CHAPTER 6 - MEDICAID
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- Medicaid-financed services reached an estimated 60 million people in 2006.a
- In 2004, Medicaid spent $288 billionb in combined federal and state funds, and estimated total spending in 2006 is $320 billion.c
- Medicaid is the largest insurer of low-income children,d low-income pregnant women and newborns,e low-income people with disabilities,f people with AIDS,g and those requiring nursing home care.h
- Medicaid is a critical source of financing for the nation’s health care safety net, including community health centers, public clinics, and other providers that serve low-income people.i
- Medicaid provides benefits to the children of workers whose employers don’t offer coverage, to disabled people who must wait 24 months for Medicare coverage, and to individuals who need more services than are available in a range of other programs, such as the Ryan White CARE Act for people living with HIV/AIDS.j
Along with private insurance and Medicare, Medicaid is a cornerstone of the American health care system. It is a surprisingly flexible program1-available in the event of both general recessions and individual job losses, as well as when private employers drop their insurance coverage.2 Medicaid was a first-responder during Katrina3, as well as earlier public health emergencies, such as the HIV/AIDS epidemic4 and the terrorist attacks of 9/11.5
Medicaid finances services for tens of millions of Americans, reaching an estimated 60 million people (roughly 20 percent of the U.S. population) at some point in 2006.6 (More than 38 million were covered for all of 2005, according to the Census Bureau.)7 The program now spends an estimated $320 billion a year in combined federal and state funds,8 and accounts for about 17 percent of all U.S. health expenditures.9
It is the program that states love to hate, because costs have been rising steadily. (See chart, “Actual and Projected Total Medicaid Spending, 2000-2005.”) Expressed as a share of total state budgets – which includes federal funding – Medicaid consumed 22 percent of average state spending in FY 2004. Expressed as a share of the states’ own revenue, the program was 13 percent of spending that year, a dramatic increase from 6 percent in 1989.10 (See chart, “Medicaid as a Share of State Budgets, 2004.”) During the next 10 years, the Congressional Budget Office (CBO) projects that federal Medicaid spending (excluding the state share) is on track to double, from an estimated $190 billion in FY 2006 to $363 billion by 2015.11
Medicaid is the largest insurer of low-income children,12 low-income pregnant women and newborns,13 low-income people with disabilities,14 people with AIDS,15 and frail elders requiring nursing home care. Medicaid paid $37 billion of the $92 billion tab for institutional care of the elderly in 2004.16 Many people think Medicare pays for custodial (long-term) nursing home care, but in fact, while the Medicare program does pay for institutional care in certain settings such as skilled nursing facilities, these services are time-limited and are aimed at rehabilitation.
Public hospitals and children’s hospitals receive Medicaid funding, and the program is a critical source of financing for the nation’s health care safety net, including community health centers, public clinics, and other providers that serve low-income people.17 Medicaid provides benefits to some children of workers whose employers don’t offer coverage; to severely disabled working-age adults who are deemed eligible for Medicare, but who must wait two years for Medicare coverage; and to individuals who need more services than are available through such programs as the Ryan White CARE Act for people living with HIV/AIDS.18
Medicaid is constantly evolving. Whether Congress changes the law, or states obtain waivers to provide services differently than would otherwise be allowed, there are always new developments in Medicaid.
A Brief History of Medicaid’s Evolving Coverage
Medicaid’s role in bridging the many coverage and financing gaps in the U.S. health care would probably be quite a surprise to its original authors. Congress created the program in 1965 to serve people receiving cash assistance: children, their "caretaker relatives,” and the "aged, blind, and disabled.” During the 1980’s, this began to change: In 1986, Congress expanded the program to allow states to cover all pregnant women and infants below the federal poverty level (FPL) – whether they were receiving welfare or not. By 1988, this coverage became mandatory.
Similarly, in 1986, Congress created the “Qualified Medicare Beneficiaries” (QMB) program (pronounced “QUIM-bee”) to give low-income seniors relief from Medicare’s out-of-pocket costs, such as the program’s deductible for hospitalizations. This program was originally a state option, but by 1988, QMB coverage was required.
The next year, Congress expanded eligibility to include all pregnant women and young children up to 133 percent of the FPL. Then, in 1990, Congress required states to phase in coverage of all children in families below poverty, starting with those born after Sept. 30, 1983, and created the Medicare "Specified Low-Income Medicare Beneficiaries” (SLMB) program (pronounced “SLIM-bee”) to provide more limited relief for Medicare cost-sharing to seniors with incomes up to 135 FPL.
More recently, Medicaid has evolved into a platform for coverage of adults with disabilities who are not low-income, but who are still priced out of the private health insurance market due to risk underwriting. (For information on underwriting, see Chapter 2, Private Health Coverage.) In 1997, for example, states were given the option of including working people with disabilities with income up to 250 percent of poverty. In 1999, these income limits were removed.
Most recently, as part of the Deficit Reduction Act of 2005 (DRA), a provision was enacted to allow coverage for children with disabilities whose families are middle-income. Children with disabilities are often enrolled in Medicaid, where they have access to comprehensive coverage through the Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit, which guarantees regular health visits and dental, hearing, and vision screenings, as well as any treatment found in the screenings to be medically necessary.
Running parallel to these evolutions in individual eligibility, Medicaid financing of certain programs has also changed over time. For example, in 1981, Congress created the Disproportionate Share Hospitals (DSH) program, providing funding for states to make special payments to facilities that serve a high proportion of uninsured people. Eight years later, guarantees of Medicaid coverage for community health centers and other clinics known as Federally Qualified Health Centers serving rural areas and other underserved areas took effect.
Medicaid: A Federalist Model That Directs Who and What Is Covered
As the brief history above shows, Medicaid’s structure is a crystallization of one form of Federalism – a program that is jointly funded and administered by the federal government and the states. States are required to meet minimum federal standards for who will be eligible, what benefits will be provided, and how states will account for drawing down federal funds.
Beyond these requirements, each state has substantial flexibility to expand coverage and benefits, to design its service delivery system, and to set payment rates for providers. Across the country, the extent of state discretion is evident in the range of services and types of beneficiaries covered, in the amount states pay per beneficiary, and in payments to providers.
Some of the variation is because federal funding to states also varies widely, governed by a financing formula known as the Federal Medical Assistance Percentage (FMAP). The lowest level of federal contribution, which occurs in 17 states and territories, is a 50 percent match. In other words, of every dollar spent on Medicaid, the federal government contributes 50 cents. The highest federal contribution, in Mississippi, is a little more than three to one (almost 76 percent in FY 2007). Thus, of every dollar spent on Medicaid in Mississippi in FY 2007, the federal government will contribute 76 cents. Across all states, the average federal Medicaid contribution is 57 percent.19 A slightly higher percentage, the “enhanced” FMAP, is used to calculate the federal contribution toward the cost of Medicaid’s closest cousin, the State Children’s Health Insurance Program (SCHIP).20 (See Chapter 3, “Children’s Health Coverage”.)
Medicaid’s entitlement to individuals means that states as a condition of receiving federal funds must enroll all eligible people who apply. During a recession or an epidemic, if more people become eligible and apply for the program, states must enroll them and there can be no waiting lists. The law’s open-ended federal financing to the states for expenses incurred means that as enrollment increases, so does federal matching money.21
To receive Medicaid, a person must be both “categorically eligible” and also meet financial eligibility requirements. The principal groups that federal law requires all states to cover (and who thus are “categorically eligible”) are low-income children and pregnant women, and low-income frail elders and persons with disabilities. (See chart, “Medicaid Enrollees and Expenditures, 2004.”) There are other more narrowly defined groups, such as recipients of adoption or foster care assistance.
If applicants do not fit into one of these “categorical eligibility” groups – even if their incomes and assets are low enough to meet financial eligibility requirements – they cannot enroll in Medicaid. Most notably, “childless adults,” or people between 21 and 64 who are not parents living with dependent children, are almost always ineligible for Medicaid (unless they meet a strict standard of long-term disability).
In addition to the mandatory coverage groups, states can elect to expand eligibility to various groups of people, who are sometimes referred to as “optional” populations. Many states have elected to cover groups that are categorically eligible – e.g., pregnant women and young children – at income levels that are higher than federal law requires.
Other “optional” groups that many states cover are individuals known as “medically needy,” whose high monthly medical expenses push them below state-established minimum income thresholds, people who live in certain long-term care institutions (principally intermediate care facilities for people with mental retardation), and those who are at risk of being institutionalized.
Moving in the other direction, eligibility restrictions have also become more common for some optional groups, particularly immigrants. In general, legal immigrants are not eligible for Medicaid during their first five years in the U.S. Undocumented immigrants are not eligible for most Medicaid benefits at all, although they may be covered for certain emergency services and infectious disease control services.22
Recurring congressional debates during the last decade have sought to change the nature of the Medicaid entitlement – sometimes attempting to make it more expansive, at other times, more restrictive.
Some of the most prominent debates have focused on “block grant” proposals that would provide fixed amounts of federal funding to each state. Although varying in details, block grant proposals would eliminate the requirement to enroll all beneficiaries who meet eligibility requirements.
Medicaid’s constellation of benefits (see box, “Medicaid Benefits”) is designed to meet the acute and long-term care needs of vulnerable groups of people, many of whom are demonstrably sicker, more disabled and frailer than many privately insured people.
For adults, states have wide discretion to design the duration and frequency of services —both those that are required and those that are allowed. For example, many states limit the number of days a beneficiary can spend in the hospital each year or the annual number of visits to a physician. Some have strictly limited the number of prescription drugs that a person may receive per month, or services such as dental care and eyeglasses.23 But to receive federal matching payments, the benefit must be sufficient in “amount, duration, and scope” to achieve its purpose.24 For instance, an immunization program must include all recommended booster shots.
With regard to optional benefits, while states have created a wide array of different programs, all offer prescription drugs, and nearly all cover rehabilitation services, eyeglasses, and dentistry; in contrast, only around half cover chiropractors and psychologists, and few cover respiratory care and the services of medical social workers.25
Congress and the states have regularly turned to Medicaid to address certain public health crises. Following tuberculosis outbreaks in the late 1980s, states were allowed in 1993 to extend eligibility for Medicaid to people who tested positive for TB.26 And in an effort to increase pediatric immunization rates, Medicaid was expanded in 1994 to pay for vaccines for uninsured and underinsured children who are not themselves Medicaid beneficiaries.27 In 2000, states were given the authority to cover uninsured women who are diagnosed with breast or cervical cancer through screening programs run by the Centers for Disease Control and Prevention.28
States often request federal permission (called “waivers”) to deviate from some aspect of federal law. Sometimes states apply for waivers to provide services to categories of people who would not otherwise qualify under federal law; another common reason is to deliver services that could not otherwise be offered. In general, waivers are required to be “budget neutral” over the life of the waiver.29
There are two main types of waivers, each named after the section in the Social Security statute that authorizes it: 1115 waivers, which are statewide, and 1915(c) waivers. Both are time-limited (usually for three or five years) and can be renewed.30 Home and community-based waivers under section 1915(c) have often been used to allow states to offer a more comprehensive package of services than they otherwise could to individuals needing substantial assistance to live in the community – e.g., case management and habilitation (services that teach individuals the skills necessary to live in non-institutional settings), adult day care and respite care. In 2006, 254 home and community-based services (HCBS) waivers were operating.31 The most recent enrollment data, from 2002, show nearly a million beneficiaries were then covered under 1915(c) waivers.
A number of states have used the research and demonstration authority of 1115 waivers for far-reaching changes to their Medicaid programs. Some of these waivers redistribute DSH funds and use the money saved to expand coverage. Other 1115 waivers have been used more as cost-control devices to limit eligibility and benefits. Some analysts argue that during the past few years, the Bush Administration has allowed states to broadly restructure their programs under 1115 waivers in exchange for accepting prospective aggregate limits that resemble block grants.32
States have also used waiver authority to develop “Cash and Counseling” programs, which allow beneficiaries to control their own budgets for hiring a personal care assistant and to purchase supplementary services aimed at promoting independence.33 (For additional information see Chapter 7, “Long-term Care”.)
Spending, Enrollment and Coverage Trends in Medicaid
The Congressional Budget Office predicts that Medicaid spending will grow by more than 8 percent a year over the next decade. But rising health care costs are also an issue of concern for private insurers, other health care programs, and the economy as a whole (see Chapter 8 on Health Care Costs for details.) To take one example, the new Medicare prescription drug benefit is projected to increase Medicare spending by 17 percent in 2006 and 14 percent in 2007.34 (See Chapter 5, “Medicare Prescription Drugs”.)
Medicaid is tied to the fiscal health of states, and the growth in state revenues has been variable in recent years. This led to some state cutbacks in eligibility and benefits during the last five years.
Despite this, the post-9/11 economic downturn and other factors spurred rises in Medicaid enrollment and spending. Between FY 2004 and FY 2005 alone, state Medicaid expenses went up 12.8 percent and federal Medicaid expenses increased 4.7 percent.35 (See chart, “Growth in Medicaid Expenditures by Region, FY 2004 to FY 2005.”) Between 2000 and 2005, the number of people enrolled for an entire year increased from 29.5 million to 38.1 million.36 The number of individuals receiving some services that were financed by Medicaid was higher, reaching an estimated 60 million by 2006.37 These coverage increases have had a notable impact: Medicaid and the State Children's Health Insurance Program (SCHIP) have successfully reduced the number of uninsured children.38 (For more on children’s coverage, see Chapter 3, “Children’s Health Coverage”).
An emerging pattern in Medicaid is the move away from any single model of service delivery. Some divergence arises from each state’s decision about the options it chooses to cover. Another factor driving divergence is the underlying level of—and changes in—the private insurance market, and a third factor is the amount of per-person spending for different groups of Medicaid beneficiaries. This spending variation is wide: For example, in 2002, Maine spent $4,731 per elderly person in Medicaid, while Connecticut spent $21,105.39
In the future, the Deficit Reduction Act of 2005 (DRA) is likely to spur even greater divergence among Medicaid programs around the country. Before the DRA, federal law strictly limited what states could charge beneficiaries. Premiums and enrollment fees were usually prohibited (except through waivers), as were other forms of cost-sharing for some groups (for example, pregnant women and children) and certain services (e.g., hospice care and emergency room services). When cost-sharing was allowed, it was generally limited to a “nominal” level of no more than $3. Moreover, Medicaid prohibited withholding services from a beneficiary if he or she were unable to pay.40
The DRA replaces these provisions and allows a tiered schedule of cost-sharing, largely based on a beneficiary’s income level. Although exceptions exist, especially for children, the new rules allow people with incomes under the poverty level to be charged co-payments that are to be “nominal,” but that can total up to five percent of their annual income.41
Those whose income is between 100 percent and 150 percent of poverty may be assessed for cost-sharing up to 10 percent of the cost of specific items and services, for a total of no more than five percent of their income. People whose income is above 150 percent of poverty are subject to paying premiums and cost-sharing – up to 20 percent of the cost of an item or service, for a total no more than five percent of their income. Certain services, notably pregnancy-related services and children’s preventive services, are exempt from these copayments.
The statute permits states to set up varying cost-sharing rules for different groups of people, and to vary cost-sharing by geographic area. For example, people living with AIDS can be charged different rates than people living with mental illness, or people living in rural areas may be charged different rates than people living in urban areas. Importantly, states can now choose to permit providers to refuse care to beneficiaries who cannot pay their cost-sharing.42
Taking a page from the SCHIP playbook, the DRA allows states to replace the standard Medicaid benefits package for some groups with “benchmark plans” that resemble commercial insurance. Medicaid coverage may include coverage in a plan that is available to state employees, the plan offered by the largest commercial HMO in the state, or the Blue Cross-Blue Shield plan for federal employees. Some states have moved quickly to do this, including West Virginia43 and Idaho.44
States may also develop other benchmark coverage standards if they are accepted by the federal government as “appropriate.” People with disabilities cannot be required to enroll in plans offering benchmark coverage, nor can pregnant women, but children are not exempt. However, if a state replaces its standard Medicaid program for children with a benchmark plan, it must also provide “wrap-around” coverage for the EPSDT benefit.45
Following the enactment of SCHIP in 1997, many states made efforts to simplify enrollment procedures as a means of encouraging eligible people to enroll for services. But in a reversal of this trend, as of July 1, 2006, the DRA requires Medicaid beneficiaries to periodically document their citizenship using a passport, birth certificate or other specified forms. While the stated impetus for this change was to address immigration issues, it is widely expected to pose difficulties for many older Americans who do not have such papers.46 Some states, including California and Ohio, decided to delay implementing the documentation provision.47,48 A class-action lawsuit was also filed.49
In other provisions, the DRA gives states new tools to fight fraud by allowing states that have whistleblower statutes allowing recovery for false claims against Medicaid to keep an additional 10 percent of any recoveries.50 And in recognition of Medicaid’s role in helping Katrina evacuees with little or no documentation to obtain medical care, DRA provided $2 billion in additional funding.51
Current Policy Debates and Proposals
The series of changes in Medicaid that are featured in the DRA are in part the work of the Bush Administration’s appointed Medicaid Commission52 and the National Governors Association.53 The Medicaid Commission is required to report final recommendations for “stabilizing” Medicaid in a series of additional proposals, due by December 31, 2006.54
The recommendations, some of which may be of interest to the 110th Congress, could range from modest to sweeping. For example, ideas that have been discussed during the Commission’s public meetings include proposals to split Medicaid into different programs for acute care, chronic conditions, and prevention; to convert the program into a block grant; to eliminate categorical eligibility and base eligibility on function instead; to create a tax to raise revenue for subsidies to help purchase long-term care; to mandate all people to purchase private long-term care insurance; and to devise ways to enroll young men in the program.55
Another issue, in the wake of enactment of the Medicare prescription drug benefit, is the objection by some states to the law’s required financing mechanism, known as the “clawback.” The Medicare Modernization Act requires that states provide funding equivalent to 90 percent of the estimated amount that they would otherwise have spent on medications for the so-called “dual eligible” population that is comprised of frail, low-income elders. However, in June 2006, the Supreme Court declined to hear a lawsuit filed by five states to block collection of state funds.56
One thing seems certain: As Medicaid continues to evolve, the fundamental tensions inherent between the federal government and the states over costs and control of coverage will continue.
- How is health coverage of people insured in your state changing? Are losses in private insurance accompanied by increases in Medicaid enrollment among adults? Is the same pattern true for children?
- How much does your state project Medicaid spending will be next year? In five years, and in 10 years? How is that affecting state budget planning? What are the leading ideas for controlling costs without sacrificing coverage?
- How does your state compare to its neighboring states or to the U.S. as a whole in Medicaid coverage and spending? Using the custom data sheets (available at http://www.kff.org/mfs/ index.jsp), what are the significant differences in eligibility, benefits, and spending between your state and others? What are the underlying reasons?
- What changes has your state made in eligibility or benefits recently? How have these changes affected access for beneficiaries? How have they affected those health care providers (such as public hospitals, community health centers, or nursing homes) that serve a large number of Medicaid beneficiaries?
- What are the relative costs of providing health services to Medicaid beneficiaries in your state? Are most of the program dollars used to pay for children’s health, or for nursing home care? Do recent or proposed cuts in the program target services for certain groups of beneficiaries, and if so, is this related to their cost?
- Is your state implementing new cost-sharing requirements for beneficiaries, and new benchmark plans? Is the state enrolling the disabled children of families with higher-incomes in Medicaid?
- New cost-sharing requirements may save states money if they deter people from enrolling and induce beneficiaries to seek fewer services. Is this occurring in your state?
- How are the Deficit Reduction Act citizenship documentation requirements being implemented in your state? Are there elderly people or nursing home residents without papers? What have they used for records until now?
Experts and Websites
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Ferguson, Christine, Associate Research Professor, Department of Health Policy, George Washington University, 202/696-6922
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Waxman, Judy, Vice President for Health and Reproductive Rights, National Women's Law Center, 202/588-5180
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Westmoreland, Tim, Research Professor, Health Policy Institute, Georgetown University, 202/687-1058
Wilson, Joy Johnson, Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400
Wooldridge, Judith, Senior Vice President, Mathematica Policy Research, 609/275-2370
Wright Edelman, Marian, President, Children's Defense Fund, 202/628-8787
Zuckerman, Steve, Principal Research Associate, The Urban Institute, 202/833-7200
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Smith, Dennis, Director, Center for Medicaid and State Operations, Centers for Medicare and Medicaid Services, 202/690-7428
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American Enterprise Insititute www.aei.org
American Hospital Association www.aha.org
American Medical Association www.ama-assn.org
Center for Health Program Development and Management www.chpdm.org
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Center for Medicare Advocacy www.medicareadvocaay.org
Center on Budget and Policy Priorities www.cbpp.org
Centers for Medicare and Medicaid Services www.cms.hhs.gov
Children's Defense Fund www.childrensdefense.org
The Commonwealth Fund www.cmwf.org
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Denver Health www.denverhealth.org
Economic & Social Research Institute www.esresearch.org
Families USA www.familiesusa.org
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Georgetown University Center for Children and Families http://ccf.georgetown.edu
Georgetown University Health Policy Institute http://ihcrp.georgetown.edu/
Georgetown University Public Policy Institute http://gppi.georgetown.edu/welcome.html
Government Accountability Office www.gao.gov
Health Policy R & D www.hprd.net
Kaiser Commission on Medicaid and the Uninsured www.kff.org/about/kcmu.cfm
Kaiser Family Foundation www.kff.org
The Lewin Group www.lewin.com
Maine Governor's Office for Health Policy and Finance www.healthpolicy.maine.gov/
Mathematica Policy Research www.mathematica-mpr.com
Medicaid Health Plans of America www.mhpa.org
Medicare Rights Center www.medicarerights.org
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National Association of Children's Hospitals www.childrenshospitals.net
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National Women's Law Center www.nwlc.org
Robert Wood Johnson Foundation www.rwjf.org
State Coverage Initiatives www.statecoverage.net
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Urban Institute www.urban.org
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g Westmoreland, Tim (1999). “Medicaid & HIV/AIDS Policy: A Basic Primer.” Kaiser Family Foundation, July. (http://www.kff.org/hivaids/upload/Medicaid-and-HIV-AIDS-Policy-A-Basic-Primer-Report.pdf). Retrieved on June 2, 2006.
h O’Brien, Ellen (2005). “Medicaid coverage of nursing home costs: Asset shelter for the wealthy or essential safety net?” Georgetown University Long-Term Care Financing Project, May, p. 1. (http://ltc.georgetown.edu/pdfs/nursinghomecosts.pdf). Retrieved on June 30, 2006.
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j “Ryan White CARE Act: An Update of Reauthorization from 2000 to 2004.” (2004) The Body, July. (http://www.thebody.com/aac/brochures/ryanwhite_reauthorization.html). Retrieved on June 29, 2006.
1 Mann, Cindy & Tim Westmoreland (2004). “Attending to Medicaid.” The Journal of Law, Medicine & Ethics, Fall; 32(3), p. 416-425. (http://ihcrp.georgetown.edu/pdfs/ASLME_Paper.pdf). Retrieved on June 1, 2006.
2 Dorn, Stan et al. (2005). “Medicaid Responsiveness, Health Coverage, and Economic Resilience: A Preliminary Analysis.” The Health Policy Institute of the Joint Center for Political and Economic Studies, September, p.5. (http://www.esresearch.org/documents_1-05/Medicaid_Responsive.pdf). Retrieved on June 4, 2006.
3 Kaiser Commission on Medicaid and the Uninsured (2005). “Health Coverage for Individuals Affected by Hurricane Katrina: A Comparison of Different Approaches to Extend Medicaid Coverage.” October, p.1. (http://www.kff.org/medicaid/upload/7417.pdf). Retrieved on June 4, 2006.
4 Westmoreland, Tim (1999). “Medicaid & HIV/AIDS Policy: A Basic Primer.” Kaiser Family Foundation, July, p. 5. (http://www.kff.org/hivaids/upload/Medicaid-and-HIV-AIDS-Policy-A-Basic-Primer-Report.pdf). Retrieved June 4, 2006.
5 Perry, Michael (2002). “New York’s Disaster Relief Medicaid: Insights and Implications for Covering Low-Income People.” Kaiser Commission on Medicaid and the Uninsured and the United Hospital Fund, August, p. 1. (http://www.uhfnyc.org/usr_doc/4062.pdf). Retrieved on June 29, 2006.
6 Congressional Budget Office (2006). “Medicaid Spending Growth and Options for Controlling Costs.” http://ftp.cbo.gov/ftpdocs/73xx/doc7387/07-13-Medicaid.pdf Testimony of Acting Director Donald Marron. Retrieved July 14, 2006.
7 U.S. Census Bureau (2006). “Table HI-1. Health Insurance Coverage Status and Type of Coverage by Sex, Race and Hispanic Origin: 1987 to 2005).” August 31. (www.census.gov/hhes/www/hlthins/historic/hihistt1.html)
8 Borger,Christine et al. (2006). “Health Spending Projections through 2015: Changes on the Horizon.” Health Affairs, 25; w61-w73. (www.healthaffairs.org). Retrieved on June 1, 2006.
9 Kaiser Commission on Medicaid and the Uninsured (2006). “The Medicaid Program at a Glance.” May. (http://www.kff.org/medicaid/upload/7235.pdf). Retrieved on June 1, 2006.
10 Scott, Christine (2005). “Medicaid and the Current State Fiscal Crisis.”Congressional Research Service, January. RL31773.
11 Congressional Budget Office (2006). “Medicaid Spending Growth and Options for Controlling Costs.” http://ftp.cbo.gov/ftpdocs/73xx/doc7387/07-13-Medicaid.pdf Testimony of Acting Director Donald Marron. Retrieved July 14, 2006.
12 Kaiser Commission on Medicaid and the Uninsured (2004). “Key Facts: Health Coverage for Low-Income Children.” September. (http://www.kff.org/uninsured/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=46994). Retrieved on June 2, 2006.
13 Institute of Medicine of the National Academies (2002). “Health Insurance is a Family Matter.” September. (http://www.iom.edu/report.asp?id=4356). Retrieved on June 2, 2006. 14 Crowley, Jeffrey S. & Risa Elias (2003). “Medicaid's Role for People with Disabilities.” Kaiser Commission on Medicaid and the Uninsured, August, p. 10. (http://www.kff.org/medicaid/4027.cfm). Retrieved on June 2, 2006.
15 Westmoreland, Tim (1999). “Medicaid & HIV/AIDS Policy: A Basic Primer.” Kaiser Family Foundation, July, p. 5. (http://www.kff.org/hivaids/upload/Medicaid-and-HIV-AIDS-Policy-A-Basic-Primer-Report.pdf). Retrieved on June 2, 2006.
16 Congressional Budget Office, “The Cost and Financing of Long-Term Care Services,” testimony of Douglas Holtz-Eakin, April 2005; Table 1. http://www.cbo.gov/showdoc.cfm?index=6316&sequence=0, Retrieved on June 30, 2006.
17 Kaiser Commission on Medicaid and the Uninsured (2005). “Medicaid: A Primer.” July, p. 1. (http://www.kff.org/medicaid/upload/7334%20Medicaid%20Primer_Final%20for%20posting-3.pdf). Retrieved on June 2, 2006.
18 “Ryan White CARE Act: An Update of Reauthorization from 2000 to 2004.” (2004) The Body, July. (http://www.thebody.com/aac/brochures/ryanwhite_reauthorization.html). Retrieved on June 29, 2006.
19 Congressional Budget Office (2006). “Medicaid Spending Growth and Options for Controlling Costs.” http://ftp.cbo.gov/ftpdocs/73xx/doc7387/07-13-Medicaid.pdf, Testimony of Acting Director Donald Marron. Retrieved July 14, 2006.
20 Department of Health and Human Services (2004). “Federal Financial Participation in State Assistance Expenditures, FY 2006.” (http://aspe.os.dhhs.gov/health/fmap06.htm). Retrieved on June 15, 2006 and Department of Health and Human Services (2005). “Federal Financial Participation in State Assistance Expenditures, FY 2006.” (http://aspe.hhs.gov/health/fmap07.htm) Retrieved on June 30, 2006.
21 Mann, Cindy & Tim Westmoreland (2004). “Attending to Medicaid.” The Journal of Law, Medicine & Ethics, Fall; 32(3), p. 416-425. (http://ihcrp.georgetown.edu/pdfs/ASLME_Paper.pdf). Retrieved on June 1, 2006.
22 Schneider, Andy, et al (2002). “The Medicaid Resource Book.” Kaiser Commission on Medicaid and the Uninsured, July, p. 7. (http://www.kff.org/medicaid/2236-index.cfm). Retrieved on June 4, 2006.
23 Kaiser Commission on Medicaid and the Uninsured (2005). “Medicaid: A Primer.” July, p. 6. (http://www.kff.org/medicaid/upload/7334%20Medicaid%20Primer_Final%20for%20posting-3.pdf). Retrieved on June 5, 2006.
24 Schneider, Andy and Rachel Garfield (2003). “Medicaid as Health Insurer: Current Benefits and Flexibility.” Kaiser Commission on Medicaid and the Uninsured, November, p. 4. (http://www.kff.org/medicaid/upload/Medicaid-as-a-Health-Insurer-Current-Benefits-and-Flexibility.pdf) Retrieved on June 15, 2006.
25 Kaiser Commission on Medicaid and the Uninsured. “Medicaid Benefits: Online Database.” October 2004. (http://www.kff.org/medicaid/benefits/service_main.jsp). Retrieved on June 16, 2006.
26 Centers for Medicare and Medicaid Services. “Optional Medicaid Benefit for Tuberculosis (TB)-Related Services.” (http://www.cms.hhs.gov/MedicaidSpecialCovCond/04_Tuberculosis.asp). Retrieved on June 1, 2006.
27 Centers for Disease Control and Prevention (2004). “Vaccines for Children Program.” (http://www.cdc.gov/programs/immun10.htm). Retrieved on June 14, 2006.
28 Centers for Disease Control and Prevention. “Breast and Cervical Cancer Prevention and Treatment Act of 2000.” (www.cdc.gov/cancer/nbccedp/bccpdfs/publ354-106.pdf). Retrieved on June 30, 2006.
29 Schneider, A., et al, “The Medicaid Resource Book” (2002). Published by the Kaiser Family Foundation. July, p. 82.
30 “Medicaid Waivers.” National Association of State Medicaid Directors. (http://www.nasmd.org/waivers/waivers.htm). Retrieved on June 30, 2006.
31 Kaiser Commission on Medicaid and the Uninsured, “Charting a Course for Medicaid: Future Directions in Long-Term Care Coverage” (2006). Background briefing charts, Long-Term Care Roundtable.
32 Kaiser Commission on Medicaid and the Uninsured (2003). “Section 1115 Medicaid and SCHIP Waivers: Policy Implications of Recent Activity.” June, p. 1. (http://www.kff.org/medicaid/upload/Section-1115-Medicaid-and-SCHIP-Waivers-Policy-Implications-of-Recent-Activities-Policy-Brief.pdf). Retrieved on June 15, 2006.
33 Alliance for Health Reform (2006). “Cash & Counseling Moves Into the Mainstream.” April, p. 1. (http://www.allhealth.org/recent/issue_briefs/Cash%20and%20Counseling.pdf). Retrieved on June 15, 2006.
34 Congressional Budget Office (2006). “The Budget and Economic Outlook: Fiscal Years 2007-2016.” January, p. XII. (http://ftp.cbo.gov/ftpdocs/70xx/doc7027/01-26-BudgetOutlook.pdf). Retrieved on June 5, 2006.
35 National Association of State Budget Officers (2005). “”2004 State Expenditure Report.” P. 48. (www.nasbo.org/Publications/PDFs/2004ExpendReport.pdf)
36 U.S. Census Bureau (2006). "Table HI-4. Health Insurance Coverage Status and Type of Coverage by State: All People: 1987 to 2005." (www.census.gov/hhes/www/hlthins/historic/hihistt4.html).
37 Congressional Budget Office (2006). "Medicaid Spending Growth and Options for Controlling Costs." (http://ftp.cbo.gov/ftpdocs/73xx/doc7387/07-13-Medicaid.pdf), Testimony of Acting Director Donald Marron. Retrieved July 14, 2006.
38 Kaiser Commission on Medicaid and the Uninsured (2006). “Medicaid Enrollment and Spending Trends.” May. (http://www.kff.org/medicaid/upload/7523.pdf). Retrieved on June 5, 2006.
39 Kaiser Commission on Medicaid and the Uninsured (2006). “State Medicaid Fact Sheets.” (http://www.kff.org/mfs/index.jsp). Retrieved on June 16, 2006.
40 Guyer, Jocelyn, et.al. (2006). “A Review of Medicaid Provisions Affecting Children and Families.” The Center for Children and Families, March, p. 4. (http://jonesd.ihcrp.georgetown.edu/%7ejonesd3/reconbrief013006.pdf). Retrieved on June 5, 2006.
41 Note: There is an apparent drafting error in DRA, leaving some people under poverty with fewer protections than people above poverty. It is widely expected that this mistake will be corrected, either by administrative guidance from HHS or by a technical amendment by the Congress. See Guyer, Jocelyn (2006). “A Summary of Federal Medicaid Cost-Sharing and Premium Standards: Current Law v. The Deficit Reduction Act.” Center for Children and Families, Georgetown University Health Policy Institute. February, p. 3. (http://ccf.georgetown.edu/pdfs/recontable020906.pdf). Retrieved on June 5, 2006.
42 Guyer, Jocelyn (2006). “A Summary of Federal Medicaid Cost-Sharing and Premium Standards: Current Law v. The Deficit Reduction Act.” Center for Children and Families, Georgetown University Health Policy Institute. February 8. (http://ccf.georgetown.edu/pdfs/recontable020906.pdf). Retrieved on June 5, 2006.
43 Solomon, Judith (2006). “West Virginia’s Medicaid Changes Unlikely to Reduce State Costs or Improve Beneficiaries’ Health.” Center on Budget and Policy Priorities, May. (http://www.cbpp.org/5-31-06health.htm). Retrieved on June 30, 2006.
44 Hahn, Gregory. “Government Approves Idaho Medicaid Overhaul.” Idaho Statesman, May 26. (http://www.idahostatesman.com/apps/pbcs.dll/article?AID=/20060526/NEWS01/605260367/1002). Retrieved on June 29, 2006.
45 Kaiser Commission on Medicaid and the Uninsured (2006). “Deficit Reduction Act of 2005: Implications for Medicaid.” February, p. 3. (http://www.kff.org/medicaid/upload/7465.pdf). Retrieved on June 4, 2006.
46 Guyer, Jocelyn, et.al. (2006). “A Review of Medicaid Provisions Affecting Children and Families.” The Center for Children and Families, March, p. 6. (http://jonesd.ihcrp.georgetown.edu/%7ejonesd3/reconbrief013006.pdf). Retrieved on June 5, 2006.
47 Lin, Rong-Gong ll (2006). “State to Delay Benefit Rule.” The Los Angeles Times, June 7.(www.namicalifornia.org/document-detail.aspx?page=newsviews&tabb=currentnews&lang=ENG&idno=254). Retrieved on June 16, 2006.
48 Leingang, Matt (2006). “Citizen Medicaid rule awaits.” The Cincinnati Enquirer, June 22. (http://news.enquirer.com/apps/pbcs.dll/article?AID=/20060622/NEWS01/606220381/1056). Retrieved on June 29, 2006.
49 Kemper, Bob (2006). “Medicaid Citizenship Law Faces Court Fight.” The Atlanta Journal-Constitution, June 28. (http://www.ajc.com/search/content/auto/epaper/editions/today/
news_442a314e25f311bc0083.html). Retrieved on June 29, 2006.
50 Public Law 109-171. (2006). February. (http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ171.109.pdf). Retrieved on June 16, 2006.
51 Kaiser Commission on Medicaid and the Uninsured (2006). “Deficit Reduction Act of 2005: Implications for Medicaid.” February. (http://www.kff.org/medicaid/upload/7465.pdf). Retrieved on June 4, 2006.
52 “Medicaid Commission Finds $1 Billion More Than Asked to Cut” (2005). Senior Journal, September 1. (http://www.seniorjournal.com/NEWS/Medicaid/5-09-01MedicaidCuts.htm). Retrieved on June 29, 2006.
53 National Governors Association (2005). “Short-Run Medicaid Reform.” August. (http://www.aapd-dc.org/News/commission/MedicaidReform.pdf). Retrieved on June 29, 2006.
54 Kaiser Daily Health Report (2005). “Federal Medicaid Commission Named; Former Tennessee Governor To Lead Panel,” 11 July. (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=31293). Retrieved on June 29, 2006.
55 Medicaid Commission (2006). Meeting Summary. May, p. 4. (http://www.aapd-dc.org/News/commission/downloads/mcMay2006mtg.pdf). Retrieved on June 29, 2006.
56 Kaiser Daily Health Report (2006). “Supreme Court Declines to Block Portion of Medicare Law Requiring States to Contribute to Cost of Drug Benefit” 20 June. (http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=38011). Retrieved on June 29, 2006.