June 2017 | Issue Brief Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? Robin Rudowitz, Allison Valentine, Petry Ubri and Julia Zur Executive Summary In 2017, Congress has been debating legislation, the American Health Care Act (AHCA), which would end the enhanced federal matching funds for the Affordable Care Act (ACA) Medicaid expansion and fundamentally alter the structure and financing of the Medicaid program. Specifically, it would cap and significantly reduce the amount of federal funding provided to states for Medicaid through a per capita cap or block grant. The Congressional Budget Office estimated that the AHCA as passed by the House would reduce federal Medicaid spending by $834 billion from 2017-2026 and reduce enrollment by 14 million by 2026 compared to projections in current law. The proposed Trump Administration budget for FY 2018 would have deeper Medicaid reductions. The cap on federal funding would lock-in current state spending patterns that reflect historic Medicaid policy choices. Today, Medicaid is a state and federal partnership where the federal government sets core requirements for Medicaid and states administer the program; financing for Medicaid is shared by states and the federal government with no caps. Due to flexibility in the current law, states historically have made different Medicaid decisions related to coverage, scope of benefits, reimbursement rates and delivery system models. In response to a funding cap, each state would need to make budget decisions to fill in gaps in federal funding (through taxes or other budget cuts) or to restrict Medicaid programs. All states could face challenges responding to Figure ES-1 federal Medicaid cuts and caps to varying All states would face challenges in responding to federal Medicaid cuts and caps, but 6 in 10 rank in the top 5 for multiple risk factors. degrees, but states with certain characteristics are more at risk. This analysis Factors that Affect Variation in Medicaid Spending and States’ Ability to Respond to Federal Medicaid Cuts & Caps examines 30 factors in five groups that could be high risk factors affecting states’ ability to respond to Medicaid Policy Revenue and Health Care Choices: Demographics: Health Status: Budget Choices: Costs/ Access: federal Medicaid cuts and caps and identifies states ACA Expansion Poverty Rate Overall Health Personal Income High NHE Ranking Total Taxable Spending Eligibility Unemployment ranked in the top five for each factor as high risk (ES- Benefits Age Disability Resources ESI Premiums Mental Health Tax Collections Access to a Doctor 1). This analysis shows that more than 6 in 10 Reimbursement Rates Urban / Rural Status Medicaid Match % in a Health Race Opioid Death Rate Rate Shortage Area states rank in the top five for multiple risk Delivery Systems Rate of New HIV State and Local Medicaid Cases Spending Per Physician factors. Eleven states rank in the top five for five or Capita Participation more risk factors (Alabama, Arizona, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, South Carolina, Texas, and West Virginia). States that adopted the Medicaid expansion have experienced gains in coverage and financing that are at risk under proposals like the AHCA that would end the enhanced federal match for the expansion. However, states that have not adopted the expansion would lose the option to access enhanced federal matching dollars for coverage in the future.  Arkansas, Kentucky, Nevada and Oregon are among states that rank in the top five for multiple risk factors tied to the end of enhanced funding for expansion (i.e. large coverage gains, a high share of expansion enrollees, and a high share of expansion funding relative to the total). In total numbers, California, New York, Pennsylvania, Ohio and Illinois account for the largest number of enrollees in the expansion group (54%) and California, New York, Ohio, Michigan and Illinois account for the highest levels of federal expansion funding (52%).  Non-expansion states would lose the future option to provide coverage to poor uninsured adults with enhanced federal dollars. Florida, Georgia and Texas have the largest number of uninsured residents who fall into the coverage gap (i.e. not eligible for Medicaid but have incomes below poverty so are not eligible for tax credits in the Marketplace) and the highest overall uninsured rates. States with limited Medicaid programs and other challenging characteristics such as poor demographic indicators, poor health status, high cost health care markets and low state fiscal capacity could face more challenges in responding to per capita cap or block grant policies. States with limited Medicaid benefits or low provider reimbursement rates have less room to make further restrictions in benefits or to lower rates in response to reductions in federal financing. For these states, trade- offs within Medicaid would be difficult. States with an aging population, high levels of disability, a high share of people in health professional shortage areas or low per capita income may have higher demand for Medicaid services, but less capacity (especially with limited federal financing) to address those issues. In addition, because financing caps lock states into historic Medicaid decisions, states with limited programs and other risk factors will have a harder time adapting to future changes such as increased costs or changing demographics. One example of an emerging health issue is the opioid epidemic. Medicaid plays a central role in the nation’s effort to address the opioid epidemic through coverage of people struggling with opioid addiction and financing for states, limited funding could impede efforts to address this as well as other future health issues. The findings below show states that rank in the top five for multiple risk factors within each of the five categories (beyond expansion):  Medicaid Policy Choices: Alabama, Hawaii, Mississippi and Missouri have more than one restrictive Medicaid policies that would make it more challenging for them to implement additional program reductions (i.e. low eligibility levels, limited benefits, low provider reimbursement, high managed care penetration and/or a lower share of community based long-term care services).  Demographics: Alaska, District of Columbia, Louisiana, New Mexico and Wyoming each have multiple demographic characteristics that indicate higher needs for Medicaid (i.e. high poverty, high unemployment, faster expected growth in the 85 year old population, high share of the population in rural areas, and / or high share of the population that is non-white). Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 2  Health Status: Alabama, Arkansas, Louisiana, Mississippi and West Virginia have populations with multiple high health needs (i.e. overall poor health status, high share reporting a disability, high share reporting poor mental health, high opioid death rate and/or high rate of new HIV cases). Ohio, New Hampshire and West Virginia reported the highest opioid related drug overdoses at over 24 people in every 100,000.  Revenue and Budget Choices: Alabama, Arizona, Idaho, Mississippi, New Mexico, South Carolina, Tennessee and West Virginia have multiple tax capacity challenges (i.e. low personal income, low total taxable resources, low tax effort or share of taxes relative to personal income, high Medicaid match rates, and/or low state and local spending per capita).  Health Care Costs/Access: Alaska, Alabama, Florida, Louisiana, Massachusetts, Mississippi and New York have high cost health care markets and access challenges (i.e. high national health expenditures per capita, high employer sponsored insurance premiums, high share or people not seeking care due to cost, high share of the population in a shortage area and/or lower Medicaid physician participation). While all states have risk factors to varying degrees, this analysis shows that more than 6 in 10 states rank in the top five for multiple risk factors. Eleven states rank in the top five for five or more risk factors (Alabama, Arizona, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, South Carolina, Texas, and West Virginia). States that have multiple risk factors could face even more challenges making Medicaid program cuts or filling gaps in federal funding. Looking ahead, limiting the growth in federal Medicaid spending could force states to make difficult choices in their current programs and could also limit states ability to afford new drug therapies or other medical advances, adapt to changing demographics or make future investments to improve delivery systems or address broader health status issues in the future. Tables with state-level data for each of the 30 risk factors considered in the analysis are included at the end of the report. Sources for data included in the tables and described in the report can be found in the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 3 Introduction Medicaid, the nation’s primary health insurance program for low-income and high-need Americans, is jointly financed by states and the federal government, but states administer Medicaid programs within broad federal rules. Under federal law, Medicaid provides an entitlement to coverage to individuals who are eligible for the program and a guarantee to federal matching dollars. Given the current financing structure of the program, Medicaid is both a budget item and a revenue item in state budgets. State Medicaid policy choices (including the ACA coverage expansion, other eligibility levels, scope of benefits, reimbursement rates and delivery system models) as well as other factors such as demographics, health needs, health care markets, and state fiscal capacity affect Medicaid spending. Due to all of these factors, Medicaid coverage and financing vary significantly across states (Figures 1 and 2). Figure 1 Figure 2 Spending per full-benefit Medicaid enrollee in FY 2014 Medicaid spending varies across states due to a variety of factors. varies across states. WA VT ME Factors that Affect Variation in Medicaid Spending OR MT ND MN NY NH MA Across States WI ID SD MI RI WY CT PA IA NJ Medicaid Policy Revenue and Health Care NE OH DE NV IL IN MD Choices: Demographics: Health Status: Budget Choices: Costs/ Access: UT WV VA CO KS MO DC ACA Expansion Poverty Rate Overall Health Personal Income High NHE CA KY NC Ranking Total Taxable Spending TN Eligibility Unemployment OK SC AZ AR Disability Resources ESI Premiums NM Benefits Age MS AL GA Mental Health Tax Collections Access to a Doctor LA Reimbursement Urban / Rural TX Status Medicaid Match % in a Health AK Rates Race FL Opioid Death Rate Rate Shortage Area HI Delivery Systems Rate of New HIV State and Local Medicaid $4,000 - $5,300 (7 states) Cases Spending Per Physician $5,300 - $6,200 (15 states) Capita Participation $6,200 - $7,500 (13 states) $7,500 - $10,500+ (16 states, including DC) SOURCE: KFF estimates based on analysis of data from the FFY 2014 Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports. Because FY 2014 data was missing some or all quarters for some states, we adjusted the data using secondary data to represent a full fiscal year of enrollment. This brief, builds on earlier work that examined the factors contributing to variation in Medicaid spending from 2012. This update reflects changes including the implementation of the ACA and a slowly improving economy. In 2017, Congress has been debating the AHCA, legislation that could eliminate enhanced federal matching funds for the ACA Medicaid expansion and fundamentally change the structure and financing of the overall program by capping and significantly reducing the amount of federal funds provided to states. This brief examines 30 key factors that contribute to variation in Medicaid per enrollee spending and highlights states that may be at particularly high risk under federal cuts or caps in Medicaid funding. We identify “high risk” states as ranking in the top five for each factor. While we use this ranking construct, there may not be significant differences between states that follow in rank order. The brief has findings in five key areas:  Medicaid policy choices (including implementation of the ACA Medicaid expansion);  Demographics;  Health status;  Available tax revenues and state budget choices; and  Health care markets (costs and access). Table 1 includes state level data to show expansion status, Medicaid per enrollee spending for FFY 2014 and number of state residents. The appendix provides sources for data included in the tables and described in the report. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 4 Key Findings 1. MEDICAID POLICY CHOICES MEDICAID ACA EXPANSION The ACA expanded Medicaid coverage to nearly all adults up to 138% of the federal poverty level (FPL) and provided states with enhanced federal financing for this new coverage; however, the Supreme Court ruling that effectively gave states the option to adopt the expansion resulted in even greater variation in Medicaid programs across states. Following the implementation of the ACA in 2014, millions of people have enrolled in new coverage options (Medicaid and Marketplace), and the uninsured rate for the non-elderly had dropped to a historic low of 10% by early 2016. The proposed elimination of federal enhanced matching funds for the ACA Medicaid expansion included in the AHCA would have different implications for states based on the decision to implement the expansion and the effects of that decision in a given state. States that expanded have experienced benefits tied to coverage gains and financing that could be at risk, while non-expansion states risk the future loss of Medicaid enhanced matching funds for expansion (Figure 3 - states in multiple categories are shown in orange). Figure 3 States that adopted the Medicaid expansion could lose more financing and coverage with changes to the ACA enhanced match rate; non-expansion states would lose the option to finance new coverage. High Share of High Share Largest Federal Expansion Largest Number of Expansion Percentage Point Highest Uninsured Funding as % of People in the Enrollees as % of Reduction in Rate All Federal Coverage Gap Total Uninsured Medicaid Oregon Washington Nevada Texas Texas New York Oregon Kentucky Georgia Florida Arkansas Nevada California Florida Georgia New West Virginia Kentucky Mississippi North Carolina Hampshire Kentucky Hawaii Arkansas Oklahoma South Carolina NOTE: States in multiple categories are shown in orange. Expansion States. Policy proposals that would end the enhanced federal matching funds for the ACA Medicaid expansion could have significant implications for coverage and financing in expansion states. To date, 32 states (including DC) adopted the Medicaid expansion. Coverage gains were particularly large among low-income people living in states that expanded Medicaid. At the start of 2016, there were 14.4 million adults in the Medicaid expansion group, including 11 million who were “newly” eligible due to the ACA expansion. Overall, expansion enrollment accounted for about 20% of all Medicaid enrollment. From 2014-2016, the federal government financed 100% of the costs of those newly eligible under the expansion. Under the law, this rate phased down to 95% in 2017 and gradually phases down to 90% by 2020. Federal funding for the expansion group totaled $68.2 billion in FY 2015 (about 21% of all federal Medicaid funding). In total numbers, California, New York, Pennsylvania, Ohio and Illinois account for the largest number of enrollees in the expansion group (54%) and California, New York, Ohio, Michigan and Illinois account for the highest levels of federal expansion funding (52%). Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 5  In Oregon, New York, Arkansas, West Figure 4 Virginia, and Kentucky, Medicaid expansion Medicaid Expansion Enrollees as a Share of Total Enrollees, enrollees accounted for 35% or more of total January-March 2016 enrollment (Figure 4). WA VT ME MT ND* NH  In Washington, Oregon, Nevada and OR MN WI NY MA ID SD MI RI WY CT PA Kentucky, expansion funding accounts for at NV NE IA IL IN OH NJ DE MD UT WV VA least 40% of all federal Medicaid funds. CA CO KS MO KY NC DC TN OK AR SC  AZ Nevada, Kentucky, California, New NM MS AL GA LA* TX Hampshire and Arkansas experienced the AK HI FL largest percentage point reduction in the <20% (2 states) 20%-29% (15 states, including DC) ≥30% (13 states) uninsured from 2013 to 2015. Did not expand Medicaid (19 states) Note: *Louisiana did not expand Medicaid until July 1, 2016 and thus does not have expansion enrollees. There is no data available from CMS on North Dakota. Eight of the expansion states (Arkansas, Arizona, Source: Kaiser Commission on Medicaid and the Uninsured analysis of Medicaid spending and enrollment data collected from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES). Illinois, Indiana, Michigan, New Hampshire, New Mexico and Washington) have legislation requiring them to reduce or eliminate the expansion if the federal match rate is reduced. Other states are likely to eliminate or scale back their expansion coverage due to the increased cost if federal funding is reduced. As a result, many expansion adults in these states would likely become uninsured since they would not be able to afford other coverage options. Adults covered by Medicaid typically work in low-wage jobs that do not provide health coverage or are family caregivers, and many have chronic conditions or disabilities. Increases in uninsured rates among these adults would increase strains on other parts of state health care systems, including community health centers and hospitals. Non-Expansion States. The 19 states that have not expanded would lose the option to expand in the future and access to enhanced federal funds to support their capacity to cover low-income uninsured adults. Most of the non-expansion states (12 of 19) limit Medicaid eligibility for parents to less than half the poverty level and other low-income adults are not eligible regardless of income, except in Wisconsin. Many poor parents and other adults in these states fall into a coverage gap since they do not qualify for Medicaid, but have incomes below 100% of poverty so cannot access tax credits to purchase Marketplace coverage. The ongoing coverage gap for low-income adults in these states limits state capacity to achieve overall improvements in population health. Texas, Florida, Georgia, North Carolina, and South Carolina are the states with the highest number of adults who fall into the coverage gap. Table 2 includes state level data related to the ACA Medicaid expansion and source information can be found in the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 6 OTHER MEDICAID POLICY CHOICES States administer Medicaid within broad federal rules. The federal government sets core requirements, but states have flexibility to determine eligibility levels, benefits, provider payments, and delivery systems. There is a great deal of variation across states in how their Medicaid programs are structured, and therefore differences in spending on the program due to policy choices made by states. Under a per capita cap or block grant policy, states could be locked into historic decisions about their Medicaid programs. States with more limited Medicaid programs in terms of eligibility, benefits and payment rates could be at higher risk with reductions or caps in federal financing because it could be more difficult for these states to find savings if some core federal requirements remain in place. Moreover, nearly all community based long-term care services are an optional service in Medicaid, so states that have lower levels of home and community- based services (HCBS) may find it difficult to expand these services to shift utilization and achieve savings from reductions in more costly institutional care in the face of federal Medicaid cuts. The AHCA repeals the 6% enhanced federal funding for the Community First Choice Option to provide attendant care services as of 2020, which would result in a $12 billion decrease in Figure 5 federal funding over 10 years and further hinder Medicaid policy choices place some states at higher risk with federal Medicaid cuts or caps and could lock in historic decisions. efforts to increase community integration. In addition, states that have already moved enrollees to Low Eligibility No Adult Low Physician High MCO Low Share of Community- Dental Health managed care would not be able to recoup some of for Parents Coverage Fee Index Penetration Based LTC Care the one-time savings that some states experience in Alabama Alabama Rhode Island Tennessee Mississippi that transition. Texas Arizona New Jersey Hawaii Florida Figure 5 identifies states with restrictive Medicaid Missouri Delaware Michigan Iowa Indiana programs that would face particular challenges to Idaho Tennessee California New Louisiana Hampshire achieving increased savings within their programs in Mississippi Missouri Kansas Hawaii response to reductions in federal funding. States in multiple categories are shown in orange. NOTE: States in multiple categories are shown in orange. Only 4 states reported no dental health coverage for adutls, Eligibility. Federal law requires states to cover certain population groups up to minimum income eligibility levels in order to receive federal matching funds. Figure 6 States can expand coverage beyond federal Medicaid Income Eligibility Levels for Parents of minimum levels and receive federal matching funds. Dependent Children, January 2017 As of January 2017, the median eligibility levels were WA VT ME MT ND NH 255% of the federal poverty level (FPL) for children OR SD MN WI NY MA ID MI CT RI and 138% FPL for parents and adults without WY PA IA NJ NE OH DE NV IL IN MD dependent children. Eligibility levels for adults in CA UT CO KS MO KY WV VA DC NC non-expansion states are much lower for parents TN OK AR SC AZ NM MS AL GA and Wisconsin is the only non-expansion state to AK TX LA FL provide Medicaid coverage to childless adults. HI <50% FPL (12 states) Alabama, Texas, Missouri, Idaho and Mississippi 50% up to 138% FPL (7 states) >138% FPL (32 states, including DC) have the lowest eligibility levels for parents. The NOTE: Eligibility levels are based on 2017 federal poverty levels (FPLs) for a family of three. The FPL for a family of three in 2017 was $20,420. Thresholds include the standard five percentage point of the FPL disregard. median eligibility thresholds for parents in non- SOURCE: Based on results from a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2017. expansion states is 44% FPL (Figure 6). Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 7 Benefits. States participating in Medicaid must cover a core set of benefits, but states can also receive federal matching funds for coverage of “optional benefits.” All states cover some optional benefits, but the scope of state benefit packages varies widely across states. States also have flexibility in determining the amount, duration and scope of the benefits they offer. Adult dental benefits can be used as a proxy to understand the variation across state benefit packages. While almost all states (46) and DC currently provide some dental benefits for adults in Medicaid, the scope of Medicaid adult dental benefits varies widely by state. As of February 2016, 15 states provided extensive adult dental benefits, 19 states provided limited dental benefits, and 13 states covered only dental care for pain relief or emergency care for injuries, trauma, or extractions. Four states provided no dental benefits at all. Like other optional Medicaid services, adult dental benefits are often cut when states face budget pressures. Payment Rates/Physician Fees. States largely determine provider payments within limited federal requirements. Federal law requires that payments be consistent with efficiency, economy, quality and access, and safeguard against unnecessary utilization. For physicians and other providers, states are required to pay rates that are sufficient to ensure access equal to the rest of the area population. In 2014, Medicaid paid physicians on average 66% of Medicare rates and 59% of what Medicare pays for primary care. Relative to what other states reimburse for physicians, Rhode Island, New Jersey, Michigan, California and Missouri have the lowest physician fee index. Managed Care. Today, 39 states contract with managed care organizations (MCOs) and risk-based managed care is the dominant delivery system in Medicaid. Hawaii, Tennessee, Iowa, New Hampshire, Kansas and New Jersey all report that at least 95% of enrollees are in MCOs. Sometimes, when states first transition to managed care arrangements, they can see some savings relative to fee-for-service arrangements, but savings are not sustained not over time. States that have already transitioned to managed care have less ability to use this as a mechanism to reduce future per enrollee costs. Long-Term Care Setting. Medicaid covers a continuum of long-term care service settings. Driven by requirements under the Americans with Disabilities Act (ADA), consumer preferences and efforts to control long-term care costs, states continue to work on reorienting their Medicaid long-term care delivery systems away from institutional settings and toward more community-based services. Overall, more than half of spending (55%) for long-term care is for HCBS, but this varies by state from a high of 82% in Oregon to 31% in Mississippi. Table 3 includes state level data related to Medicaid policies and source information can be found in the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 8 2. DEMOGRAPHICS Demographic characteristics vary across states. These characteristics affect demand for Medicaid as well as public health services more broadly. States with high rates of poverty, unemployment, and uninsured could have higher demands for Medicaid. Similarly, because Medicaid is the largest provider of long-term services and supports, states with higher shares of elderly as well as states facing the fastest growth projections in their population over 85 years old could face increased demand for Medicaid. In addition, Medicaid plays an important role in providing coverage to people of color as well as people in rural areas. States with demographic factors that contribute to high demand for Medicaid could be disproportionately impacted by cuts or caps in federal Medicaid funding compared to other states. High demand and limited funding could make it challenging for these states to meet the needs of the residents in their state. Individuals in poverty or who are unemployed are unlikely to have another source of health coverage and those who are uninsured are at risk for not getting needed health services. Figure 7 highlights states with demographic characteristics that lead to increased need for Medicaid. States in multiple categories are shown in orange. Figure 7 States with certain demographic characteristics are at higher risk with federal Medicaid cuts or caps. High Share of High Share of High High Projected High Poverty Population in Population that Unemployment Growth 85+ Rural Areas is Non-White New Mexico New Mexico Alaska Montana Hawaii District of Kentucky Alaska Nevada North Dakota Columbia District of Mississippi Arizona Wyoming New Mexico Columbia Louisiana Louisiana New Mexico South Dakota California Georgia Alabama Wyoming Vermont Texas NOTE: States in multiple categories are shown in orange. Poverty. Many government assistance programs are targeted to help low-income families. Programs administered or supported by the United States Department of Health and Human Services (HHS) use the department's federal poverty guidelines. The annual federal poverty level in 2017 is $12,060 for an individual and $20,420 for a family of three. In 2015, 14% of people living in the U.S. had incomes below the poverty level. The percent of the population living below poverty varies by state, ranging from less than 10% of residents in Alaska, Connecticut, Minnesota, New Hampshire and Utah up to 20% in Kentucky and New Mexico. Unemployment. During an economic downturn, individuals lose jobs, incomes drop, and state revenues decline at the same time that demand for public programs such as Medicaid, cash assistance, and food stamps increase. During the most recent recession, unemployment peaked at 10% in October 2009. The economy has been improving since then and unemployment rates have been stable at less than 5% since May 2016, but rates vary across states. As of April 2017, the national unemployment rate was 4.4%. Colorado, Hawaii, Maine, Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 9 Nebraska, New Hampshire, North Dakota, and South Dakota had unemployment rates at 3% or less, while Alaska and New Mexico had rates greater than 6%. Age. Demand for health care services varies by age. For example, those over the age of 65 are more likely to need long-term care services than children, who generally require fewer medical services and mostly preventive care and acute care. In 2015, the elderly accounted for 15% of the population and the population 85 years of age and older accounted for 2%.1 From 2015 to 2030, the percent of the population 85 years and older is expected to grow by 41% with 21 states projecting growth in the 85 and older population of more than 50% (Figure 8). Figure 8 Projected Change in Share of Persons 85+, from 2015 to 2030 WA VT ME MT ND NH MN OR WI NY MA ID SD MI RI WY CT PA NJ IA NE OH DE NV IL IN MD UT WV VA CO DC CA KS MO KY NC TN OK AR SC AZ NM MS AL GA TX LA AK FL HI <0% (1 state, DC) 0%-29% (15 states) 30%-49% (14 states) ≥ 50% (21 states) SOURCE: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005, compiled by the US Administration on Aging. Rural. States with large rural populations tend to have poorer residents with complex and costly health needs, which are often exacerbated by workforce shortages and large geographic distances between patients and providers. Medicaid plays a central role in helping to fill gaps in private coverage in rural areas. States including Montana, North Dakota, and Wyoming have all of their populations living in rural areas. Race. Communities of color are more likely to face disparities in health and access to health care and Medicaid plays an important role in improving coverage for persons of color. In seven states (California, District of Columbia, Hawaii, Maryland, Nevada, New Mexico, and Texas), the share of the population that is non-white is 50% or more. Table 4 includes state level data related to demographic characteristics and source information can be found in the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 10 3. HEALTH STATUS Health status characteristics vary across states and these characteristics affect demand for Medicaid as well as public health services more broadly. Medicaid plays an important role in serving individuals with disabilities, addressing public health crises, and providing mental health care. Medicaid also plays a central role in helping states address the opioid crisis and the HIV epidemic. Cuts or caps in federal Medicaid financing could increase the challenges in addressing the opioid and HIV epidemics and providing care for individuals with disabilities. Figure 9 shows states that have particularly high health needs across certain measures; states in multiple categories are shown in orange. Figure 9 States with poor health status characteristics are at higher risk with federal Medicaid cuts or caps. High % Overall High % High Rate of Reporting High Opioid Poorest Reporting a New HIV Poor Mental Death Rate Health Status Disability Cases Health District of Mississippi West Virginia Oregon West Virginia Columbia Louisiana Utah New Louisiana Arkansas Hampshire Arkansas Alabama Illinois Ohio Georgia Alabama Kentucky Colorado Rhode Island Florida Oklahoma Maine Indiana Massachusetts Maryland NOTE: States in multiple categories are shown in orange. Overall Health Ranking. America’s Health Rankings® Annual Report provides annual state-by-state rankings based on behaviors, community and environment, policy, clinical care, and outcomes data. Based on these data, Hawaii, Massachusetts, Connecticut, Minnesota and Vermont are the healthiest states and Mississippi, Louisiana, Arkansas, Alabama and Oklahoma have the greatest challenges. Disability. Medicaid covers more than 3 in 10 nonelderly adults with disabilities, providing a broad range of medical and long-term care services that enable people with disabilities to live and work in the community. There are a number of factors that determine the Figure 10 need for health and long-term care services in states, Share of Non-Institutionalized Population Reporting a Disability, 2015 including the prevalence of disability and chronic WA VT ME conditions as well as other indicators of health. In MT ND MN NH MA 2015, 13% of the non-institutionalized population OR WI NY ID SD MI RI WY CT PA NJ IA reported having a disability. Sixteen states had 15% NV UT NE IL IN OH WV VA DE MD CO DC KS or more of noninstitutionalized people reporting a CA MO KY NC TN OK AR SC disability (Figure 10). In FY 2014, Medicaid enrollees AZ NM MS AL GA TX LA with a disability accounted for 40% of Medicaid AK FL spending, but only 14% of Medicaid enrollment; the HI <12% (14 states, including DC) spending per enrollee for these individuals was three 12%-14% (21 states) >15% (16 states) times as much as the average spending per all SOURCE: W Erickson, C Lee, and S von Schrader, 2015 Disability Status Report: United States, (Ithaca, NY: Cornell University Yang Tan Institute on Employment and Disability (YTI), 2016. Retrieved April 8, 2017 from www.disabilitystatistics.org. enrollees.2 Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 11 Mental Health. The Medicaid program covers a disproportionate share of individuals with behavioral health conditions. More than one in four adults with Medicaid (27%) have a mental illness. The Medicaid program serves as a safety net for many low-income individuals with behavioral health conditions by facilitating access to and financing numerous services, including clinical services, case management, prescription medication and rehabilitative services. Over one-third of adults nationally (35%) report poor mental health. Opioid Deaths. The opioid epidemic is increasing among Americans with addiction to heroin and prescription painkillers. Medicaid plays a central role in the nation’s effort to address the opioid epidemic through coverage of people struggling with opioid addiction and financing for states. In 2015, more than 10 people in every 100,000 died from an opioid related drug overdose nationally and opioid overdoses accounted for 63% of all drug overdoses. West Virginia, New Hampshire and Ohio reported the highest opioid related drug overdoses at over 24 people in every 100,000. HIV. Medicaid is the largest source of coverage for individuals with HIV. By covering more people with HIV and increasing state capacity to provide treatment to individuals with HIV, Medicaid plays a key role in curbing the epidemic. In 2015, the new HIV diagnoses rate among adults and adolescents was 14.7 people for every 100,000. Table 5 includes state level data related to health status and source information can be found in the appendix. 4. AVAILABLE REVENUES AND STATE BUDGET CHOICES States vary in the amount of revenue resources available and in how they tap into those resources to pay for public services and programs. States also make different decisions about how revenue is allocated across different areas of spending. Medicaid is an important revenue source for states, but also a major source of spending. Figure 11 highlights states with lower tax bases, lower tax collections and higher federal Medicaid match rates, which would be at higher risk with reductions or caps in federal financing because it would be more difficult for these states to offset the loss of federal funds with state funds. States in multiple categories are shown in orange. Figure 11 States with less tax capacity and high Medicaid match rates are at higher risk with federal Medicaid cuts or caps. Low Tax Low Total Low Personal Collections as a Low State Taxable High Medicaid Income Per Share of Spending Per Resources Per FMAP Capita Personal Capita Capita Income Mississippi Mississippi Tennessee Idaho Mississippi West Virginia Arizona Florida Arizona West Virginia South Carolina Idaho Alabama Georgia New Mexico Idaho South Carolina South Dakota Nevada South Carolina New Mexico Alabama Oklahoma Tennessee Alabama NOTE: States in multiple categories are shown in orange. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 12 Tax Base. A states’ tax base provides a measure of resources that may be available to a state. Two measures of tax base include personal income and total taxable resources. Per capita personal income3 is currently used to determine the Federal Medical Assistance Figure 12 Percentage (FMAP) for Medicaid. States with low Personal Income per Capita, 2014 personal income per capita have a higher FMAP. Personal income per capita does not include all WA MT ND VT ME NH potential taxable income sources in a state.4 In 2014, MN OR WI NY MA ID SD MI WY CT RI PA personal income per capita was $46,049 nationally NV NE IA IL IN OH DE MD NJ UT WV (Figure 12). Total taxable resources (TTR) is an CO VA DC CA KS MO KY NC TN alternative and more comprehensive measure of tax AZ NM OK AR MS AL GA SC base designed to better account for a state’s available AK TX LA FL resources to provide public services.5,6 Mississippi, HI West Virginia, South Carolina, Idaho and New <$40,000 (14 states) $40,000-$50,000 (26 states) >$50,000 (11 states, including DC) Mexico had the lowest personal income per capita in 2014. Mississippi, Arizona, Idaho, South Carolina SOURCE: Bureau of Economic Analysis, state personal income accounts, 2014. and Alabama had the lowest TTR in 2014. Tax Collections. Tax collections are one measure of how a state taps into its available resources. In 2014, tax collections per capita averaged $4,675 across the U.S.7 This brief examines tax collections as a percent of personal income as a proxy for a more representative measure of tax effort, that is, how much a state collects in taxes relative to its tax capacity. Tax collections as a share of personal income averaged 10%. Tennessee, Florida, Alabama, South Dakota and Oklahoma had the lowest tax collections as a share of personal income. State and Local Spending Per Capita. Because states must balance their budgets annually, state spending is a function of how much revenue is collected. Average state and local spending per capita in 2014 was $8,489. Idaho, Arizona, Georgia, Nevada and Tennessee had the lowest state and local spending per capita from all sources. Federal Medical Assistance Percentage (FMAP). As noted above, the FMAP is based on a state’s relative personal income per capita. States with lower relative personal income have a higher FMAP. In FY 2018, the FMAP ranged from a floor of 50% to a high of 76% in Mississippi. Table 6 includes state level data related to income, tax, spending data and FMAP variables and source information can be found in the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 13 5. HEALTH CARE MARKETS (COSTS AND ACCESS) Medicaid programs purchase services from the private market as other insurers do. Therefore, some of the variation in Medicaid spending is due to differences in health care markets and the ability to access care as well as the number of providers and health care facilities in a given state. The share of the population living in health professional shortage areas and the share of providers accepting Medicaid also varies by state and can contribute to overall variation in per enrollee costs. Figure 13 States with high cost health care markets and access challenges Figure 13 highlights states with high health care are at higher risk with federal Medicaid cuts or caps. costs and limited access, which could be at higher risk under reductions or caps in federal financing High Health Spending Per High Family Not Seen a Doctor Due to % Population in a Shortage Lower Rates of Physician ESI Premium because it would become increasingly difficult to Capita Cost Area Participation purchase services in a high cost market or make Delaware Alaska Mississippi Mississippi New Jersey improvements in access to care. It also highlights Massachusetts New York Texas New Mexico California states with low Medicaid physician participation, Alaska New Florida Florida Hampshire Louisiana which would be at risk under Medicaid cuts or caps District of Connecticut Alabama Arizona Louisiana because it would be difficult to increase provider Columbia Maine Massachusetts South Carolina Alabama New York rates beyond the caps to promote additional provider participation. States in multiple categories are shown NOTE: States in multiple categories are shown in orange. in orange. Health Care Costs. Medicaid spending is, in part, affected by the cost of procuring health care in the state market. Differences in the cost of obtaining health care in a particular state affects the amount state Medicaid programs have to spend in order to purchase services. Health care costs typically outpace inflation. In 2009, national health expenditures (NHE) per capita were $6,815. Half of all U.S. residents and 56% of non-elderly residents are covered by employer-sponsored insurance (ESI) plans. In 2015, the average premium cost for a family (including the employee and employer shares) for employer-based coverage was $17,322 (with 73% paid by the employer). Access to Care. Access varies across states due to factors such as provider availability, geography and population density, payment, and other local factors. The presence of access barriers may influence Medicaid beneficiaries’ ability to access services and, in turn, state Medicaid spending. Nationally, 13% of the population reported that they had not seen a doctor because of Figure 14 cost. This was most likely to occur in Mississippi, Share of Population in Health Professional Shortage Area Texas, Florida, Alabama, and South Carolina. Areas for Primary Care, as of December 31, 2016 with a documented shortage of providers are WA MT ND VT ME NH designated as Health Professional Shortage Areas MN OR WI NY MA ID SD MI RI WY CT (HPSAs) by the Health Resources and Services PA NJ IA NE OH DE NV IL IN MD UT WV VA Administration (HRSA). As of December 2016, CO DC CA KS MO KY NC TN HRSA had designated 6,626 primary care HPSAs AZ NM OK AR MS AL GA SC across the country, affecting over 66 million people. AK TX LA FL Nationally, 20% of the population lives in a primary HI care HPSA. Mississippi, New Mexico, Louisiana, ≤15% (14 states) 16%-25% (22 states) >25% (15 states, including DC) Arizona and Alabama have the highest share of their SOURCE: Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human populations in primary care HPSAs (Figure 14). Services, Designated Health Professional Shortage Areas Statistics: Designated HPSA Quarterly Summary, as of December 31, 2016. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 14 Physician Participation. Nationally, 69% of all office-based physicians accept new Medicaid patients. The percentage of physicians accepting new Medicaid patients varies by state, ranging from 39% in New Jersey to 97% in Nebraska. In one-quarter of states (14), more than 85% of physicians accept new Medicaid patients. Table 7 includes state level data related to health care market costs and access, and source information can be found in the appendix. Looking Ahead Today, Medicaid is a state and federal partnership. The program is largely administered by states within broad federal rules. States have flexibility to make policy choices related to eligibility, benefits and how to deliver and pay for care. States and the federal government share financing for Medicaid and states have a guarantee to federal matching dollars with no set limit. Under current law, Medicaid spending per enrollee varies across states due to a complex array of factors that involve state policy choices, residents’ needs for public health services as well as health and long-term care, states’ abilities to raise revenue and collect revenue, Medicaid policy choices, and the underlying health care market in a state. Congress continues to debate and consider legislation to eliminate the enhanced match for the Medicaid ACA expansion and cut and cap federal Medicaid financing through a block grant or per capita cap. The cap on federal funding would lock-in current state spending patterns that reflect historic Medicaid policy choices. All states could face challenges responding to federal Medicaid cuts and caps, but states with certain characteristics are more at risk. Challenging demographics, poor health status, low tax capacity and state spending, high health care costs and poor access are key factors that would place states at higher risk from a per capita cap or block grant. If states are locked in to prior policy choices, states with limited eligibility and benefits, lower provider rates and those that have already moved to capitated care arrangements could be at higher risk with federal Medicaid spending caps because these states would have few options to reduce the scope of the program or generate new efficiencies. States that have seen the largest gains in coverage and those that have high shares of federal Medicaid dollars from the expansion could see the biggest losses if the ACA Medicaid expansion funds are eliminated, while other states that have not expanded, could lose the future opportunity to expand and see similar gains in coverage and financing. This analysis of 30 factors in 5 groups shows that all states have risk factors to varying degrees; more than 6 in 10 states rank in the top five for multiple risk factors. Eleven states rank in the top five for five or more risk factors (Alabama, Arizona, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, South Carolina, Texas, and West Virginia). Looking ahead, limiting the growth in federal Medicaid spending could force states to make difficult choices in their current programs and could also limit states’ ability to afford new drug therapies or other medical advances, adapt to changing demographics or make future investments to improve delivery systems or address broader health status issues. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 15 Table 1: State Characteristics Medicaid Spending per  Total Number of  Expansion Status, State Full‐Benefit Enrollee,  Residents,  As of January 1, 2017 FFY 2014 2015 United States N/A $6,396 318,868,500 Alabama Non‐expansion $4,827 4,833,900 Alaska Expansion $10,001 705,300 Arizona Expansion $5,801 6,739,500 Arkansas Expansion $6,109 2,953,000 California Expansion $5,318 39,113,900 Colorado Expansion $4,898 5,421,300 Connecticut Expansion $8,446 3,571,700 Delaware Expansion $9,041 959,100 District of Columbia Expansion $9,237 676,800 Florida Non‐expansion $4,788 20,085,300 Georgia Non‐expansion $4,838 10,104,900 Hawaii Expansion $6,084 1,386,000 Idaho Non‐expansion $5,452 1,659,500 Illinois Expansion $5,301 12,701,800 Indiana Expansion $7,777 6,512,100 Iowa Expansion $6,223 3,100,600 Kansas Non‐expansion $6,670 2,852,400 Kentucky Expansion $6,572 4,383,400 Louisiana Expansion $5,740 4,604,200 Maine Non‐expansion $7,507 1,341,900 Maryland Expansion $8,118 5,900,500 Massachusetts Expansion $8,620 6,785,700 Michigan Expansion $6,411 9,862,100 Minnesota Expansion $8,973 5,463,000 Mississippi Non‐expansion $6,780 2,948,600 Missouri Non‐expansion $8,501 5,962,700 Montana Expansion $6,733 1,018,100 Nebraska Non‐expansion $6,455 1,859,800 Nevada Expansion $4,003 2,867,400 New Hampshire Expansion $7,472 1,292,800 New Jersey Expansion $4,969 8,941,600 New Mexico Expansion $6,026 2,041,000 New York Expansion $8,618 19,695,000 North Carolina Non‐expansion $5,573 9,902,000 North Dakota Expansion $10,721 763,400 Ohio Expansion $7,010 11,450,900 Oklahoma Non‐expansion $5,608 3,902,900 Oregon Expansion $6,604 4,032,800 Pennsylvania Expansion $9,638 12,595,900 Rhode Island Expansion $8,315 1,044,800 South Carolina Non‐expansion $4,169 4,794,700 South Dakota Non‐expansion $5,988 848,400 Tennessee Non‐expansion $6,718 6,616,500 Texas Non‐expansion $6,495 27,434,400 Utah Non‐expansion $5,326 3,004,500 Vermont Expansion $8,787 609,700 Virginia Non‐expansion $7,678 8,217,200 Washington Expansion $5,510 7,194,700 West Virginia Expansion $5,854 1,797,500 Wisconsin Non‐expansion $5,828 5,738,100 Wyoming Non‐expansion $6,602 574,800 NOTE: For notes and sources, see the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 16 Table 2. Affordable Care Act (ACA) Expansion Expansion Enrollees,  Federal Expansion Funding,  Percentage Point  Number of Poor  January‐March 2016 FFY 2015 Change in  Nonelderly  Uninsured Nonelderly  State Share of All  Uninsured Rates  Uninsured Rate,  Adults in the Coverage  Share of Total  Amount  for Nonelderly,  2015 Gap,  Number Federal  Enrollees (millions) 2013 to 2015 2016 Medicaid United States 14,409,600 20% $68,156 21% ‐4.8% 10% 2,625,000 Alabama ‐ ‐ ‐ ‐ ‐5.3% 12% 126,000 Alaska 14,400 10% N/A N/A ‐1.5% 14% ‐ Arizona 418,400 22% $2,054 26% ‐6.8% 14% ‐ Arkansas 303,900 40% $1,379 32% ‐7.1% 11% ‐ California 3,541,700 27% $18,974 38% ‐7.8% 9% ‐ Colorado 425,500 32% $1,349 31% ‐3.8% 10% ‐ Connecticut 207,600 24% $1,301 29% ‐4.8% 7% ‐ Delaware 67,900 31% $336 30% ‐0.2% 8% ‐ District of Columbia 62,600 26% $341 18% ‐4.3% 5% ‐ Florida ‐ ‐ ‐ ‐ ‐6.8% 15% 467,000 Georgia ‐ ‐ ‐ ‐ ‐2.7% 16% 309,000 Hawaii 110,000 34% $486 38% 0.2% 6% ‐ Idaho ‐ ‐ ‐ ‐ ‐3.7% 13% 33,000 Illinois 681,000 23% $3,189 31% ‐4.6% 7% ‐ Indiana 381,600 30% $912 14% ‐3.6% 11% ‐ Iowa 149,300 25% $730 25% ‐3.1% 6% ‐ Kansas ‐ ‐ ‐ ‐ ‐0.1% 11% 56,000 Kentucky 443,300 35% $2,976 40% ‐9.1% 7% ‐ Louisiana N/A N/A N/A N/A ‐3.9% 12% ‐ Maine ‐ ‐ ‐ ‐ ‐5.6% 6% N/A Maryland 248,200 22% $1,758 31% ‐5.8% 7% ‐ Massachusetts 398,300 22% $1,469 17% 1.3% 5% ‐ Michigan 637,200 27% $3,212 28% ‐5.3% 7% ‐ Minnesota 222,900 18% $1,745 27% ‐0.7% 7% ‐ Mississippi ‐ ‐ ‐ ‐ ‐1.7% 15% 103,000 Missouri ‐ ‐ ‐ ‐ ‐2.7% 10% 96,000 Montana 46,700 23% N/A N/A ‐6.7% 12% ‐ Nebraska ‐ ‐ ‐ ‐ ‐0.8% 10% 19,000 Nevada 203,900 34% $918 40% ‐9.2% 13% ‐ New Hampshire 52,900 28% $283 28% ‐7.2% 6% ‐ New Jersey 552,400 33% $2,948 33% ‐4.4% 9% ‐ New Mexico 243,100 28% $1,382 35% ‐5.1% 14% ‐ New York 2,161,100 44% $7,717 23% ‐3.5% 8% ‐ North Carolina ‐ ‐ ‐ ‐ ‐4.6% 13% 219,000 North Dakota N/A N/A $240 35% ‐2.8% 9% ‐ Ohio 682,900 23% $3,464 24% ‐7.0% 7% ‐ Oklahoma ‐ ‐ ‐ ‐ ‐3.0% 15% 82,000 Oregon 550,600 50% $2,664 42% ‐6.1% 8% ‐ Pennsylvania 702,800 26% $1,854 14% ‐4.7% 7% ‐ Rhode Island 60,500 21% $460 30% ‐5.2% 6% ‐ South Carolina ‐ ‐ ‐ ‐ ‐6.1% 13% 136,000 South Dakota ‐ ‐ ‐ ‐ ‐1.2% 10% 14,000 Tennessee ‐ ‐ ‐ ‐ ‐2.5% 13% 93,000 Texas ‐ ‐ ‐ ‐ ‐5.1% 18% 684,000 Utah ‐ ‐ ‐ ‐ ‐2.4% 11% 32,000 Vermont 63,300 30% $210 21% ‐3.0% 6% ‐ Virginia ‐ ‐ ‐ ‐ ‐2.4% 11% 136,000 Washington 594,900 33% $3,090 44% ‐5.4% 8% ‐ West Virginia 180,500 35% $713 25% ‐6.6% 8% ‐ Wisconsin ‐ ‐ ‐ ‐ ‐2.8% 8% ‐ Wyoming ‐ ‐ ‐ ‐ ‐6.8% 11% 8,000 NOTE: For notes and sources, see the appendix. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 17 Table 3. Medicaid Policy Share of Medicaid  Share of Long Term Care  Eligibility Income  Scope of Medicaid  Medicaid  Population in a  Spending on Home and  Levels for Parents  Adult Dental  Physician  State Managed Care  Community Based  (% FPL),  Benefits, Fee Index,  Organization,  Services,  as of January 1, 2017 as of February 2016 2014 as of July 1, 2016 FY 2015 United States 138% N/A 1.00 N/A 55% Alabama 18% None 1.04 ‐ 42% Alaska 141% Extensive 2.54 ‐ 63% Arizona 138% None 1.22 93% 70% Arkansas 138% Limited 1.07 ‐ 52% California 138% Extensive 0.81 85% N/A Colorado 138% Limited 1.10 9% 65% Connecticut 155% Extensive 1.48 ‐ 51% Delaware 138% None 1.56 94% 45% District of Columbia 221% Limited 1.40 76% 54% Florida 33% Emergency‐Only 0.87 93% 33% Georgia 37% Emergency‐Only 1.08 69% 47% Hawaii 138% Emergency‐Only 0.96 100% 40% Idaho 26% Emergency‐Only 1.26 ‐ 51% Illinois 138% Limited 0.96 63% 46% Indiana 139% Limited 0.87 79% 34% Iowa 138% Extensive 1.12 96% 52% Kansas 38% Limited 1.13 95% 49% Kentucky 138% Limited 1.07 91% 41% Louisiana 138% Limited 1.04 70% 38% Maine 105% Emergency‐Only 0.93 ‐ 55% Maryland 138% Emergency‐Only 1.55 80% 57% Massachusetts 138% Extensive 1.23 54% 65% Michigan 138% Limited 0.80 75% 40% Minnesota 138% Limited 1.04 75% 77% Mississippi 27% Emergency‐Only 1.29 70% 31% Missouri 22% Limited 0.86 51% 58% Montana 138% Limited 1.62 ‐ 57% Nebraska 63% Limited 1.20 77% 51% Nevada 138% Emergency‐Only 1.24 77% 54% New Hampshire 138% Emergency‐Only 0.89 96% 52% New Jersey 138% Extensive 0.76 95% 44% New Mexico 138% Extensive 1.32 88% 79% New York 138% Extensive 0.93 77% 58% North Carolina 44% Extensive 1.15 ‐ N/A North Dakota 138% Extensive 2.15 22% 42% Ohio 138% Extensive 0.89 88% 51% Oklahoma 44% Emergency‐Only 1.29 ‐ 45% Oregon 138% Extensive 1.23 86% 82% Pennsylvania 138% Limited 0.97 83% 47% Rhode Island 138% Extensive 0.57 90% 57% South Carolina 67% Limited 1.16 73% 48% South Dakota 51% Limited 1.14 ‐ 48% Tennessee 99% None N/A 100% 48% Texas 18% Emergency‐Only 0.96 88% 58% Utah 44% Emergency‐Only 1.11 82% 51% Vermont 138% Limited 1.22 ‐ 69% Virginia 38% Limited 1.21 83% 56% Washington 138% Extensive 1.13 83% 68% West Virginia 138% Emergency‐Only 1.15 63% 47% Wisconsin 100% Extensive 1.00 67% 65% Wyoming 56% Limited 1.50 ‐ 49% NOTE: For notes and sources, see the appendix.  Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 18 Table 4. Demographics Percent of the   Percent of Nonelderly  Percent of Total  Unemployment  Projected Change  Population Below  Population in Rural  Population that is  State Rate,  in Persons 85+,   Poverty,  Areas,  Non‐White,  as of April 2017 2015 to 2030 2015 2015 2015 United States 14% 4% 41% 19% 39% Alabama 17% 5% 36% 34% 35% Alaska 9% 7% 135% 59% 42% Arizona 17% 5% 84% 17% 49% Arkansas 16% 4% 34% 51% 26% California 14% 5% 52% 3% 61% Colorado 10% 2% 54% 19% 31% Connecticut 9% 5% 29% 0% 30% Delaware 11% 5% 51% 0% 37% District of Columbia 17% 6% ‐8% 0% 63% Florida 16% 5% 52% 5% 46% Georgia 18% 5% 62% 22% 48% Hawaii 11% 3% 50% 18% 81% Idaho 12% 3% 61% 52% 16% Illinois 11% 5% 26% 15% 37% Indiana 14% 4% 25% 30% 20% Iowa 10% 3% 16% 52% 15% Kansas 14% 4% 24% 46% 25% Kentucky 20% 5% 34% 49% 15% Louisiana 19% 6% 35% 33% 42% Maine 12% 3% 42% 45% 9% Maryland 10% 4% 48% 4% 50% Massachusetts 12% 4% 25% 1% 27% Michigan 13% 5% 27% 21% 24% Minnesota 8% 4% 35% 34% 18% Mississippi 19% 5% 31% 60% 44% Missouri 10% 4% 30% 35% 20% Montana 12% 4% 52% 100% 10% Nebraska 10% 3% 21% 44% 21% Nevada 13% 5% 95% 9% 50% New Hampshire 7% 3% 52% 25% 9% New Jersey 11% 4% 32% 0% 44% New Mexico 20% 7% 66% 67% 62% New York 14% 4% 28% 10% 42% North Carolina 15% 5% 51% 22% 38% North Dakota 11% 3% 19% 100% 15% Ohio 14% 5% 20% 20% 21% Oklahoma 15% 4% 32% 47% 35% Oregon 12% 4% 41% 32% 26% Pennsylvania 12% 5% 14% 12% 24% Rhode Island 12% 4% 16% 0% 28% South Carolina 14% 4% 60% 24% 36% South Dakota 14% 3% 23% 78% 17% Tennessee 15% 5% 48% 30% 27% Texas 15% 5% 59% 15% 56% Utah 9% 3% 59% 24% 19% Vermont 11% 3% 56% 73% 6% Virginia 11% 4% 61% 23% 38% Washington 11% 5% 56% 16% 31% West Virginia 15% 5% 22% 46% 7% Wisconsin 11% 3% 30% 33% 22% Wyoming 10% 4% 64% 100% 15% NOTE: For notes and sources, see the appendix.  Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 19 Table 5. Health Status Percent of Non‐ Age‐Adjusted  New HIV Diagnoses,  Share of Adults  Overall State  Institutionalized  Opioid Overdose  Among Adults and  Reporting Poor  State Health Ranking,  Population Who  Death Rate per  Adolescents, per  Mental Health,  2016 Reported a Disability,  100,000,  100,000,  2015 2015 2015 2015 United States N/A 13% 34% 10.4 14.7 Alabama 47 17% 35% 6.1 11.8 Alaska 30 12% 37% 11.0 4.0 Arizona 29 13% 35% 10.2 12.7 Arkansas 48 17% 36% 7.2 10.4 California 16 11% 36% 4.9 14.5 Colorado 10 10% 37% 8.7 8.2 Connecticut 3 11% 36% 19.2 8.8 Delaware 31 12% 32% 14.8 13.6 District of Columbia N/A 11% 36% 14.5 66.1 Florida 36 13% 34% 9.4 27.9 Georgia 41 12% 33% 8.4 28.3 Hawaii 1 11% 29% 4.1 9.6 Idaho 15 14% 37% 6.0 2.8 Illinois 26 11% 39% 10.7 13.7 Indiana 39 14% 37% 8.5 11.5 Iowa 17 12% 31% 5.8 4.8 Kansas 27 12% 30% 5.4 6.1 Kentucky 45 17% 36% 21.0 9.1 Louisiana 49 15% 35% 6.3 29.2 Maine 22 17% 36% 19.3 3.9 Maryland 18 11% 33% 17.7 26.7 Massachusetts 2 12% 36% 23.3 10.3 Michigan 34 15% 37% 13.6 8.7 Minnesota 4 11% 31% 6.2 6.3 Mississippi 50 16% 32% 5.3 20.6 Missouri 37 15% 33% 11.7 9.1 Montana 23 15% 32% 5.0 2.2 Nebraska 12 11% 30% 3.1 5.2 Nevada 35 13% 35% 13.8 20.1 New Hampshire 6 13% 33% 31.3 1.9 New Jersey 9 10% 29% 9.8 15.8 New Mexico 38 15% 33% 17.9 7.8 New York 13 11% 35% 10.8 18.6 North Carolina 32 14% 31% 11.9 15.9 North Dakota 11 10% 34% 4.8 3.5 Ohio 40 14% 35% 24.7 9.5 Oklahoma 46 15% 33% 11.2 9.9 Oregon 21 15% 41% 7.9 6.2 Pennsylvania 28 14% 35% 11.2 10.7 Rhode Island 14 13% 37% 23.5 7.0 South Carolina 42 15% 35% 11.4 16.9 South Dakota 24 13% 28% 3.5 3.3 Tennessee 44 16% 34% 16.0 12.9 Texas 33 12% 30% 4.7 20.1 Utah 8 10% 40% 15.9 5.0 Vermont 5 15% 35% 13.4 2.0 Virginia 19 11% 29% 9.9 13.6 Washington 7 13% 37% 9.3 7.4 West Virginia 43 20% 34% 36.0 4.7 Wisconsin 20 12% 35% 11.2 4.7 Wyoming 25 13% 32% 7.9 3.1 NOTE: For notes and sources, see the appendix.  Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 20 Table 6. Available Revenues and State Budgets Personal  Total Taxable  Tax Collections as  Total State and  Federal Medical  Income Per  Resources Per  a percent of  Local Spending  Assistance  State Capita,  Capita,  Personal Income,  Per Capita,  Percentage (FMAP),  2014 2014 2014 2014 2018 United States $46,049 $67,368 10% $8,489 N/A Alabama $37,512 $50,379 8% $7,459 71% Alaska $54,012 $84,210 14% $19,800 50% Arizona $37,895 $46,752 9% $6,365 70% Arkansas $37,782 $50,575 10% $7,498 71% California $49,985 $71,575 11% $9,563 50% Colorado $48,869 $73,865 9% $8,127 50% Connecticut $64,864 $92,337 11% $9,968 50% Delaware $46,378 $79,564 10% $10,241 56% District of Columbia $69,838 $101,971 14% $18,152 70% Florida $42,737 $55,590 8% $6,960 62% Georgia $38,980 $61,061 9% $6,487 69% Hawaii $46,034 $56,472 12% $9,638 55% Idaho $36,734 $47,530 9% $6,335 71% Illinois $47,643 $71,841 12% $8,479 51% Indiana $39,578 $61,533 9% $7,248 66% Iowa $44,937 $65,952 10% $9,285 58% Kansas $44,891 $62,711 10% $8,271 55% Kentucky $37,396 $52,660 10% $7,572 71% Louisiana $42,030 $63,919 9% $8,884 64% Maine $40,745 $51,198 12% $8,680 64% Maryland $54,176 $80,503 10% $9,300 50% Massachusetts $58,737 $90,483 10% $10,038 50% Michigan $40,740 $57,686 9% $7,670 65% Minnesota $48,998 $75,284 12% $9,415 50% Mississippi $34,431 $45,061 10% $8,077 76% Missouri $41,639 $60,118 8% $7,059 65% Montana $39,903 $51,143 10% $8,325 65% Nebraska $47,557 $69,871 10% $8,335 53% Nevada $40,742 $54,386 10% $6,504 66% New Hampshire $52,773 $71,875 8% $7,612 50% New Jersey $57,620 $85,831 11% $9,858 50% New Mexico $37,091 $51,773 11% $8,990 72% New York $55,611 $90,484 15% $12,440 50% North Carolina $39,171 $57,599 9% $7,226 68% North Dakota $55,802 $89,450 17% $11,059 50% Ohio $42,236 $62,964 10% $8,258 63% Oklahoma $43,637 $59,460 8% $7,363 59% Oregon $41,220 $61,706 10% $8,829 64% Pennsylvania $47,679 $67,096 10% $8,666 52% Rhode Island $48,359 $69,154 11% $9,190 51% South Carolina $36,677 $49,320 9% $7,660 72% South Dakota $45,279 $64,866 8% $7,467 55% Tennessee $40,457 $55,528 8% $6,624 66% Texas $45,669 $70,961 9% $7,289 57% Utah $37,664 $55,978 9% $7,122 70% Vermont $46,428 $58,855 12% $10,746 53% Virginia $50,345 $76,273 8% $8,084 50% Washington $49,610 $71,504 9% $8,774 50% West Virginia $36,132 $50,554 11% $7,996 73% Wisconsin $44,186 $64,038 10% $8,581 59% Wyoming $54,584 $83,005 11% $13,141 50% NOTE: For notes and sources, see the appendix.  Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 21 Table 7. Health Care Markets (Costs and Access) Average Family  Share of Adults  Share of Population in  Physicians  National Health  Premium for  Reporting Not  Health Profession  Accepting New  Expenditures Per  State Employer‐Based  Seeing a Doctor  Shortage Area for  Medicaid  Capita,  Health Insurance,  Due to Cost,  Primary Care,  Patients,  2009 2015 2015 as of December 2016 2013 United States $6,815 $17,322 13% 20% 69% Alabama $6,272 $15,953 17% 37% 68% Alaska $9,128 $21,089 14% 18% 90% Arizona $5,434 $16,999 15% 41% 70% Arkansas $6,167 $14,218 16% 15% 90% California $6,238 $18,045 12% 17% 54% Colorado $5,994 $16,940 12% 17% 70% Connecticut $8,654 $18,269 11% 11% 73% Delaware $10,349 $18,920 11% 21% 80% District of Columbia $8,480 $19,104 9% 35% 69% Florida $7,156 $16,009 17% 24% 56% Georgia $5,467 $17,307 16% 24% 72% Hawaii $6,856 $15,959 8% 10% 68% Idaho $5,658 $16,691 14% 29% 87% Illinois $6,756 $17,227 11% 27% 73% Indiana $6,666 $17,121 14% 29% 86% Iowa $6,921 $16,257 7% 21% 90% Kansas $6,782 $16,740 11% 23% 65% Kentucky $6,596 $16,622 12% 23% 83% Louisiana $6,795 $17,242 16% 41% 57% Maine $8,521 $16,117 9% 7% 80% Maryland $7,492 $17,961 11% 16% 66% Massachusetts $9,278 $18,454 9% 7% 76% Michigan $6,618 $15,628 13% 21% 70% Minnesota $7,409 $16,925 8% 8% 94% Mississippi $6,571 $16,081 19% 57% 83% Missouri $6,967 $16,849 14% 28% 70% Montana $6,640 $17,317 11% 25% 90% Nebraska $7,048 $16,201 12% 2% 97% Nevada $5,735 $17,434 15% 20% 79% New Hampshire $7,839 $19,208 9% 7% 88% New Jersey $7,583 $18,280 12% 0% 39% New Mexico $6,651 $17,349 14% 49% 93% New York $8,341 $19,630 12% 20% 57% North Carolina $6,444 $17,141 16% 14% 80% North Dakota $7,749 $16,020 8% 24% 96% Ohio $7,076 $16,900 11% 12% 79% Oklahoma $6,532 $16,811 15% 31% 79% Oregon $6,580 $17,141 13% 23% 77% Pennsylvania $7,730 $17,344 12% 5% 81% Rhode Island $8,309 $17,590 10% 14% 71% South Carolina $6,323 $16,764 16% 30% 72% South Dakota $7,056 $16,194 8% 23% 94% Tennessee $6,411 $15,635 16% 22% 76% Texas $5,924 $17,216 18% 19% 58% Utah $5,031 $15,998 13% 19% 77% Vermont $7,635 $17,835 8% 2% 83% Virginia $6,286 $17,566 12% 16% 70% Washington $6,782 $16,627 11% 18% 71% West Virginia $7,667 $18,322 14% 30% 83% Wisconsin $7,233 $17,662 9% 17% 88% Wyoming $7,040 $17,015 12% 25% 94% NOTE: For notes and sources, see the appendix.  Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 22 Appendix: Table Notes and Sources TABLE 1: STATE CHARACTERISTICS Expansion Status, as of January 1, 2017 Source: Kaiser Family Foundation's State health Facts, Status of State Action on the Medicaid Expansion Decision, as of January 1, 2017. Share of Medicaid Spending, by Enrollment Group, FFY 2014 Source: Kaiser Family Foundation estimates based on analysis of data from the FFY 2014 Medicaid Statistical Information System (MSIS) and CMS-64 reports. Because FY 2014 data was missing some or all quarters for some states, we adjusted the data using secondary data to represent a full fiscal year of enrollment. Total Number of Residents, 2015 Note: Population numbers are rounded to the nearest 100. Source: Kaiser Family Foundation estimates based on the Census Bureau's March 2016 Current Population Survey (CPS: Annual Social and Economic Supplement). TABLE 2: ACA EXPANSION Expansion Enrollees, Number and as a Share of Total Medicaid Enrollees, January-March 2016 Note: Louisiana expanded Medicaid on July 1, 2016 and thus has no expansion enrollment in January-March 2016. Data is not available for North Dakota. Source: Kaiser Family Foundation analysis of Medicaid spending and enrollment data collected from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES). Federal Expansion Funding, Amount and as a Share of all Federal Medicaid Spending, FFY 2015 Note: Alaska expanded on September 1, 2015 and thus reported expansion data for one month in FFY 2015. Louisiana (7/1/2016) and Montana (1/1/2016) expanded after FFY 2015. Source: CMS, Medicaid Budget and Expenditure System (MBES) Expenditure Reports, December 2016. Percentage Point Change in Uninsured Rate for Nonelderly, 2013-2015 Source: Kaiser Family Foundation estimates based on the Census Bureau's March 2014 and March 2016 Current Population Survey (CPS: Annual Social and Economic Supplements). Nonelderly Uninsured Rate, 2015 Source: Kaiser Family Foundation estimates based on the Census Bureau's March 2014, March 2015, and March 2016 Current Population Survey (CPS: Annual Social and Economic Supplements). Number of Adults in the Medicaid Coverage Gap, 2016 Note: Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. No data is available for Maine. Source: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 23 TABLE 3: MEDICAID POLICY Eligibility Income Levels for Parents, as a Percent of the Federal Poverty Level, as of January 1, 2017 Notes: Eligibility levels are based on the FPL for a family of three, which is $20,420. Sources: Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings from a 50-State Survey, Kaiser Family Foundation, January 2017. Based on a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families, 2017. Scope of Medicaid Adult Dental Benefits, as of February 2016 Source: Center for Health Care Strategies, Inc. (CHCS), Medicaid Adult Dental Benefits: An Overview, (Hamilton, NJ: CHCS, May 2017), https://www.chcs.org/resource/medicaid-adult-dental-benefits-overview/. Medicaid Physician Fee Index, 2014 Note: Tennessee does not have a Medicaid fee-for-service program and so data is not applicable. Source: Stephen Zuckerman, Laura Skopec, and Kristen McCormack, “Reversing the Medicaid Fee Bump: How Much Could Medicaid Physician Fees for Primary Care Fall in 2015?,” Urban Institute, December 2014. Shared of Medicaid Population in a Managed Care Organization (MCO), as of July 1, 2016 Source: Vernon K. Smith, Kathleen Gifford, Eileen Ellis, and Barbara Edwards, Health Management Associates; and Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse and Allison Valentine, Kaiser Commission on Medicaid and the Uninsured. Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017, Kaiser Family Foundation, October 2016. Percent of Long-Term Care Spending for Home and Community Based Services (HCBS), FY 2015 Note: Data do not include expenditures for managed care programs in California and North Carolina. Percent HCBS is not calculated for these states because a significant portion of data are missing. Source: Truven, Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2015, April 14, 2017 TABLE 4: DEMOGRAPHICS Percent of the population below 100% FPL, 2015 Note: The U.S. Census Bureau's poverty threshold for a family with two adults and one child was $19,078 in 2015. Source: Kaiser Family Foundation estimates based on the Census Bureau's March 2016 Current Population Survey (CPS: Annual Social and Economic Supplements). Unemployment Rate, as of April 2017 Source: Bureau of Labor Statistics (BLS), Regional and State Employment and Unemployment (Monthly), Table 1, Civilian labor force and unemployment by state and selected area, seasonally adjusted, April 2017; and BLS Employment Situation News Release, State Employment and Unemployment Summary – April 2017, May 19, 2017. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 24 Projected Change in persons 85+, from 2015 to 2030 Source: U.S. Census Bureau, Population Division, Interim State Population Projections, 2005, compiled by the US Administration on Aging. Percent of Nonelderly Population in Rural Areas, 2015 Source: Kaiser Family Foundation analysis based on the 2015 American Community Survey 1-Year Estimates. Percent of Total Population that is Non-White, 2015 Note: Non-White includes Black, Hispanic, Asians, NHOPIs, American Indians and persons of two or more races. Sources: Kaiser Family Foundation estimates based on the Census Bureau's March 2016 Current Population Survey (CPS: Annual Social and Economic Supplements). TABLE 5: HEALTH STATUS Overall State Health Ranking, 2016 Note: The Overall Health Status Score is compiled by the United Health Foundation and is a weighted standard deviation relative to the US value. It is based on a series of measures related to health behavior, community and environment, policy, clinical care, and health outcomes. For a complete list of measures and methodology, see http://assets.americashealthrankings.org/app/uploads/ahr16-complete-v2.pdf. The District of Columbia is not ranked. Source: United Health Foundation, America’s Health Rankings: 2016 Annual Report; May 25, 2016. Percentage of Non-Institutionalized Population Who Reported a Disability, 2015 Source: Erickson, W., Lee, C., von Schrader, S. (2017). Disability Statistics from the 2014 American Community Survey (ACS). Ithaca, NY: Cornell University Employment and Disability Institute (EDI). Retrieved June 7, 2017 from www.disabilitystatistics.org. Percent of Adults Reporting Poor Mental Health, 2015 Source: Kaiser Family Foundation analysis of the Centers for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2013-2015 Survey Results. Age-Adjusted Opioid Overdose Deaths Rates, per 100,000 Source: Kaiser Family Foundation analysis of Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. Multiple Cause of Death 1999-2015 on CDC WONDER Online Database, released 2016. Data are from the Multiple Cause of Death Files, 1999-2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on March 2, 2017. New HIV Diagnoses, Among Adults and Adolescents, per 100,000 Population, 2015 Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) AtlasPlus accessed February 2017. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 25 TABLE 6: TAXES Personal Income Per Capita, 2014 Source: Bureau of Economic Analysis, state personal income accounts, 2014. Total Taxable Resources Per Capita, 2014 Source: U.S. Department of Treasury, Total Taxable Resources, accessed April 2017. Tax Collections as a Percent of Personal Income Source: KFF analysis of Bureau of Economic Analysis, state personal income accounts, 2015; and U.S. Census Bureau, 2014 State & Local Government Finance, 2014. Total State and Local Spending per Capita, 2014 Source: U.S. Census Bureau, 2014 State & Local Government Finance, 2014. Federal Medical Assistance Percentage (FMAP) for Medicaid, 2018 Source: Federal Register, November 15, 2016 (Vol 81, No. 220), pp 80078-80080. TABLE 7: COSTS AND ACCESS Health Care Expenditures per Capita, 2009 Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Expenditure Data: Health Expenditures by State of Residence, December 2011. U.S. Population by State, 1991-2009 obtained from the U.S. Bureau of the Census, February, 2011. Average Family Premium per Enrolled Employee for Employer-Based Health Insurance, 2015 Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. Medical Expenditure Panel Survey (MEPS) -Insurance Component, 2013-2015, Tables II.D.1, II.D.2, II.D.3 available at: Medical Expenditure Panel Survey (MEPS). Share of Adults Reporting not Seeing a Doctor Due to Cost, 2015 Source: Kaiser Family Foundation analysis of the Center for Disease Control and Prevention (CDC)'s Behavioral Risk Factor Surveillance System (BRFSS) 2013-2015 Survey Results. Share of Population in Health Profession Shortage Area for Primary Care, as of December 2016 Sources: Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, Designated Health Professional Shortage Areas Statistics: Designated HPSA Quarterly Summary, as of December 31, 2016 and U.S. Census Bureau, State Population Totals Datasets: 2010-2016. Physicians Accepting new Medicaid Patients, 2013 Source: Hing et al., “Acceptance of new Patients with Public and Private Insurance b Office-based Physicians: United States, 2013,” NCHS Data Brief, No. 195, March 2015, CDC, USDHHS. Factors Affecting States’ Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? 26 Endnotes 1 KFF analysis of the March 2016 Current Population Survey, Annual Social and Economic Supplement. 2 KFF estimates based on analysis of data from the FFY 2014 Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports. 3 Personal income is the income that is received by persons from all sources. It is calculated as the sum of wage and salary disbursements, supplements to wages and salaries, proprietors' income with inventory valuation and capital consumption adjustments, rental income of persons with capital consumption adjustment, personal dividend income, personal interest income, and personal current transfer receipts, less contributions for government social insurance. This measure of income is calculated as the personal income of the residents of a given area divided by the resident population of the area. BEA uses the Census Bureau's annual midyear population estimates. http://www.bea.gov/regional/definitions/nextpage.cfm?key=Per%20capita%20personal%20income%20%28dollars%29. 4 Items excluded from person income include profits retained for investment purposes by corporations or other business entities and business or commuter income earned in the state by out of state residents, which can be influential in areas with large commuter populations, i.e. New York and New Jersey. 5 TTR estimates are currently used to allocate funds for the Community Mental Health Services and Substance Abuse Prevention and Treatment block grants. 6 Total Taxable Resources (TTR) for the District of Columbia was calculated to be over $101,000. However, because the District of Columbia does not have the same legal right as the states to tax certain resources, using the same methodology to derive TTR estimates for the District of Columbia is flawed. http://www.treasury.gov/resource-center/economic-policy/Documents/wpnewm.pdf. 7 U.S. Census Bureau, 2014 State & Local Government Finance, 2014. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.