ithaca, NY:  Cornell University Rehabilitation  Research and Training  Center on Disability  Demographics  and Statistics   (StatsRRTC).  Retrieved Jan 30, 2012  from   3.  Centers  for Disease Control  and Prevention:  National Diabetes Surveillance  System. Available online at:   Retrieved  2/3/2012. U.S.  totals available  at  4.  Kaiser  Family  Foundation  analysis of the  Centers  for Disease Control  and Prevention’s  Behavioral Risk Factor Surveillance  System Survey  Data (BRFSS), 2011. Information  about the BRFSS  is available  at  5. Designated Health Professional Shortage Areas (HPSA) Statistics,  Health Resources and  Services Administration  (HRSA),  February 2012. Report available  here. Percentages calculated using 2010 population  data from U.S.  Census Bureau; available  at Disabilities 2 Diabetes 3 Poor Mental  Health 4 % of Population   Living  in Primary  Care  HPSAs 5 47 00 47 00 Selected Additional Medicaid Resources from the Kaiser Family Foundation Available at Faces of Medicaid Health Coverage of Children: The Role of Medicaid and CHIP Medicaid’s Role for Dual-Eligible Beneficiaries Medicaid and Long-Term Care Services and Supports People with Disabilities and Medicaid Managed Care: Key Issues to Consider A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey Medicaid Today; Preparing for Tomorrow - A Look at State Medicaid Program Spending, Enrollment and Policy Trends Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2012 and 2013 Getting Into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013 State Fiscal Conditions and Medicaid Program Changes, FY 2012-2013 Medicaid and Children’s Health Insurance Program Provisions in the New Health Reform Law Implementing the ACA’s Medicaid -Related Health Reform Provisions After the Supreme Court’s Decision The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State- by-State Analysis Faces of the Medicaid Expansion: Experiences and Profiles of Uninsured Adults Who Could Gain Coverage The Henry J. Kaiser Family F oundation Headquarters 2 400 San d Hill Road M enlo Park , CA 94025 Phone 650- 854-9400 Fax 650- 854-4800 Washington Offices and B arbara Jor dan Confer ence Center 1 330 G Str eet, NW Wa shington , DC 20005 Phone 202-347-52 70 Fax 202-347-5274 This re port (#7334-05) is available on the Ka iser Fami ly Foundation ʼs web site at www The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a non-profit private operating foundation, based in Menlo Park, California.