Originally written by Lisa Swirsky, Alliance for Health Reform. Updated by John Holahan, Urban Institute and by Deanna Okrent and Beeta Rasouli, Alliance for Health Reform.
- There were an estimated 67 million low-income beneficiaries enrolled in Medicaid in 2011 and 54 million beneficiaries were estimated to be enrolled in Medicaid for at least one month in 2011.1
- Individuals with disabilities and elderly people are projected to make up 25 percent of those enrolled in Medicaid in 2012 and to account for 64 percent of total expenditures.2 One half, or approximately 33 million Medicaid beneficiaries, are projected to be children in 2012.3
- Medicaid is the nation's primary payer for long-term care and pays for more than half of publicly financed mental health services.4
- Total Medicaid spending in FY 2010 amounted to $401.5 billion, where $269.8 billion represented federal spending and $131.7 billion represented state spending. Federal spending for FY 2011 and FY 2012 is projected to decrease, while state spending is projected to go up as a result of the end of federal enhanced funds prescribed under the American Recovery and Reinvestment Act (ARRA).5
- Expenditures for FY 2012 are expected to amount to $457.4 billion, where $260.9 billion represents federal spending and $196.5 represents state spending.6 On June 28, 2012, the U.S. Supreme Court ruled the Affordable Care Act’s Medicaid expansion provision as unconstitutionally coercive to states. Previously, the Congressional Budget Office (CBO) estimated that the ACA would expand Medicaid coverage to 17 million new beneficiaries by 2022. After the Supreme Court’s ruling, however, the CBO revised its approximation to 11 million individuals. 7
Medicaid was signed into law in July 1965. It has since undergone a number of changes and enhancements, yet remains essentially an entitlement program for low-income individuals, administered by each state and financed jointly by each state and the federal government. It is authorized under Title XIX of the Social Security Act and initially was enacted to provide health care services to low-income children deprived of parental support, their caretaker relatives, the elderly, the blind, and individuals with disabilities. In 1981, freedom of choice waivers (Section1915b) and home and community-based care waivers (Section1915c) were mandated; and states were required to make additional payments to hospitals treating a disproportionate share of low-income patients (called disproportionate share hospitals or "DSH"). Other program nuances were established by law over the years, including the Qualified Medicare Beneficiary (QMB) eligibility rule in 1988, and the Specified Low-Income Medicare Beneficiary (SLMB) eligibility group in 1990 (see below for more about QMB and SLMB).8
States choose to participate in Medicaid, and all do, but they must accept certain federal rules and must cover certain groups if they are to receive federal Medicaid funding. They must, for example, provide certain mandatory benefits such as inpatient hospital services, laboratory and x-ray services, and physician services.9 Medicaid also mandates a benefits package for children known as Early and Periodic Screening, Diagnostic and Treatment.10 And, federal law requires every state to provide nursing home care and home health care for the qualified poor. This results in Medicaid paying for nearly half of long-term care.11 (See Chapter 9, “Long-Term Care,” for more.)
The American Recovery and Reinvestment Act (ARRA) granted an enhanced federal match12 that was extended through June 2011. To qualify for the enhanced match, states had to meet maintenance of effort (MOE) requirements. That is, they were required to maintain the “eligibility standards, methodologies, and procedures” that were in effect on July 1, 2008 for their programs. MOE requirements also apply to the Medicaid provisions under the Patient Protection and Affordable Care Act (ACA) that begin in 2014. (See more below on Federal Medical Assistance Percentage or “FMAP.”)
Prior to the 2014 implementation of the Medicaid expansion provisions of the ACA (see below), states must cover:
1) Poor families that meet financial requirements for cash welfare benefits in effect in 1996;
2) Families for one year after transitioning from welfare to work;
3) Pregnant women and children under age six with incomes below 133 percent of the federal poverty level (FPL);
4) Children ages six through 18 with income below 100 percent of the poverty level; and
5) Poor disabled or elderly persons who qualify for cash assistance under Supplemental Security Income (SSI).13
States can voluntarily choose to cover other groups, such as pregnant women and infants between 133 percent and 185 percent of FPL and certain categorically qualified individuals whose medical expenses have made them medically needy.14
About half of Medicaid’s approximately 68 million beneficiaries are children. 15 About 27 percent were adults in families with dependent children. About 15 percent were individuals with disabilities, and 8 percent of elderly people, on average, enrolled in Medicaid during 2012.16
Medicaid is funded jointly by the federal government and states. In FY 2010, Medicaid outlays totaled $401.5 billion; where $269.8 billion, or 67 percent, represented federal spending, and $131.7 billion, or 33 percent, represented state spending.17 Medicaid expenditures for FY 2011 are projected to increase by 7 percent to a total of $432 billion, where federal spending is projected to drop to 63 percent or $272.8 billion.18 This decrease in the amount of federal support for the program is a result of ending the enhanced federal funds prescribed under ARRA.19 Medicaid expenditures for FY 2012 are projected to increase to $457.4 billion, where $261 billion represents federal spending and $197 billion represents state spending.20 Total Medicaid expenditures are projected to reach $811 billion in 2019.21 These projections reflect the significant increase in Medicaid enrollment that is anticipated to occur in 2014 as a result of the expansion of Medicaid eligibility under the ACA. These projections may change, however, depending on how many states decide not to expand Medicaid .
Medicaid accounts for 8 percent of spending on prescription drugs and 17 percent of national spending on hospital care.22
More than half of Medicaid spending is attributable to five percent of the enrolled population – those with the greatest care needs.23 And although children made up 50 percent of the Medicaid population in 2011, they accounted for only 22 percent of costs. Non-elderly adults, who made up 27 percent of Medicaid beneficiaries, accounted for just 14 percent of the costs.24
In contrast, the elderly made up only 8 percent of the population, but accounted for 20 percent of Medicaid costs. Individuals with disabilities made up 15 percent of the Medicaid population but accounted for 44 percent of costs.25 Similar spending for these populations has also been projected for 2012. (See chart “Medicaid Enrollees and Expenditures by Enrollment Group, 2012”)
Much of Medicaid spending involves coverage for so-called “dual eligibles,”26 individuals entitled to both Medicare and Medicaid. This population makes up 15 percent of Medicaid enrollees and accounts for 39 percent of Medicaid costs.27 Medicaid provides coverage that wraps around Medicare to individuals who are eligible for full Medicaid coverage. Medicare is the primary payer for the acute care benefits that both programs cover, with Medicaid paying the difference up to the state’s payment limit for a given service. About 60 percent of dual eligibles are over the age of 65,28 contributing to the fact that much of the Medicaid spending by dual eligibles is on long-term services.29
There are other benefits for lower-income Medicare beneficiaries entitled to some—but not full—Medicaid benefits. These benefits, collectively called the Medicare Savings Program, provide help with a variety of out-of-pocket costs. The Qualified Medicare Beneficiary program (QMB or “Quimby”), one part of the Medicare Savings Program, pays for Medicare premiums, deductibles and coinsurance for people with incomes below 100 percent of the federal poverty level (FPL) and with resources two times the standard allowed under the Supplemental Security Income program.
Specified Low-Income Medicare Beneficiaries (SLMB or “Slimby”) have their Medicare Part B premiums paid if they are between 100 and 120 percent of the FPL and have resources at or below twice that allowed under SSI. (Part B pays for doctors.) Qualifying individuals can get help with their Part B premiums if they are between 120 and 135 percent of the FPL. However, this benefit is not an entitlement; states receive a limited amount of money from the federal government.
The ACA established two new federal entities—the Federal Coordinated Health Care Office (FCHCO – also known as the “Office of Duals”) and the Center for Medicare and Medicaid Innovation (Innovation Center, or CMMI)—that are involved in efforts to study and improve care for dual eligible beneficiaries.30 The Innovation Center announced a new initiative with the Medicare-Medicaid Coordination Office that will fund state demonstration projects. These projects will examine programs that fully integrate care for dual eligibles. The Innovation Center selected 15 states with contracts of up to $1 million to support the design of innovative service delivery and payment models for duals. The 15 states are: California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin.31 Funds are for the development of demonstration proposals that describe how the state would structure, implement, and evaluate a model to improve the quality, coordination, and cost effectiveness of care for dual eligible individuals. These selected states may also choose to test two new models to address the issue of financial misalignment between Medicare and Medicaid, under what is called the Financial Alignment Initiative. Massachusetts is the first state to partner with CMS in this demonstration to test models that aim to better align the financing of the two programs.32
FEDERAL MEDICAL ASSISTANCE PERCENTAGE
The federal government reimburses states for a part of their Medicaid program expenses. The federal share, known as the federal medical assistance percentage (FMAP), differs from state to state, based on state per capita income. The federal matching rate the government provides to a state ranges from 50 percent to 74 percent.33
The FMAP temporarily increased, however, by 6.2 percentage points for each state under the American Recovery and Reinvestment Act enacted into law in early 2009. Some states with substantial increases in unemployment qualified for additional FMAP increases.34 The increase remained in effect through the “recession adjustment period,” which was originally scheduled to end December 31, 2010, but was extended through June 2011.
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 (ACA)
Before the U.S. Supreme Court ruled on the constitutionality of the Medicaid expansion under the ACA, states would have been required to expand Medicaid to all individuals under age 65 with incomes up to 133 percent of the federal poverty level (FPL) or risk losing existing Medicaid funds. On June 28, 2012, however, the court ruled that the government could not compel states to expand Medicaid. Thus, states that refuse to comply with the new expansion under the ACA will not lose existing funds, but they won’t get ACA Medicaid expansion funds. The financing of the reform is somewhat complex. Currently, states receive federal assistance based on a sliding scale, where the percentage of program costs paid by the federal government (the FMAP described above) is higher for lower-income states.
States will receive their current matching rate for those who are currently enrolled in the program and those eligible under pre-reform criteria who take up coverage after the Medicaid reforms become effective in 2014.
For those who are newly eligible under the ACA, states will receive a very high matching rate; federal funding for these individuals will be 100 percent for 2014-2016, 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and thereafter. States that have already expanded eligibility to childless adults will receive a higher FMAP that will increase each year so that by 2019 they receive the same federal financing, 90 percent, as states receive for new eligibles.
Second, states that expanded coverage to childless adults beginning on April 1, 2010 will receive their regular FMAP for these individuals until 2014. This provision may be particularly attractive to states that were covering large numbers of childless adults under a state-funded program.
Third, the law will increase Medicaid payments for providers in family medicine, general internal medicine, or pediatric medicine who provide primary care in fee-for-service and managed care practices. Rates will increase to 100 percent of Medicare payment rates for 2013 and 2014; these increased payment rates are 100 percent federally financed.
Fourth, states are required to maintain current Medicaid (and Children’s Health Insurance Program) eligibility levels for children until 2019, and maintain current Medicaid eligibility levels for adults, until the new health insurance exchanges are fully operational. (See Chapter 1, Health Reform, for details.)
Established under the CHIP reauthorization of 2009 (CHIPRA) and later expanded and funded under ACA is the Medicaid and CHIP Payment and Access Commission (MACPAC). This entity is designed to review policies and make recommendations to Congress, the Secretary of Health and Human Services (HHS), and the states on a wide range of issues affecting Medicaid and CHIP populations, including health care reform.35
CHIPRA also included a set of quality provisions that are designed to help develop child-specific quality measures and improve quality of care delivered to children through Medicaid, CHIP and private insurance. The law required HHS to establish a Pediatric Quality Measures Program by 2011. (See more about CHIPRA in the chapter on Children’s Health.)36
LIKELY POLICY DEBATES
The expansion of Medicaid to adults with income up to 133 percent of the federal poverty level under the Patient Protection and Affordable Care Act will mean large increases in enrollment in states that choose to participate. Because of the very high federal matching rates available to states for new enrollees, new state financial burdens will be relatively low, initially. However, the administrative burden of large increases in enrollment is likely to be significant. Are states equipped for those new responsibilities? States that opt out of the Medicaid expansion could end up insuring fewer Americans that currently lack coverage. This could result in pressures from providers and communities encouraging state participation in the expansion.
Medicaid enrollees often cycle in and out of the program as their employment and subsequently their income status changes. Once the state insurance exchanges are operational in 2014, how will the Medicaid program coordinate these cyclical changes with individuals’ ability and eligibility to purchase insurance on the exchange? To qualify for subsidies? Creating a seamless system may be the subject of much debate about who or which state agency should be in charge of such enrollment issues and how they will coordinate with federal agencies determining subsidies.
States are facing enormous problems in paying for their current Medicaid programs because of the continuing aftereffects of the recession. The American Recovery and Reinvestment Act has helped states finance higher levels of enrollment.
Even with the extension of the enhanced FMAP from ARRA, a number of states made mid-year budget cuts to close shortfalls for FY 2011. States have implemented various Medicaid cost containment strategies including provider rate cuts, benefit restrictions, provider assessments and administrative cuts. 37
The financing of Medicaid will be a significant issue in the upcoming debates over the deficit and entitlement reform. States have been reasonably aggressive over the years in attempting to control health care costs. Most efforts will involve attempts to control spending on high-cost populations either through new capitated arrangements for the chronically ill, including long-term care populations, or through delivery system reforms such as medical homes. The debt reduction task force of the Bipartisan Policy Center recommended several actions that would include cuts to Medicaid. 38 In the short term, the task force recommended that Medicaid apply managed care principles in all states to aged Supplementary Security Income (SSI) beneficiaries. In the longer term they proposed a federal-state negotiation to allocate program responsibilities between the federal government and the states so that each would fully finance and administer its selected components of the Medicaid program. The task force asserted that this would restore incentives for cost containment and slow future program spending growth.
Likewise, the National Commission on Fiscal Responsibility and Reform has listed Medicaid as a deficit reduction target.39 Some Medicaid advocates have expressed concerns that cuts to Medicaid would affect the most vulnerable populations, especially older adults.
TIPS FOR REPORTERS
- Make sure you understand the difference between Medicaid and Medicare, especially with regard to long-term care. Medicaid will grow substantially with health reform and will serve far more people than will Medicare. Medicare covers some nursing home care and home health care but usually these follow hospitalization. The true long-term care services that are provided to the chronically ill are financed by Medicaid. Read the Medicare and long-term care chapters in the Alliance Sourcebook for details.
- State financing for Medicaid is complicated. For example, financing of Medicaid can refer to Medicaid spending for your state, including federal Medicaid funds, or Medicaid spending using state-only funds, not including federal matching funds. It is also important to realize that Medicaid financing often substitutes for uncompensated care provided to the uninsured. Uninsured patients who are not covered by Medicaid would become financial burdens to hospitals and clinics and much of that care is financed with state and local taxes.
- Most states contract with managed care organizations to provide coverage to beneficiaries. What contractual obligations between the state and the insurer exist to ensure quality of care? How are these obligations enforced? How will managed care change with health reform?
- Dual eligibles are a constant point of contention between federal and state governments. Be sure to sort out what state and federal obligations are toward these individuals and whether the respective obligations are being met. The ACA created a new office tasked to improve the coordination between federal government and the states for the care of dual eligibles. Follow the progress of this new entity, especially with regard to its funding and recommendations.
- Be mindful of which groups and services are mandated to be covered by Medicaid and which groups and services are covered at your state’s option. Coverage for voluntary groups varies significantly from state to state, while mandatory coverage is the same across states. The same is true for benefits.
- After the Supreme Court’s decision on the ACA’s Medicaid expansion, many questions remain about the implementation of provisions related to Medicaid. Pay close attention to what direction states are likely to lean in when it comes to the Medicaid expansion.
- Is your state considering not expanding its Medicaid program in 2014? Governors, their Medicaid directors and legislators aren’t necessarily in agreement on whether to move forward, so it might be worth seeing if there is disagreement within your state.
- How has the serious recession and slow recovery affected your state’s ability to maintain existing Medicaid benefits and provider reimbursement rates? Is your state cutting Medicaid benefits to help balance its budget? How so? Is it seeking a waiver from maintenance-of-effort requirements?
- What level of uptake is there in your state for QMB or SLMB? Is there a special effort to reach qualifying potential beneficiaries?
- How are access to care and quality affected by the relatively low payment levels that Medicaid sets for hospitals, physicians and other providers? What percentage of physicians in your state accepts Medicaid patients? Do these physicians have practices made up largely of Medicaid patients?
- What strategies is your state pursuing to contain Medicaid costs, improve efficiency, and improve quality?
- What impact are Medicaid budgetary problems having on safety net providers such as community health clinics and public hospitals? How will these safety net providers be affected by health reform?
- The American Recovery and Reinvestment Act of 2009 includes financial incentives toward the adoption of electronic health records (EHRs) by several types of Medicaid providers (physicians, nurse midwives, nurse practitioners, dentists, certain physician assistants, children’s hospitals and general acute care hospitals) that serve a high volume of Medicaid patients.40 Is this incentive causing providers in your area to get on board with EHRs? If not, why not? What hurdles do providers face?
- The ACA will provide for large – if temporary – increases in Medicaid physician payment rates. How do physicians expect to respond to these rates? Will there be greater physician participation in Medicaid? Will physicians be willing to care for patients who would otherwise be seen in community health centers and emergency rooms, thus reducing the net new costs of the higher payment rates?
Joan Alker, Co-Executive Director, Center for Children and Families, Georgetown University, 202/784-4075, email@example.com
Karen Davis, President, The Commonwealth Fund, 212/606-3800, KD@cmwf.org
Stan Dorn, Senior Research Associate, Urban Institute, 202/833-7200
Marian Wright Edelman, President, Children's Defense Fund, 202/628-8787
Judy Feder, Professor, Public Policy Institute, Georgetown University, 202/687-8397
Marsha Gold, Senior Fellow, Mathematica Policy Research, 202/484-4227
Dan Hawkins , Senior Vice President, Public Policy and Research, National Association of Community Health Centers, 301/347-0400x3001, firstname.lastname@example.org
Robert Helms , Resident Scholar, American Enterprise Institute, 202/862-5877, email@example.com
Catherine Hess, Managing Director for Coverage and Access, National Academy of State Health Policy, firstname.lastname@example.org
John Holahan, Director of Health Policy Research, Urban Institute, 202/261-5666
Genevieve Kenney, Senior Fellow, Urban Institute, 202/833-7200
Barbara Lyons, Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270, email@example.com
Enrique Martinez-Vidal, Vice President, AcademyHealth, and Director, State Coverage Initiatives Program, 202/292-6700
Charles Milligan, Executive Director, Hilltop Institute, UMBC, 410/455-6274, firstname.lastname@example.org
Judy Moore, Co-Director, National Health Policy Forum, 202/872-0292
Patricia Nemore, Attorney, Center for Medicare Advocacy, (202)293-5760x102, email@example.com
Nina Owcharenko, Senior Policy Analyst, Center for Health Policy Studies, The Heritage Foundation, 202/608-6221
Edwin Park, Co-Director of Health Policy, Center on Budget and Policy Priorities, 510/524-8033
Scott Pattison, Executive Director, National Association of State Budget Officers, 202-624- 8804, firstname.lastname@example.org
Ron Pollack, Executive Director, Families USA, 202/628-3030, Communications Director: David Lemmon -- email@example.com
Sara Rosenbaum, Chair of Department of Health Policy, George Washington University, 202-530- 2343, firstname.lastname@example.org
Diane Rowland, Executive Vice President, Kaiser Family Foundation, 202/347-5270, email@example.com
Matt Salo, Executive Director, National Association of Medicaid Directors, 800-507-6050
John Sheils, Vice President, The Lewin Group, 703/269-5610,
Bruce Siegel, CEO, National Association of Public Hospitals and Health Systems, 202/585-0100
Stephen Somers, President, Center for Health Care Strategies, 609/528-8400, firstname.lastname@example.org
James Tallon, President, United Hospital Fund, 212/494-0700, email@example.com
Grace-Marie Turner, President, Galen Institute, 703/299-8900
Judy Waxman, Vice President for Health and Reproductive Rights, National Women's Law Center, 202/588-5180, firstname.lastname@example.org
Alan Weil, Executive Director, National Academy for State Health Policy, 202-903-0101, email@example.com
Judith Wooldridge, Senior Vice President, Mathematica Policy Research, 609/275-2370
Tom Bradley, Unit Chief, Health Systems and Medicare Cost Estimates Unit, Congressional Budget Office, 202/226-9010
James Cosgrove, Director, Health Care, Government Accountability Office, 202/512-7029, firstname.lastname@example.org
Bill Lasowski, Deputy Director, Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services, 410/786-2003
Cindy Mann, Director, Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services, 410-786-3871 x 9114, email@example.com
Trish Riley, Director, Maine Governor's Office of Health Policy and Finance, 207/624-7442, firstname.lastname@example.org
Richard Rimkunas, Head, Health Insurance and Financing, Congressional Research Service, 202/707-7334
Brenda Craine, Director, Washington Media Relations, American Medical Association, 202/789-7447, email@example.com
Lynda Flowers, Senior Policy Advisor, AARP, 202/434-3889, firstname.lastname@example.org
Patricia Gabow, CEO and Medical Director, Denver Health, 303/436-6606, email@example.com
Thomas Johnson, Executive Director, Medicaid Health Plans of America, 202/857-5720, firstname.lastname@example.org
Mary Mason, Chief Medical Officer, Centene Corporation, 314/725-4477
Alicia Mitchell, Vice President, Media Relations, American Hospital Association, 202/626-2339
Meg Murray, Chief Executive Officer, Association for Community Affiliated Plans, 202/204-7509, email@example.com
1 Congressional Budget Office. “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/43059_Medicaid.pdf
2 Congressional Budget Office. “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/43059_Medicaid.pdf
3 Congressional Budget Office. “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/43059_Medicaid.pdf
4 Congressional Research Service (2008). “Medicaid: A Primer.” January 17, CRS-12. (www.policyarchive.org/bitstream/handle/10207/2676/RL33202_20051222.pdf?sequence=1).
5 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf
6 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf
7 The Kaiser Family Foundation. “A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion.” August 2012. http://www.kff.org/healthreform/upload/8347.pdf
8 CMS. “Key Milestones in CMS Programs”. https://www.cms.gov/History/
9 Congressional Research Service (2008). “Medicaid: A Primer.” January 17, CRS-4. (www.policyarchive.org/bitstream/handle/10207/2676/RL33202_20051222.pdf?sequence=1).
10 Congressional Research Service (2008). “Medicaid: A Primer.” January 17, p. CRS-5
(www.policyarchive.org/bitstream/handle/10207/2676/RL33202_20051222.pdf?sequence=1). See also: Centers for Medicare and Medicaid Services, Overview of Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit. (http://www.cms.hhs.gov/medicaidearlyperiodicscrn/).
11 National Clearinghouse for Long-term Care Information http://www.longtermcare.gov/LTC/Main_Site/Paying_LTC/Costs_Of_Care/Costs_Of_Care.aspx
12 National Health Law Program (2009). “State Maintenance of Effort Requirements for Enhanced FMAP”
13 Congressional Research Service (2008). “Medicaid: A Primer.” January 17, CRS-2-3. (www.policyarchive.org/bitstream/handle/10207/2676/RL33202_20051222.pdf?sequence=1).
14 Congressional Research Service (2008). “Medicaid: A Primer.” January 17, CRS-3. (www.policyarchive.org/bitstream/handle/10207/2676/RL33202_20051222.pdf?sequence=1).
15 Congressional Budget Office. “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/43059_Medicaid.pdf
16 Congressional Budget Office. “Medicaid Spending and Enrollment Detail for CBO’s March 2012 Baseline.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/43059_Medicaid.pdf
17 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-
18 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf
19 Vernon K. Smith, Kathleen Gifford, Eileen Eillis, Robin Rudowitz and Laura Snyder. “Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2011 and 2012.” Kaiser Commission on Medicaid and the Uninsured and Health Management Associates Report. http://www.kff.org/medicaid/upload/8248-ES.pdf
20 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf
21 Center for Medicare and Medicaid Services, Office of the Actuary. “2011 Actuarial Report on The Financial Outlook for Medicaid.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/MedicaidReport2011.pdf
22 Center for Medicare and Medicaid Services, Office of the Actuary. “National Health Expenditures.” January 2009.
23 The Kaiser Family Foundation (2008). “Medicaid: A Primer.” December, page 15. (www.kff.org/medicaid/7334.cfm).
24 Georgetown University Health Policy Institute, Center for Children and Families. “About Medicaid for Children and Families http://ccf.georgetown.edu/index/about-medicaid-full
25 Georgetown University Health Policy Institute, Center for Children and Families. “About Medicaid for Children and Families http://ccf.georgetown.edu/index/about-medicaid-full
27 Kaiser Commission on Medicaid and the Uninsured. “Dual Eligibles: Medicaid’s Role for Low-Income Medicare Beneficiaries.” May 2011.( http://www.kff.org/medicaid/upload/4091-08.pdf)
29 John Holahan, Dawn M. Miller, and David Rousseau, “Rethinking Medicaid's Financing Role for Medicare Enrollees.” Kaiser Commission on Medicaid and the Uninsured, February 2009.
30 Kaiser Commission on Medicaid and the Uninsured (2010). ”Dual Eligibles: Medicaid’s Role for Low-Income Medicare Beneficiaries.” http://www.kff.org/medicaid/upload/4091-07.pdf
31 Center for Mediciare & Medicaid Innovation (2012). “State Demonstrations”
32 Centers for Medicare and Medicaid Services. “CMS and Massachusetts Partner to Coordinate Care for Medicare-Medicaid Enrollees.” August 23, 2012.
33 Georgetown University Health Policy Institute, Center for Children and Families. http://ccf.georgetown.edu/medicaid/about-medicaid/
34 The American Recovery and Reinvestment Act of 2009 (H.R.1.) Section 5001, Temporary Increase of Medicaid FMAP. (http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.1:).
35 MACPAC. http://www.macpac.gov/
36 Georgetown University Center for Children and Families (2010). “Understanding the New Quality Initiatives in CHIPRA.” http://ccf.georgetown.edu/index/cms-filesystem-action?file=ccf%20publications/federal%20schip%20policy/quality%20paper%202-1.pdf
37 Kaiser Commission on Medicaid and the Uninsured (2011).
“Waiting for Economic Recovery, Poised for Health Care Reform: A Mid-Year Update for FY 2011 - Looking Forward to FY 2012 “
38 Bipartisan Debt Reduction Task Force Report (2010) “Restoring America’s Future” http://bipartisanpolicy.org/sites/default/files/FINAL%20DRTF%20EXECUTIVE%20SUMMARY_0.pdf
39 WSJ “Deficit Plan Wins Backers” http://online.wsj.com/article/SB10001424052748704594804575648503541856136.html
40 The American Recovery and Reinvestment Act of 2009 (H.R.1.) Section 4201, Medicaid Provider HIT Adoption and Operation Payments; Implementation Funding. (http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.1:).